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Recent eLetters

Displaying 11-20 letters out of 214 published

  1. Biotin-Thiamine-Responsive Basal Ganglia Disease Can mimic Acute Disseminated Encephalomyelitis

    I read this article with interest as we too made a diagnosis of post-streptococcal acute disseminated encephalomyelitis with basal ganglia swelling in a female aged 11, who had presented with altered conscious level and dystonia, with similar distribution of basal ganglia lesions on MR brain imaging. However, a diagnosis of Biotin-Thiamine-Responsive Basal Ganglia Disease was considered, and homozygous SLC19A3 mutation was confirmed. This is a treatable condition requiring lifelong biotin and thiamine, and I urge the authors to consider testing their patient for this condition promptly. Many thanks for the opportunity to share this potentially important piece of clinical information. Your sincerely, Katharine Forrest

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  2. Are EBV- associated acute acalculous cholecystitis and EBV-associated cholestatic hepatitis with reactive gall bladder wall thickening synonymous?

    Dear Editor, We read with interest, the case report written by Dr. Magdalani et al., "Acute Acalculous cholecystitis in a Lebanese girl with primary Epstein- Barr viral infection" in the British Medical Journal Case Reports published on 18 April, 2016.

    The authors describe a case of a previously healthy, 16 year old girl, who presented with history of 10 day fever, sore throat, and upper abdominal pain. She appeared clinically stable, with mild leukocytosis (predominantly lymphocytic), mild transaminitis and a cholestatic pattern of direct hyperbilirubinemia.

    A diagnosis of EBV associated with acute acalculous cholecystitis (AAC) was established with sonographic findings of significant gall bladder wall thickening. Her gall bladder was not dilated, and there was no pericholecystic fluid. She was treated with antibiotics with resolution of her symptoms. The authors noted that the benefit of antibiotics is questionable.

    Her symptomology and laboratory findings can also be described as consistent with EBV hepatitis. GB wall thickening in acute hepatitis is well known and is attributed to reactive/viral pericholecystitis. The mechanism is proposed to be due to impaired hepatic function with reduced secretion of bile, or from immunological/inflammatory damage to hepatic and biliary cells (1-6). We believe, like others, that the associated sonographic findings (1, 2, 5, 6) can be attributed to diffuse reactive gall bladder wall thickening secondary to peritoneal fluid produced as a result of extra biliary inflammatory process. Management is supportive, with review of literature in this paper showing resolution in 28 of 29 patients diagnosed with EBV associated AAC.

    AAC carries with it considerable mortality as evidenced by literature. Epidemiologically, it occurs in a select cohort of patients who are clinically sick, on prolonged parenteral nutrition, or immunosuppressed patients. Without intervention (cholecystectomy or cholecystostomy tube placement, and steroids in autoimmune patients), it progresses rapidly to gangrenous gall bladder and then perforation (7, 8). It is usually associated with more serious morbidity and higher mortality rates than calculous cholecystitis. The pathophysiology of cystic duct obstruction in AAC is attributed to ischemia to cystic duct, leading to endothelial injury, gall bladder stasis, and eventual necrosis.

    We and others believe that sonographic findings should not be the sole diagnostic criteria for AAC (1, 3). Differential diagnoses such as EBV, CMV, malaria, and other viral hepatides should be taken into consideration. A diagnosis of AAC should be suspected in the sicker, hospitalized patient, and mandates an admission to a monitored unit, and early operative intervention. We suggest obtaining a HIDA scan, in cases of uncertain diagnosis, with the understanding that the sensitivity and specificity are slightly decrease, since the obstruction is functional and not mechanical.

