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Recent eLetters

Displaying 1-10 letters out of 257 published

  1. Optic nerve involvement in Acute Lymbhobastic Leukaemia , more than what meets the eye

    Acute Lymphoblastic Leukaemia can affect the eye in various ways . It may present with an ischaemic optic nerve involvement (1) or optic nerve swelling due to direct involvement . But sometimes it may also present as an optic nerve involvement as an effect of a drug like Linezolid which has been used for treatment of infections which coexist (2) or it may present as an infiltration of the nerve in combination with herpes virus (3)

    Though papillodema is the most frequent sign of optic nerve involvement it can be absent in direct infiltration of the nerve by leukemic cells, or present just due to increased intracranial pressure , or swelling because of retrolaminar leukemic invasion.

    The involvement in invasion of the optic nerve usually occurs during the evolution of acute lymphoblastic leukemia, but that , when as is elucidated in the present case and also by Mess et al earlier in 2003, is the first sign of acute lymphoblastic leukemia or of extramedullary relapse after remission , it usually means a poor prognosis for the patient, especially if it happens when the patient is still receiving treatment, rather than after it. And so earlier it is picked up, the better .Hence the value of a routine check even in absence of symptoms .

    Optic nerve swelling may mean many things and one needs to differentiate the causes of the optic nerve swelling clinically and with non invasive tests like Ocular coherence tomography ( OCT ) so as to institute proper therapy . Optic nerve involvement, as one needs to emphasise again , is not always a result of leukaemia infiltration as a surprise in remission . Sometimes Peripapillary retinal leukemic infiltration may be associated with papilledema in a patient without cranial or optic nerve involvement.(4) . Optic nerve swelling may be seen due to optic neuritis (5) which can be seen sometimes in cases of leukaemia without leukaemic infiltration .Sometimes the peri neuritis may be transient (6) Papillodema due to central nervous system involvement may be seen .Medications used for treatment may sometimes cause secondary optic nerve affectation and may include but be not limited to toxicity of chemotherapy, antibiotics or radiotherapy, ischemia after anaemia or hyperviscosity, and opportunistic infections in immunocompromised patients. In such cases to figure out whether the optic nerve involvement is indeed direct infiltration one may look for other layers of eye being involved . (7) So if there are other layers involved there is a clue and an eye surgeon will pick it up because conjunctival , scleral and trabecular involvement is characteristic

    But in a case where optic nerve alone is involved one can use OCT to figure out what's hapenning at the optic nerve level. The swelling begins not at superior or inferior edge of the optic nerve as in papillodema due to raised intra cranial pressure and "doesn't follow ISNT rule " ( that's a rule in glaucoma where loss occurs in that order but sometimes swellings occur in similar way ) and also one doesn't see a typical swelling of optic neuritis then it's obvious that a lot of clues are waiting to be picked up

    The present case report helped us manage a case locally and so we are thankful to the authors and the journal for the same

    The optic nerve is relatively unaffected by systemic chemotherapy and serves as a sanctuary of ALL.(8) So it is probably essential that an eye surgeon opinion is sought regularly since there's a lot they can tell , lots more than meets the non ophthalmologist's eye .

    Reference :-

    1) Chaudhuri T, Roy S, Roy P. Ischaemic optic neuropathy induced sudden blindness as an initial presentation of acute lymphoblastic leukemia. Indian J Med Paediatr Oncol 2013;34:335-6

    2) Joshi L, Taylor SRJ, Large O, Yacoub S, Lightman S (2009). A case of optic neuropathy after short-term linezolid use in a patient with acute lymphocytic leukemia. Clin Infect Dis 48:73-74. ISSN 1537-6591.

    3) Bhatt UK, Gregory ME, Madi MS, Fraser M, Woodruff HA (2008). Sequential leukemic infiltration and human herpervirus optic neuropathy in acute lymphoblastic leukemia. Journal of AAPOS 12:200-202. ISSN 1528-3933.

