The diagnostic excellence of infective endocarditis (IE) requires careful physical examination. In the current case reported by Ittyachen et al, a diagnosis of IE was made on Day 6 of hospitalization. However, no visualization of vegetation by transthoracic echocardiography, especially on Day 1, is common because of its low sensitivity (1). Patients with acute heart failure along with mitral regurgitation need rapid diagnostic evaluation for possibility of IE.

There were no documentation for physical findings as important signs of IE except cardiac murmur and oral hygiene. The accurate diagnosis based on physical diagnosis might have been achieved earlier if a high index of suspicion for IE with careful examination had been considered. I always recommend checking nails, fingers, palms, planters, conjunctivae, oral mucosa, and optic fundi in suspected cases of IE. The list to search should include splinter hemorrhage, Osler node, Janeway purpura, mucosal petechiae, and Roth spot (2).

Yasuharu Tokuda, MD MPH
Consultant Physician and Director
Muribushi Okinawa Center for Teaching Hospitals, Urasoe City, Okinawa, Japan.

References

(1) Baddour LM, et al; American Heart Association Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease of the Council on Cardiovascular Disease in the Young, Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and Stroke Council. Infective Endocarditis in Adults: Diagnosis, Antimicrobial Therapy, and Management of Complications: A Scientific Statement for Healthcare Professionals From the American Heart Association. Circulation. 2015 Oct 13;132(15):1435-86.
(2) Joseph D. Sapira. The Art and Science of Bedside Diagnosis. First Edition. Williams & Wilkins. 1990.

Respected Editor and Dr. Pulst,

Thank you for your interest in our case. We agree with your comment that Friedreich ataxia (FRDA) is an autosomal recessive neurodegenerative disease caused by bi-allelic expansion of an intronic GAA repeat in the frataxin (FXN) gene, but our patient had eight GAA repeats on allele-1 and 37 repeats (pre-mutated allele) on allele-2. The pre-mutated allele can be responsible for the disease, in
rare cases, by causing somatic expansion or pre-mutation in cell populations. But this occurs only when in the setting of the second allele in the clear pathogenic range of expansion. This intronic GAA expansion further silences the FXN gene, resulting in pathologically suppressed levels of the frataxin protein. As per the respected reader, even though the patient had the probability of compound
heterozygous mutation with a pathogenic point mutation in one allele, the second allele would not be pathogenic at 37 GAA repeats.

Usually, individuals with ataxia who are heterozygous for an expanded GAA repeat (> 66) may contain a separate loss-of-function mutation in the FXN gene copy over the allele with normal GAA repeat length. In the relevant clinical context, these patients should be considered to have Friedreich ataxia. [1] However, in populations where the prevalence of Friedreich ataxia carriers is high, such an
individual may have a different disorder responsible for ataxia apart from being a carrier for Friedreich ataxia. [1] Nevertheless, investigators should look for an FXN loss-of-function mutation in heterozygosity with the GAA repeat expansion whenever possible, both by sequencing the FXN coding exons and the adjoining intronic sequences and by gene-dosage determination to rule out significant deletions. [1] These types of facilities are only available in the research faculties which are not available in our case, the same has been accepted as a limitation of our case. Sharma P et al. studied the carrier frequency estimation in a sample of 790 healthy study subjects across India. They reported the prevalence of “carrier state” to be 0.63% i.e. 5 in 790. They reported an approximately 19% prevalence of long-normal alleles (>12 alleles) with the longest repeats being 28. [2] The estimated prevalence of FRDA is 1/1,00,000 based on carrier frequency in the Indian population. [2]