    References: 1. Debnath et al. Is it acalculous cholecystitis or reactive/viral pericholecystits in acute hepatitis? Braz J Infect Dis 2010;14(6):647-648 2. Lee et al. Acalcuous diffuse gall bladder wall thickening in children. Pediatr Gastroenterol Hepatol Nutr 2014 June 17(2):98-103 3. Shkalim-Zemer et al. Cholestatic Hepatitis Induced by Epstein - Barr virus in a Pediatric Population. Clinical Pediatrics 2015, Vol. 54(12) 1153-1157 4. Khoo. Acute cholestatic hepatitis induced by Epstein-Barr virus infection in an adult: a case report. Journal of Medical Case Reports (2016) 10:75 5. Debnath et al. Post-prandial paradoxical filling of gall bladder in patients with acute hepatitis: Myth or reality? Medical Journal Armed Forces of India 68 (2012) 346 e349 6. Poddighe, .Acalculous Acute Cholecystitis in Previously Healthy Children: General Overview and Analysis of Pediatric Infectious Cases. Int J Hepatol. 2015; 2015: 459608. 7. Owen et al. Acute Acalculous Cholecystitis. Curr Treat Options Gastroenterol. 2005 Apr;8(2):99-104. 8. Barie et al. Acute acalculous cholecystitis. Gastroenterol Clin North Am. 2010 Jun;39(2):343-57.

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  3. BESS ( benign enlargement of subara chnoid spaces)

    The authors rightly mention in their case report that it is not an uncommon finding in normal infants who are referred to the paediatrician because of large head size or a rapid increase in OFC. My concern is that the patient 1 in the case report may send a wrong message to the trainees or other doctors that CT head is the primary mode of imaging in such cases because of high dose of radiation involved with a CT. Most of them can be confirmed /recognized by a cranial ultrasound which can be easily performed even in a district general hospital setting and followed up by a repeat U/S if necessary, as the anterior fonatenelle is open in a large number of cases at that age. A CT or MRI should be needed rarely unless we have a case like patient 2 in the case report with head injury or suspicion of non accidental injury etc.

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  4. Oscillicoccinum has no benefit for influenza - it's inactive

    The authors make a claim that the patient developed angioedema following ingestion of oscillococcinum, a homeopathic "remedy" used for treating influenza symptoms. The authors claim that evidence of benefit exists to claim that this preparation has proven clinical activity. Unfortunately, they omit to use up-to-date information to base this claim on. The most recent Cochrane review (1), published January 2015 and authored by two well-known homeopaths concluded "There is insufficient good evidence to enable robust conclusions to be made about oscillococcinum in the prevention or treatment of influenza and influenza -like illness. Our findings do not rule out the possibility that oscillococcinum could have a clinically useful treatment effect but, given the low quality of the eligible studies, the evidence is not compelling. There was no evidence of clinically important harms due to oscillococcinum." The second problem with this report is the constituents of the oscillococcinum remedy itself. It is based on a preparation of Barbary duck heart and liver, misinterpreted by French physician Joseph Roy of a preparation of blood samples from victims of Spanish Flu towards the end of World War 1 (2). The preparation is supplied in the form of lactose pills onto which the remedy has been dripped. The solution dripped onto the pills has been diluted to the homeopathic "potency" of 200C. This involves serial centessimal dilutions to a factor of 200. This means that it is not possible to find a single particle or molecule of the original starting material in the final diluted solution. Serial dilution beyond the 12C "potency" exceeds Avogadro's constant. Dilution to 200C means that you could search the entire known universe and still fail to find a single entity from the starting material! (3) Their patient would appear to have had an allergic response to something, but if it is the pills he took, then it could only be the lactose, which is possible but unlikely. This therefore begs the question as to what the patient actually had the allergic reaction to? He should undergo a formal allergy review by a specialist, possibly including formal testing to work out what the allergy really is.

    1. http://www.cochrane.org/CD001957/ARI_homeopathic-oscillococcinumr- for-preventing-and-treating-influenza-and-influenza-like-illness 2. http://www.homeowatch.org/history/oscillo.html 3. https://www.sciencebasedmedicine.org/homeopathy-as-nanoparticles/

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  5. Not all ST - T & QRS complex changes are myocardial injury.

    I completely agree with the authors in saying that all ST-T changes are not myocardial injury.

    In my experience, not all new widened QRS complex changes (LBBB) indicate myocardial infarction or injury.

    I would like to say this on the basis that quite a few times, a patient with new wide QRS complex and bradycardia is referred to cardiology to rule out myocardial infarction and after investigations patient is found to have severe hyperkalemia and with ARF or an undiagnosed and progressive CKD. After immediate correction of hyperkalemia with glucose -insuln infusion, and intravenous Normal saline, and inj. frussemide in non-oliguric patients, the ECG changes revert back to normal.

