eLetters

286 e-Letters

  • Thinking outside the box is important, but carries some risk

    We read with interest the article by Bhandare and Ruchi (1). They diagnosed severe organic mercury (Hg) poisoning in a 69 year old man with known hypertension and diabetes who presented with a transient altered mental status. The diagnosis was based on a history of increased fish consumption and a blood Hg level of 35 ng/mL. Methylmercury (MeHg) is the form present in seafood, but there are multiple chemical forms of Hg and each has different health consequences. Everyone who consumes seafood is exposed to MeHg, but it is the dosage that is critical. The US EPA determined the MeHg reference dose (defined as “…a daily oral exposure …that is likely to be without an appreciable risk of deleterious effects during a lifetime”) to be 5.8 ng/mL in blood. That value was based on dividing the lowest observed adverse effect level of 58 ng/mL (a value reported from a large, controversial epidemiological study) by a safety factor of 10. Blood MeHg exposures of 35 ng/mL and higher are common, with no evidence of clinical symptoms. For example, residents of the Seychelles islands consume large amounts of marine fish, have documented blood MeHg exposures at or above 35 ng/mL, and are asymptomatic. A recent Seychelles study of 1,266 mothers reported that they ate fish with meals 8.5 ± 4.5 times per week while pregnant and had a mean blood Hg level of 18.2 ng/mL (2). The maximum blood Hg level in that study was 84.2 ng/mL and no mother reported clinical manifestations. The mean...

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  • Interesting Queries

    Dear Editors

    While I have not doubt there are incidents involving vascular migration of Implanon NXT, the presentation of this case study raises some interesting questions verging to concerns about the details:

    1. As stated by the authors, the device measures 4 cm long and 2 mm diameters. The suggested radioopaque foreign body shown in Figure 1 and 2 appears to be disproportionately long. These images suggest the skeletal frame involving torso of the woman is no wider than 25-30 cm (bone-wise) which meant this is an extra-ordinarily small woman.

    2. CT Chest reported ‘hyperdense image with 40 mm, compatible with Implanon in the anterior basal segment of the lower left lobe in intravascular topography'. Interestingly the authors stated that "Implanon was removed by video assisted thoracoscopic surgery without pulmonary resection. Surgical procedure and postoperative course had no complications. " As reader may be aware, video assisted thoracoscopic surgery (VATS) primarily involved the insertion of thoracoscopes into pleural cavities via small incision on the chest. It would have been helpful to know if the implanon device had been found in the pulmonary vasculature, lung tissue or actually in the pleural space itself. As reflected in the article's own reference (1) on an example of VATS retrieval, it is no simple matter.

    The lack of such details in the article raises more questions than answers

    Reference
    1. Th...

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  • Karl Otto Geier, MD, MSc, Acupuncturist.

    Dear authors. The location of the needle was interscapular, but it does not mention the exact site since the interscapular would be the spine. Anyway, I think pneumothorax must have been arrived from puncturing a pleural bubble. More, was "bounce" maneuver stimulation performed with the needle? This maneuver entails numerous punctures of the bubble, facilitating the pneumothorax.

  • Replay to “Prescribing lessons from an ocular chemical injury: Vitaros inadvertently dispensed instead of VitA-POS”

    Dear Editor,
    We read with interest the report in the present Journal of Edington M. et al [1] titled “Prescribing lessons from an ocular chemical injury: Vitaros inadvertently dispensed instead of VitA-POS”.
    Erectile disfunction drugs play a role increasing levels of cyclic guanosine monophosphate (cGMP) with subsequent effects on nitric-oxide release. This condition can lead to acute angle-closure glaucoma (AACG) in case of anatomical predisposition. AACG is an ophthalmic emergency, it can lead to irreversible blindness if not identified and treated immediately and precipitating factors include certain drugs as nitrates, bronchodilators, cough mixtures, cold and flu medication, antidepressants, antihistamines and anticonvulsants [2]. Furthermore, a precedent case of AACG following sildenafil citrated therapy is also described [3].
    We would like underline that this situation could lead to more serious effects, that only the mild chemical ocular injury, in presence of ophthalmic structural diseases.

    References:
    1. Edington M, Connolly J, Lockington D. Prescribing lessons from an ocular chemical injury: Vitaros inadvertently dispensed instead of VitA-POS. BMJ Case Rep. 2018 Dec 3;11(1). doi: 10.1136/bcr-2018-227468.
    2. Murray D. Emergency management: angle-closure glaucoma. Community Eye Health. 2018;31(103):64.
    3. Ramasamy B, Rowe F, Nayak H, Peckar C, Noonan C. Acute angle-closure glaucoma following sildenafil citrate-aided sexua...