We believe that due to the low prevalence of Friedreich ataxia carriers in India, we should investigate for mutations on other alleles even in heterozygous pre-mutated states, where FRDA has a high clinical likelihood. Even so, Sharma P et al. and the paper by Mukerji M et al. lack the data on the frequency of permutated alleles in the Indian population. [2,3] This underlines the lack of data on pre-mutated alleles in India. A study by Sharma R et al. shows that somatic instability of borderline alleles, which are not generally thought to cause disease, imparts a risk for clinical disease development. [4] Individual somatic cells in different organs may have dramatically varying allele sizes, implying that traditional DNA testing may be insufficient for phenotypic prediction in persons with borderline alleles. [4] In FRDA, the allele size at the lower end of the pathogenic allele range is not clearly entrenched. Although the actual frequency of borderline alleles has not been determined, they account for less than 1% of FXN alleles. As per Cook A et al. “In terms of genetics of FRDA, till date important clarifications still need to be made, particularly with regards to the specific chromatin modifiers responsible for silencing the FXN gene and the extent of this heterochromatization, and the epigenetic basis of FRDA”. [5] As more and more literature is published, FRDA is being studied and reported as an gene silencing disorder with epigenetic basis. [5]

In our case, clinical presentation along with radiological investigations pointed us towards the possibility of the FRDA despite the borderline pre-mutated heterozygous state. We already accepted the limitation in our case was the inability to perform the full genome sequencing or exome sequencing which could have predicted the point mutation or deletion.

In our case, we barely aggravated any of our findings (radiological and clinical), and a most likely diagnosis of FRDA was considered. Nowhere, we tried to manipulate or exaggerate our findings. During the care of this patient, we took opinions from our neurology department, but we did not mention them in the acknowledgment as they were not involved in the writing of the case report. Furthermore, a patient hospitalized in an internal medicine department is routinely checked and advised by the neurology department at our tertiary care hospital.

As per the respected reader, interpretation of genetic tests needs subspecialty expertise provided by medical geneticists, genetic counselors, or neurogeneticists. However, these kinds of facilities are not available at our institute, and the case was managed in resource-limited settings.

According to the esteemed reader, errors of overinterpreting genetic test results and, even more so, erroneous interpretation can be harmful to patients and their relatives. In the present clinical setting, we tried to explain the intricacies of genetic tests to the patient and their relatives. We explained the disease's degenerative nature and the clinical likelihood of the FRDA. However, in the absence of a thorough genetic workup, we left this to the patient's next of kin, whether or not to further go for a workup. Clinically his next of kin (his son) was normal. We believe that, from an ethical point of view, as a physician, we managed the patient with the best of our abilities, clinical acumen, and available resources.

In our settings, it is not always possible to contact a neurogeneticist or other such professional due to the relative non - availability of such practitioners or the patient's inability to pay for such services (here in this case the annual income of the patient was below USD 1250 [no insurance]). Though we have a neurology department, it is not possible to do NCS testing (most of the time machines are in a non-working state), or many facilities are yet unavailable. With great efforts, we were able to convince the relatives for the costly triplet primed PCR assay. For even making an MRI or any radiological scan, the patient’s affordability is an issue that we felt at every stage of treatment. In India (or any other Low-middle income country), such types of cases are handled by Internal medicine physicians (internists) primarily with neurological opinions from neurology consultants, which has happened in our case. These other factors must also be considered in the context of this case report.

We don't want to rule out completely the possibility that this might be a pre-mutated carrier state of FRDA; neither we want to mislead the scientific community. Irrespective of the genetics and diagnosis, the diagnostic dilemma we faced, and the clinical course of the patient are indeed was interesting and worth reporting. We already have accepted our limitations in the published version that we did not have access to advanced investigations required to certainly diagnose these kinds of borderline cases.

The reader is a renowned neurogeneticist and neurologist, as well as considering his vast experience in the said field, we will be more than happy to connect, discuss and collaborate with the esteemed professor on this topic.