    4) ?eki? O, Biberoglu E, Esen F. Peripapillary retinal leukemic infiltration associated with papilledema in a T-ALL patient without cranial or optic nerve involvement. Tumori. 2016 Nov 11;102(Suppl. 2). doi: 10.5301/tj.5000490

    5) Yo Han Ra, Sun Young Park, Soo Ah Im, Jee Young Kim, Nak Gyun Chung, Bin Cho. Enhancement of Optic Nerve in Leukemic Patients: Leukemic Infiltration of Optic Nerve versus Optic Neuritis.iMRI 2016;20:167-174. http://dx.doi.org/10.13104/imri.2016.20.3.167

    6) Townsend JH, Dubovy SR, Pasol J, Lam BL. Transient optic perineuritis as the initial presentation of central nervous system involvement by pre-B cell lymphocytic leukemia. J Neuroophthalmol 2013;33:162-164

    7) Rosenthal AR. Ocular manifestations of leukemia. A review. Ophthalmology 1983;90:899-905

    8) Ninane J, Taylor D, Day S. The eye as a sanctuary in acute lymphoblastic leukemia. Lancet. 1980;1:452-3.

    Conflict of Interest:

    None declared

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  2. Re:Association is not causation

    BMJ approached the authors for their comments, but did not receive a response. This case was reviewed by two external peer reviewers prior to publication. It uses cautious language throughout and correctly offers no definitive conclusions. BMJ Case Reports is not responsible for claims made in other media.

    Conflict of Interest:

    I am the Publishing Executive for BMJ Case Reports

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  3. Association is not causation

    Zaidi et al conclude that "Dietary supplements, such as curcumin, may be beneficial for some myeloma patients". This is on the basis of their single case report; in other words it is an anecdote. In contrast, the medicinal chemistry of curcumin has been studied in depth for many years. Nelson et al conclude that, despite over 120 clinical trials, no beneficial effect has been observed (1).

    I am wondering about how rigorous was the peer review of this case report. Did the reviewers evaluate what was the more likely explanation, in the light of the published literature?

    I note that Zaidi et al cite a review by Aggarwal et al in 2009 (2). Several papers from this author were withdrawn in or about 2012 as possibly fraudulent (3), casting doubt on his authority. I do not think this oversight reflects well on the authors of the present case report, or on its reviewers.

    This case report has recently attracted substantial attention from the lay media. Exaggerated claims have been made on national radio. Yet there is good evidence that cancer patients who rely on alternative treatments such as plant extracts have worse outcomes (4). Was it really responsible of the BMJ to publish this report in its present form?

    References

    1. Nelson KM, Dahlin J, Bisson J et al. The Essential Medicinal Chemistry of Curcumin. J Med Chem. 2017 Mar 9; 60(5): 1620-1637.

    2. Aggarwal BB, Harikumar KB. Potential therapeutic effects of curcumin, the anti-inflammatory agent, against neurodegenerative, cardiovascular, pulmonary, metabolic, autoimmune and neoplastic diseases. Int J Biochem Cell Biol 2009;41:40-59.

    3. Ackerman T. M.D. Anderson scientist, accused of manipulating data, retires. Houston Chronicle, March 2, 2016 Updated: March 4, 2016. http://bit.ly/2AHTN20 (accessed 8th Jan 2018)

    4. Johnson SB, Park HS, Gross CP et al. Use of Alternative Medicine for Cancer and Its Impact on Survival. Journal of the National Cancer Institute, Volume 110, Issue 1, 1 January 2018

    Conflict of Interest:

    I have had smouldering myeloma for nine years but have not required treatment.