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  • Influenza-induced rhabdomyolysis

    Influenza-induced rhabdomyolysis by Martin Brunnstrom et al 1 has called my attention because they refer to the patient's story "A man aged 29 years with a past medical history of cerebral palsy, seizures and chronic constipation".
    The authors refer to "Other causes for rhabdomyolysis were investigated and excluded" and "A muscle biopsy ruling out an underlying metabolic myopathy or polymyositis to identify a risk factor for rhabdomyolysis was not obtained."
    My comments are related to cerebral palsy and seizures.
    Can these manifestations be warning signs of an underlying metabolic or mitochondrial disease?
    Then the rhabdomyolysis could be a manifestation, for example of a mitochondrial disease exacerbated by an infection.
    Cerebral palsy (CP) is defined by its nonprogressive features. Characterization of CP is traditionally based on the predominant quality of motor impairment (spastic, dyskinetic, ataxic-hypotonic or mixed, assessed on standard neurologic examination 2
    A number of neurodegenerative, including metabolic and genetic disorders may present with similar symptoms and signs. 3
    The presence of dyskinesia or spastic quadriplegic in clinical examination, in addition to abnormal findings in neuroimaging such as syrinx malformation, cerebellar hypoplasia, white matter paucity, and abnormal signal in basal ganglia may warrant further investigation for a disorder other than CP. As inborn errors...

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  • Importance of long term thyroid function monitoring in central congenital hypothyroidism secondary to maternal thyrotoxicosis

    We wish to share our clinical experience and support the importance of long term monitoring of thyroid function in patients with central congenital hypothyroidism caused by maternal thyrotoxicosis. This is a case series of three infants with prolonged hypothyroxinaemia unrelated to the initial management of neonatal Graves’ disease (NGD). In contrast to the minimal antenatal care reported in the case report. mothers of all infants in our case series had antenatal diagnosis of Graves’ disease with appropriate management and close follow up for signs of fetal hyperthyroidism. All infants were diagnosed with NGD within two weeks of birth with two infants being commenced on antithyroid medication for 2-4 weeks as they were symptomatic with NGD.

    With resolution of NGD, thyroid function tests were monitored with subsequent hypothyroxinaemia noted between 4-8 weeks of age. Having confirmed persistent hypothyroxinaemia, all infants were commenced on thyroxine (4-10mcg/kg/day) with regular follow up of their thyroid function tests.

    The development of hypothyroxinaemia after initial treatment of NGD is uncommon however has been described previously (1). In most cases, NGD remits by 3-12 weeks once maternal antibodies are cleared (2, 3). Early transient hypothyroxinaemia in infants of poorly controlled maternal Graves’ is well reported due to high circulating antibodies particularly in the third trimester (1, 4). Postulated mechanisms include suppression of the pituita...

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  • IHC with CD99 over expression and cytogenetic analysis like translocations involving the EWS locus EWSR1 gene rearrangement are required for definitive diagnosis of Primary Ewing sarcoma of Kidney which is very rare entity

    Ewing sarcoma and primitive peripheral neuroectodermal tumor (PNET) are high-grade malignant tumours typically found in children and adolescents. These tumours belong to the family of small round cell tumours and are of neuro ectodermal origin Primary Ewing sarcoma (EWS) of the kidney is a rare tumor in adults. It was first described in 1975 by Seemayer and colleagues, and has since been sporadically documented in the literature Ewing sarcoma and primitive peripheral neuroectodermal tumor (PNET) were originally described as two distinct pathologic entities, although both share common stem-cell precursor and unique chromosomal abnormality. Because of their similar histologic and cytogenetic characteristics, these tumors are now considered part of a spectrum of neoplastic diseases now known as Ewing’s sarcoma family tumors (ESFT), which also includes other malignancies The ESFT are most common in bone. Extraskeletal ESFT are less common and can affect the skin, soft tissue, or viscera So Renal primary sarcomas are a rare group of renal tumours. Ewing sarcoma/PNET of the kidney is distinctly rare, with more than 100 cases reported globally. Among these, leiomyo sarcoma is the most common (40–60%) followed by lipo sarcoma (10–15%) Sources of renal EWS include neural cells that invaginate into the kidney during its development some authors theorize that embryonic neural crest cells migrate into the kidney and undergo tumorigenesis It is primarily a genetic disease with case...

