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Recent eLetters

Displaying 11-20 letters out of 221 published

  1. Case of CML lymphoid blast crisis presenting as bilateral breast masses

    This is an interesting case. However the postulation proposed by the authors that a case of CML going into blast crisis of Lymphoid variety appears to be slightly far from reality. Knowing that haemopoetic stem cells can develop in any cell variety it is possible that the cells described could morphologically resemble Lymphoblasts but are in fact better labeled as Undifferentiated Blasts. The patient had many symptoms of underling rapidly progressive malignant process although her basic disease of CML may have gone unnoticed for quite some time as she might not be aware of the growing size of the Spleen since we do not pay attention to our tummy size in general as compared to size of the breasts in particular. Leukemic deposits an various tissues including skin and orbits are very well known to develop during blast crisis in case of AML and the blastic transformation of the CML. The prognosis for such patients is less favourable compared to usual CML patients.

    Conflict of Interest:

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  2. Haemophilia A related haematoma. management in resourse constrained settings

    Haemophilia A is not so uncommon in India but perhaps remains unnoticed or non cared for because of the non availability of the replacement therapy or the cost factors for the therapy. This patient appears to have a milder form of the condition as no mention has been made about the frequency with which he requires the replacement of factor VIII, although it has been mentioned that at some stage the levels were less than 1%. There has been no reference as to how frequently during 24 hours the FFP was transfused. Perhaps the levels of factor VIII during the current episode was not very low and was sufficiently corrected by the volume of FFP by the care takers. It should be noted that if the hospital /clinic has the facility to prepare the FFP the blood bank can easily prepare Cryoprecipitate that can be used for replacement of the factor VIII. The methodology of preparation of the same is very simple and is now available at many centres. The use of a synthetic drug 8DDAVP can also be considered in the management of such patients, although the cost of this drug also will be a limiting factor. The frequency of spontaneous bleeding becomes less and less as these patients become older and of course they become self informed as to how to avoid the injuries.

    Conflict of Interest:

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  3. Successful treatment of recurrent rectal prolapse using three Thiersch sutures in children

    We read with interest the article from Chauhan Kashif et al, entitled "Successful treatment of recurrent rectal prolapse using 3 Thiersch sutures in an 8-year-old boy" [1] and would like to add some comments. The authors proposed a novel technique of Thiersch procedure using three sutures that included one non absorbable polypropylene suture to successfully treat a re-recurrent full-thickness rectal prolapse in an 8- year-old boy. It is important to specify in the title and background that the various options proposed by the authors to treat rectal prolapse and recurrent rectal prolapse are described in children, as other procedures are available in adults, namely the Delorme procedure and the Altemeier procedure. Moreover, injection sclerotherapy and Thiersch wire are no longer used for total rectal prolapse treatment in adults. The authors should explain the aetiology of the full-thickness rectal prolapse; they mention some kind of constipation and a Rassmussen syndrome. Do they think the chronic constipation and dyschezia were responsible for the anatomical abnormality? If yes, how do they explain that the treatment of the prolapse improved the transit time? If not, what was the cause of the prolapse? Is it part of the syndrome? The original description of the anal encirclement by Thiersch and following authors [2] involved a non absorbable material (silver wire, fascia strips, nylon strips, etc). The first and second surgical treatment of the patient in this paper included injection of 5% phenol almond oil and insertion of 1/0 PDS suture around the anal canal. As this single circumferential suture is made of absorbable material, it is not surprising that a recurrence occurred 3 months later, which is about the delay for PDS absorption in both operations. Moreover, successful outcome following the third operation may have happened because of the use of one non absorbable, polypropylene suture. One could argue that only one non absorbable suture might have been sufficient to successfully treat the patient, and that the 2 absorbable PDS sutures were unnecessary. Therefore, the procedure described in the paper is not really a novel technique, but the true Thiersch procedure. We also miss some details from the hospital stay. Did the young patient suffer from the operation? Did he experience some bleeding? Was he given some kind of regimen? Painkillers? Antibiotics? How long did he stay in hospital? Lastly, 6 months follow-up to ensure absence of recurrence is probably too short. Dealing with functional disorders such as rectal prolapse, one should wait at least 5 years to consider the surgical treatment is efficient and stable with time [3]. References 1. Chauhan K, Gan R, Singh S. Successful treatment of recurrent rectal prolapse using 3 Thiersch sutures in children. BMJ Case Rep. 2015 Nov 25;2015. pii: bcr2015211947. doi: 10.1136/bcr-2015-211947. 2. Devesa JM, Hervas PL, Vicente R, Rey A, Die J, Moreno I, et al. Anal encirclement with a simple prosthetic sling for faecal incontinence. Tech Coloproctol 2011;15:17-22. 3. Faucheron JL, Trilling B, Girard E, Sage PY, Barbois S, Reche F. Anterior rectopexy for full-thickness rectal prolapse: Technical and functional results. World J Gastroenterol 2015;21:5049-55

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  4. Opportunity for a "one health" approach overlooked?

    To Whom It May Concern

    "Lick of death: Capnocytophaga canimorsus is an important cause of sepsis in the elderly"1 describes an excellent outcome thanks to an elegant diagnostic work up and excellent treatment. However, I believe the headline "Lick of death" is unnecessarily fear-mongering and unwarranted (the patient, after all, did not die). Additionally, while the authors should be congratulated for educating practitioners about C. canimorsus, I feel there is scope for discussion with veterinarians to reduce further risk to this and other patients.