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  4. LA clot in Severe Mitral stenosis

    Varying sizes and quality of clots are seen in severe rheaumatic mitral valve stenosis, especially in Asian subcontinent. LA clots are also found in patients with non-valvular atrial fibrillation, but to a lesser extent as compared to rheumatic valvular disesase and are seen more in the advanced world. The clots can be fresh ones or multilayered organised clots or a mixture of the two. In severe mitral stenosis, because of the obvious stasis of blood in LA, there are high possibilities of clot formation, and this is seen more so in the Indian subcontinent due to poor patinet compliance with anticoagulation therapy and this is a major issue in the management of patients with rheumatic mitral stenosis.This leads to various complications such as Stroke, TIA, and embolisation to various other systemic organs and lower limbs ausing ischemia. It is important to treat these patients as an urgent case for LA clot removal and Mitral valve repalcement along with surgical management of lower limb ischemia.

    Conflict of Interest:

    None declared

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  5. excellent paper, something useful to add towards a full comprehension of this case

    I deeply appreciated the excellent description and discussion of the case in this paper. I would suggest one more piece of information to be given to the readers; not only genetic factors play a relevant role in the male breast cancers' web of causation but some, mainly occupational, exposures do too. I would therefore find it useful to know which work the patient practised, and if this occupation involved exposure to high levels of heat (e.g. in consequence of being assigned to an industrial oven). Yours sincerely Roberto

    Conflict of Interest:

    None declared

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  6. Nerf gun eye injuries

    We read with interest this case series having seen several nerf gun eye injuries in our own department. A search of the electronic patient records revealed 17 such cases since 2014. Of these 12 were male and 5 female with 9 under the age of 18. Analysis of the primary injury revealed 5 hyphemas, 5 cases of traumatic iritis, 2 corneal abrasions, 1 case of commotio retinae and 1 case of angle recession with the risk of glaucoma.

    In addition this placed an additional strain on an already stretched eye casualty as many of the patients required treatment with an average of 3 visits with 1 patient requiring 8 visits.

    We therefore support the authors call for patients and parents to be aware of the types of 'bullets' used and to use eye protection to prevent significant eye injuries.

    Conflict of Interest:

    None declared

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  7. Re:Comment to "Fatal air embolism following local anaesthetisation: does needle size matter?

    I greatly appreciate the well-advised comments from the reader on my case report, ''Fatal air embolism following local anaesthetisation: does needle size matter?''. (1) They discuss the significance of proper positioning prior to performing the biopsy. While having the appropriate hemithorax in ipsilateral-dependent position certainly minimizes the motion and reduces the risk of air embolism as the core biopsy needle traverses the lung parenchyma; our case report was meant to emphasize the risk of air embolism during the administration of local anesthetic where the needle typically does not penetrate any significant portion of lung parenchyma. Since 25-gauge needle is very small and usually not linked to air embolisms, we discussed that all the risk factors (including improper positioning) that are associated with air embolism during core biopsy are applicable to smaller Lidocaine needle as well. In our patient, it is likely that positioning in addition to negative intra-thoracic pressure generated by patient's cough resulted in air embolism.

    1. Khalid F, Rehman S, AbdulRahman R, Gupta S. Fatal air embolism following local anaesthetisation: does needle size matter? BMJ Case Rep. 2018;2018.

    Conflict of Interest:

    None declared

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  8. Kite surfing: epidemiology of trauma: literature review methods

    I read with interest Dunne et al's paper kite surfing: epidemiology of trauma. They state that 'a comprehensive review of EMBASE, PubMed and Google Scholar was conducted' and that 'the search strategy included medical subject headings (MeSH) kitesurf/kitesurfing/kitesurfing hip/kitesurfing pelvis/kitesurfing fracture/kitesurfing injury'. At the time of writing, (3 April 2018) none of these terms may be found in the MeSH thesaurus (https://meshb.nlm.nih.gov/search), and MeSH terms would not, in any case, have helped in a search of EMBASE or of Google Scholar. Existing papers in MEDLINE on kite surfing injuries have been indexed with the term Athletic Injuries, and no subordinate terms yet exist. A more productive strategy might have been to search titles and abstracts using the strings kite* ADJ3 surf* OR kitesurf*. A search using these strings on the HDAS interface finds 29 results in MEDLINE and 33 in EMBASE. A more elaborate strategy for the other concept in the search, that of pelvic and acetabular fractures is certainly possible using a combination of controlled vocabulary and natural language terms.