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  • Pancost Tumor Epidemiology and Histology

    The terms Pancoast tumors, superior sulcus tumors, and superior pulmonary sulcus tumors are applied to neoplasms located at the apical pleuro pulmonary groove. In 1924, Henry K. Pancoast, described a patient afflicted with a lung carcinoma occupying the apical thoracic cavity that was associated with a constellation of symptoms that included shoulder pain radiating down the arm, atrophy of the hand muscles, and Horner’s syndrome.[ 1] Since then, it has become widely accepted that the term Pancoast syndrome can be applied to any clinical condition in which a neoplasm in the apex of a lung is accompanied by shoulder or arm pain. Anatomically, the definition includes any tumor invading through the parietal pleura at the level of the first rib and above. The pulmonary sulcus refers to the costo vertebral gutter extending from the first rib to the diaphragm. The superior pulmonary sulcus is therefore analogous to the superior most portion of this recess. The first rib is at the base of the thoracic inlet. The thoracic inlet contains the subclavian vein anteriorly, the subclavian artery, phrenic nerve and trunks of the brachial plexus medially, and the nerve roots of the brachial plexus and the stellate ganglion posteriorly. The bony thorax in the superior sulcus includes the upper ribs and the associated vertebral bodies. It is invasion of this complex anatomical area that accounts for the classic symptoms of the Pancoast tumor. Superior sulcus carcinomas have the same biologic...

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  • Pancoast Tumor

    The terms Pancoast tumors, superior sulcus tumors, and superior pulmonary sulcus tumors are applied to neoplasms located at the apical pleuro pulmonary groove. In 1924, Henry K. Pancoast, described a patient afflicted with a lung carcinoma occupying the apical thoracic cavity that was associated with a constellation of symptoms that included shoulder pain radiating down the arm, atrophy of the hand muscles, and Horner’s syndrome.[ 1] Since then, it has become widely accepted that the term Pancoast syndrome can be applied to any clinical condition in which a neoplasm in the apex of a lung is accompanied by shoulder or arm pain. Anatomically, the definition includes any tumor invading through the parietal pleura at the level of the first rib and above. The pulmonary sulcus refers to the costo vertebral gutter extending from the first rib to the diaphragm. The superior pulmonary sulcus is therefore analogous to the superior most portion of this recess. The first rib is at the base of the thoracic inlet. The thoracic inlet contains the subclavian vein anteriorly, the subclavian artery, phrenic nerve and trunks of the brachial plexus medially, and the nerve roots of the brachial plexus and the stellate ganglion posteriorly. The bony thorax in the superior sulcus includes the upper ribs and the associated vertebral bodies. It is invasion of this complex anatomical area that accounts for the classic symptoms of the Pancoast tumor. Superior sulcus carcinomas have the same biologic...

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  • Replay to “Prescribing lessons from an ocular chemical injury: Vitaros inadvertently dispensed instead of VitA-POS”

    Dear Editor,
    We read with interest the report in the present Journal of Edington M. et al [1] titled “Prescribing lessons from an ocular chemical injury: Vitaros inadvertently dispensed instead of VitA-POS”.
    Erectile disfunction drugs play a role increasing levels of cyclic guanosine monophosphate (cGMP) with subsequent effects on nitric-oxide release. This condition can lead to acute angle-closure glaucoma (AACG) in case of anatomical predisposition. AACG is an ophthalmic emergency, it can lead to irreversible blindness if not identified and treated immediately and precipitating factors include certain drugs as nitrates, bronchodilators, cough mixtures, cold and flu medication, antidepressants, antihistamines and anticonvulsants [2]. Furthermore, a precedent case of AACG following sildenafil citrated therapy is also described [3].
    We would like underline that this situation could lead to more serious effects, that only the mild chemical ocular injury, in presence of ophthalmic structural diseases.

    References:
    1. Edington M, Connolly J, Lockington D. Prescribing lessons from an ocular chemical injury: Vitaros inadvertently dispensed instead of VitA-POS. BMJ Case Rep. 2018 Dec 3;11(1). doi: 10.1136/bcr-2018-227468.
    2. Murray D. Emergency management: angle-closure glaucoma. Community Eye Health. 2018;31(103):64.
    3. Ramasamy B, Rowe F, Nayak H, Peckar C, Noonan C. Acute angle-closure glaucoma following sildenafil citrate-aided sexua...

    Show More

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