REFERENCES:
1 Schulz JB, Boesch S, Bürk K, et al. Diagnosis and treatment of Friedreich ataxia: a European perspective. Nat Rev Neurol 2009;5:222–34. doi:10.1038/nrneurol.2009.26
2 Sharma P, Sonakar AK, Tyagi N, et al. Genetics of Ataxias in Indian Population: A Collative Insight from a Common Genetic Screening Tool. Genet Genomics Next 2022;3:n/a. doi:10.1002/ggn2.202100078
3 Mukerji M, Choudhry S, Saleem Q, et al. Molecular analysis of Friedreich’s ataxia locus in the Indian population: Friedreich’s ataxia in India. Acta Neurol Scand 2000;102:227–9. doi:10.1034/j.1600-0404.2000.102004227.x
4 Sharma R, De Biase I, Gómez M, et al. Friedreich ataxia in carriers of unstable borderline GAA triplet-repeat alleles. Ann Neurol 2004;56:898–901. doi:10.1002/ana.20333
5 Cook A, Giunti P. Friedreich’s ataxia: clinical features, pathogenesis and management. Br Med Bull 2017;124:19–30. doi:10.1093/bmb/ldx034

Maes et al suggest that the burden of organdonation related issues in organdonation after euthanasia (ODE) patients is well tolerable or may even be neglegible. They present two cases with untreatable psychiatric disorders who requested for euthanasia and expressed their deathwish to combine with postmortal organdonation. The burden relates to the patient, his family and the professionals involved in euthanasia. They propose that all psychiatric patients whom euthanasia is granted should be informed about the possibility of postmortal organ donation(1).
First, we state that the burden can even be minimized further: it is not necessary for the patient to have his euthanasia performed in the hospital. These patients can be given the sense of dying at home and transported thereafter using an anesthesia bridge to the hospital, as we have shown to be feasible(2).
Second, it is not fair to use the experience of these two evident highly for ODE motivated psychiatric patients and their families as a reference for comparable euthanasia patients who are unaware of the option of post mortal organdonation.
But third, of perimount importance, we criticize the opinion that the amount of burden for ODE patients may reach a point to be neglegible. In our opinion this burden should not be minimized, but excluded. The suggestions of Maes et al are motivated by utilistic ethical considerations and the existence of waitinglists for transplantation. The act of organdonation however is a pure altruistic one, and in the face of the ultimate choice to end one’s life incompatible with any utilistic view.
Any suggestion of organdonation to an euthanasia patient, irrespective of the underlying disorder making him to choose his own death, compromises his freedom of an eventually irrevocable and irreversible choice to end his life.
Also the treating physician should be free of any coercion during the whole project of ODE and moral pressure beyond the relationship with the (euthanasia) patient; this excludes even the suggestion for a potential organdonation.
From the first international round table conference on ODE, we became aware of the moral conflicts of healthcare providers experienced in Canada in their practice to ask euthanasia patients to consider organdonation who were not aware of this possibility, which appeared far from a neglegible burden(3). We also know from the practice in the Netherlands that healthcare professionals at the ICU experience an increasing personal burden after multiple ODEs, especially in cases of psychiatric patients.
Using the donor registry as an opportunity to bring up the issue of organ donation in case of euthanasia does not resolve the intertwinement. It is of note that the donor registry has never been designed to be used in the context of ODE. ‘Shared decision making’ also does not mean that interests of transplant recipients need to be considered by euthanasia patients.
We conclude that the altruistic deed of an ODE patient should be safeguarded against any external driven interests and coercion, while at the same time healthcare providers shape the conditions that the wish to donate will be fulfilled.
The awareness of ODE will gradually grow via social media, internet and patient platforms. There is no alternative. Most important is the separation of interests to be hold. In the extremely vulnerability of ODE, society should have no doubts that healthcare professionals, as founded in constitutional legislation, first of all seek anyone’s integrity of life, mind and person. This priority should never be compromised by any interests of others. Intertwinement of these interests may eventually further harm the challenges in ODE and post mortal organdonation in general, than it may help to reduce waitinglists for transplantation.