    Conflict of Interest:

    None declared

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  9. Is cold only a biting bystander in this story?

    I have several points about this interesting case report.

    1/ The first point that surprised me is this: apparently, this patient has had neither at the end of the procedure nor after an intercostal infiltration with long-acting local anaesthetic drug

    2/ Then this could have helped in both diagnosis and treatment. The disappearing or alleviation of pain would have clearly identified the intercostal nerve injury and even broken the vicious circle of chronic pain if it had been done early after the onset. It would have also allowed an earlier onset of physiotherapy and potentially avoided such a risky and aleatory end for this chronic pain

    3/ About the mechanistic hypothesis Intercoastal nerve injury in thoracoscopy procedures is dependent on technique, size of the device and skill of the surgeon. It is a rather frequent complication of those procedures and prevention is key. It is mainly based on a surgical approach just at the upper edge of the rib in order to avoid any damage to the vessels which lead to a haematoma compressing the nerve or directly to the nerve

    4/ chronic pain is a neurobiological issue (https://www.ncbi.nlm.nih.gov/pubmed/12931188) which is the result of a persistent lesion of a peripheral nerve. Complex neurologic and epigenetic mechanisms are at the root of chronic pain and personal traits are associated to the development of chronic pain (https://www.ncbi.nlm.nih.gov/pubmed/16355225)(https://academic.oup.com/brain/article/137/3/724/389996). In my experience, one of the worst treatment for chronic pain in a thoracic surgical incision is systemic opioids (https://journals.lww.com/painrpts/Fulltext/2017/03000/Postoperative_pain_from_mechanisms_to_treatment.1.aspx). In this setting it is probable that strong and fast movements during the short swim can have released some local fibrous tissue in the wound and that a severe stress can have interrupted the vicious circle of chronic pain which is dependent on a central thalamic role (https://www.jscimedcentral.com/Neuroscience/neuroscience-5-1075.pdf)

    5/ Is cold a biting bystander in this case? We know on the contrary that cold could lead to neuropathy in case of chronic cold but non-freezing exposure(https://academic.oup.com/brain/article/140/10/2557/4100656). When cold is used for neurolysis it is with a cryoprobe and temperatures at the tip of the probe which is in contact with the nerve (CT guided procedure) is minus 50 Celsius. It is clear that the swimming episode did not reach this range of temperature.

    This case report is clearly mysterious and in absence of imagery and testing of the nerves, it is at odd to conclude of any direct action of cold water immersion on neuropathy.

    Conflict of Interest:

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  10. Mitral stenosis - still a challange with a myriad of features,

    Rheumatic heart disease leading to mitral stenosis is seen more often in the developing countries than in the developed world. The patients are quite asymptomatic at rest until the 2nd or 3rd decade, when they may present with various signs and symptoms like dyspnoea on exertion, palpitations, easy fatigebility, dizziness, coughing up blood, chest pain or discomfort, and swelling in legs and upto 15% of patients may present with signs of systemic emboli as a first sign like transient ischemic attack, stroke, or suddden pain in abdomen due to gut ischemia or a renal infarct. Embolic phenomenon are seen in mitral stenosis patients with atrial fibrillation, but sometimes even patients in sinus rythm may present with clinical features of sytemic emboli.

    In the above case, a young women presented with a history of parasthesia and dysarthria, for the first time. Given that she was a young Mexican lady, a high level suspicion should have been on the cardiac origin of emboli and along with CT brain to rule out stroke , a 2-D cardiac echo study would have been very useful to rule out any emboli in the left heart. The echo would have given the appropriate diagnosis and guided the proper anticoagulation therapy and a further mitral valve replacement as the final treatment. In conclusion, a young patient presenting with a TIA/stroke/hemiparesis needs a thorough assessment of the source of the systemic emboli and thus a very high level of suspicion for cardiac origin.

    Conflict of Interest:

    None declared

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