    The authors conclude that the source of the patient's infection was the owner's own dog, via a lick, on the grounds that Capnocytophaga canimorsus was isolated from that patient, that it is a zoonotic organism and that the patient admitted to being licked by the dog. My understanding is that this conclusion is based on findings that C canimorsus colonises the mouths of dogs and cats. This seems reasonable though for the sake of completeness and illuminating our understanding of this condition I feel it would have been helpful to examine and test the dog, and here there is scope for veterinary input2.

    As the authors note, the elderly rely on companion animals. Could C canimorsus be isolated from the oral cavity of the patient's Italian greyhound? Was the dental and periodontal health of the dog assessed? What measures could be taken to reduce the risk of exposure, apart from avoiding being licked by the dog? A recent UK study found that 9.3 per cent of dogs suffered from periodontal disease3. What we don't know is whether regular dental scaling may reduce carriage of C canimorsus.

    Another question, perhaps to be answered by veterinarians, is whether the patient's comorbidities contributed to the licking by the dog? Companion animals may alter behaviour in response to owners, and may engage in licking or biting as an attempt to rouse owners with a reduced state of consciousness4. In fact, licking behaviour was performed by 50 per cent of seizure response dogs when owners suffered seizures5. (It is important to note that while licking may be detrimental, seizure response dogs can save lives - in the previous study, one dog brought the cordless phone, another rolled the owner, who had a history of aspiration pneumonia, onto their side, and yet another turned off the electric wheelchair as several accidents had occurred during seizures).

    Human animal interactions are complex, involving mutual benefit as well as potential risks to both parties. This complexity demands a genuine 'one health' approach. Discussion of the role of the dog in this case with a veterinarian may help illuminate and reduce animal-based risk factors.

    Sincerely,

    Anne Fawcett

    References

    1. Wilson JP, Kafetz K, Fink D. Lick of death: Capnocytophaga canimorsus is an important cause of sepsis in the elderly. BMJ Case Reports 2016;2016. 2. Speare R, Mendez D, Judd J, et al. Willingness to Consult a Veterinarian on Physician's Advice for Zoonotic Diseases: A Formal Role for Veterinarians in Medicine? Plos One 2015;10(8):8. 3. O'Neill DG, Church DB, McGreevy PD, et al. Prevalence of Disorders Recorded in Dogs Attending Primary-Care Veterinary Practices in England. Plos One 2014;9(3):16. 4. Seligman WH, Manuel A. The cat and the nap. Medical Journal of Australia 2014;200(4):229-29. 5. Kirton A, Winter A, Wirrell E, et al. Seizure response dogs: Evaluation of a formal training program. Epilepsy Behav 2008;13(3):499-504.

    Conflict of Interest:

    I am a companion animal veterinarian and co-habit with companion animals.

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  5. 7q11.23-q21.2 microdeletion: 2 years follow-up

    As reported in the original article, the developmental assessment at 13.5 months (adjusted for prematurity) showed a global developmental delay.

    Bayley III assessment at 24.8 months (adjusted for prematurity) confirmed the global developmental delay affecting cognitive, communication and motor domains (percentile ranks: 0.4, 4, 0.4, respectively). The passive tone of his upper extremities was symmetrical bilaterally, but with mild hypotonia.

    His mother also reported two major episodes of generalised tonic-clonic seizures requiring attendance to hospital and referral to epilepsy clinics.

    Conflict of Interest:

    None declared

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  6. Gastrointestinal bleeding secondary to trimethoprim-sulfamethoxol induced vitamin K deficiency

    The combination of trimethoprim and sulafamethoxole has been used for the prophylaxis of malaria for over several decades. While the development of vitamin K deficiency due to this drug combination is theoretically possible, it is not very common. There are many risk factors for vitamin K deficiency, such as diet, interactions with other drugs and basic liver function. To state that this drug combination caused vitamin K deficiency in the patient is presumptive. Other factors may have lead to reduced levels of vitamin K in this patient. Furthermore, to state that the patient developed GI bleeding secondary to vitamin K deficiency is speculative. The use of this drug combination for the prevention of malaria is important for those residing in these endemic areas and for those intending to travel to these areas.

    Conflict of Interest:

    Nil

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  7. Spleen and gone? An interesting case of fever in a young man

    The spleen can become infected as a result of septicemia, especially in immunodeficient patients. On some occasions, it can also get infected in immunologically competent patients. The spleen is known to undergo infarction in situ and may subsequently become infected. In addition, it could undergo sequestration and get infected under a variety of situations, without producing any significant symptoms and clinical findings. It is therefore not surprising to note that there was no palpable splenic mass before the radiological investigations revealed an abscess in the splenic region. The repeat admission and drainage of the collection of pus occurred because the patient may have been discharged too early and could have been avoided. Most of these patients require treatment with high doses of broad spectrum antibiotics for a sufficient duration. A possibility of accessory spleen also needs to be considered. A primary source of infection needs to be established. The prognosis is good for most immunologically competent patients as long as the usual precautions are taken after splenectomy.

    Conflict of Interest:

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  8. 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

    Conflict of Interest:

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  9. 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.

    Conflict of Interest:

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  10. 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.

    Conflict of Interest:

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