    It's important to take ST-T changes on ECG seriously, but also have to look at clinical signs and symptoms and investigations to ascertain myocardial injury especially in emergency situations.

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  6. NG tube insertion - to be taken seriously

    Insertion of the nasogastric tube is taken very casually at the medical graduate level.

    In my opinion , insertion of NG tubes should be done very judiciously and gently in an awake patient.

    Points to note --

    1) Insert the tube very gently in the backwards and downward direction in the nostril, to avoid inadvertent damage of the roof of the nasal cavity, and passage of the tube intracranial.

    2) The tube should pass in without any resistance, in case of any undue resistance, please take it out and insert again.

    3) The NG tube be confirmed by auscultation on the epigastrium by inflating air with a 20 cc syringe.

    4) The patient can have cough while insertion, but this has to subside after few minutes, if cough persists, then it is very important to confirm the proper positioning of NG tube with the 4 point test mentioned in the case report.

    5) Its also important to insert the tube gently as it can cause trauma and bleeding especially in patients on antiplatelets/anticoagulants.

    In conclusion, insertion of NG tube is a routine procedure done in the hospitals,but it needs due diligence and good practice.

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  7. Preprocedure/pre tracheostomy USG-- is it beneficial /conclusive.

    I agree with the concept of a pre-tracheostomy USG to visualize the neck veins in case of a percutaneous tracheostomy.

    But I have to 2 points against --

    1) I believe percutaneous tracheostomy is still not a routine method of choice in elective tracheostomy in difficult surgical scenario like - short neck, restricted extension, double chin, big pad of neck fat and especially if patient is sick, as the risk of loosing control of airway or bleeding complications can be significant.

    2) How far the USG will be able to show small abnormal midline neck veins, on a regular basis, and that's the reason why about 50 % of intensive care doctors do not use it as a routine screening before tracheostomy.

    I would still stress on the use of USG for screening of abnormal neck veins in case of difficult surgical scenarios, as mentioned above especially in sicker patients who are to undergo surgical or percutaneous tracheostomy.

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  8. Chloroquine induced bilateral anterior shoulder dislocation: a unique etiology for a rare clinical problem

    It is an interesting hypothesis to put forward. The bilateral dislocation of shoulder simultaneously is not very common especially if there has been no episodes of tonic clonic convulsions. However it is very difficult to associate this with the administration of Chloroquine is far fletched and in fact could be incidental. The mechanism of action of Chloroquine in the management of the basic disease does not indicate any relationship fo the drug with the clinical picture and such hypothesis need not be put forward

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  9. concurrent cryptococcal meningitis and disseminated tuberculosis occuring in an immunocompetent male

    Cryptococcal meningitis used to be quite common in immunocompromised patients, like those with HIV, before the availability of effective HRT for the same. We have seen and managed quite a number of such patients in the last decade of the last century. The prognosis used to be universally poor for these patients. Similarly, we came across disseminated cryptococcosis in immunocompetent patients as well. Some of them had tuberculosis, which happens to be still quite common in developing and underdeveloped countries. A duel treatment for both conditions offers the best possible prognosis for such patients. The fungus is widely spread in nature and a person can get infected and develop the manifestations, especially if he or she has another disease like tuberculosis or diabetes. One needs to be thinking of the possibility of more than one infection even if the patient is otherwise immunocompetent.

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  10. Uncommon mycosis in a patient with diabetes

    Disseminated cryptococcal infection in immunocompromised patients, such as those with HIV, used to be quite common. We have seen and reported a series of patients with cryptococcal meningitis and HIV in the late nineties of the last century, before the availability of effective HRT. The prognosis used to be universally poor. Some of our patients were likely to be immunocompetant since they did not have HIV. These patients mostly had disseminated tuberculosis or diabetes. Some of them did recover from the cryptococcosis, until they returned for follow up. With the availability of effective HRT for HIV, now the main factor for disseminated mycosis will be diabetes, as in the case report. The authors need to be complemented for the effective management in this case.

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