1. Maes G, Oude Voshaar R, Bollen J, Marijnissen R. Burden of organ donation after euthanasia in patients with psychiatric disorder. BMJ Case Rep. 2022 Jul 4;15(7):e246754. doi: 10.1136/bcr-2021-246754. PMID: 35787499.
2. Mulder J, Sonneveld JPC. Organ donation after medical assistance in dying at home. CMAJ. 2018 Nov 5;190(44):E1305-E1306. doi: 10.1503/cmaj.170517. PMID: 30397157; PMCID: PMC6217602.
3. Mulder J, Sonneveld H, Healey A, Van Raemdonck D. The first international roundtable on "organ donation after circulatory death by medical assistance in dying" demonstrates increasing incidence of successful patient-driven procedure. Am J Transplant. 2022 Mar;22(3):999-1000. doi: 10.1111/ajt.16879. Epub 2021 Nov 6. PMID: 34706144.

Answer by Marijnissen et al,

We thank Sonneveld and Mulder for their thoughtful comments and an opportunity to provide additional explanation to our paper 1. Sonneveld and Mulder argue that the burden of ODE should be fully excluded instead of being reduced as much as possible. In our opinion, however, excluding the patient burden completely in these delicate situations is impossible.
Nevertheless, somewhat paradoxically, the authors suggest that the burden of ODE can be reduced based on the possibility of letting people say goodbye to loved ones at home, after which they are transported to the hospital under anaesthesia. This assumption that saying goodbye at home will reduce burden however does not apply automatically for all patients and their loved ones. For example, the described opportunity has been openly discussed with the first patient some weeks prior to the ODE was performed and afterwards with the family of the second patient. However, they considered the burden of performing this procedure at home higher than saying goodbye in the hospital, as they preferred to accompany their loved ones to the ODE procedure in the hospital as well as when they actually die. This reflects, however, very personal views, which should always be considered and why in our opinion shared decision making is so important.
Sonneveld and Mulder also nuance our conclusion ‘that the burden can be minimal after ODE’ is based on two patients highly motivated for ODE’. Case-reports present by definition highly selective cases, but are important for the discovery of new ideas, for education in rare diagnoses or exceptional situations, and, as in our case, to challenge widespread believes.3 We wanted to inform other health care professionals about the possibility of organ donation after euthanasia in these patients, and its positive consequences – arguing that ODE is not necessarily or merely a burden to every patient.
We are a bit surprised that these authors feel it is better that patients are informed about ODE through social media than by their physician, who knows them best and who can provide correct and nuanced information. The report of the limited round table conference only advertises ODE with anesthesia initiated at home (ODEH) and talks about a ‘patient ‐driven process’, but how can this be patient-driven if the patient is not aware of the possibility of this procedure? Furthermore, by only focusing on avoiding an act in the interest of the transplant waiting list (which is not the way we see ODE), the authors forget to act in the interest of the dying patient by ignoring potential altruistic motives. Physicians are responsible to provide information about all possibilities a patient has, making shared decision possible – only then we can speak of an “irrevocable and irreversible choice to end his life” and “integrity of life, mind and person”. We however do not challenge that informing a patient about ODE is a very sensitive matter, because of which the registration as an organ donor might be a good starting point for this patient-physician discussion. Recently, a Dutch medical disciplinary committee judged that informed consent is also necessary when physicians decide not to perform a surgery, which demonstrates that withholding a medical act causes a burden for both patients and relatives. In other words, irrespective of whether patients chose for ODE or not, the burden of ODE can never be fully excluded. Nonetheless, more research is needed on the best way to introduce and implement ODE, probably especially in a patient with a psychiatric disorder, to minimize the burden.
Our case report on the burden of organ donation after euthanasia in patients with a psychiatric disorder was not aimed to state that the burden of ODE is low in general. Instead, it was meant to give the perspective that a doctor may do the patients short when he or she avoids discussing ODE based on the assumption that it may be too burdensome for them. Nonetheless, we fully agree that the burden for professionals working at the ICU can be substantial and this burden also involves professionals informing patients about the possibility of organ donation during a trajectory for euthanasia 4. We fully agree with the authors that patients should always be prevented from feeling pressure to donate their organs. To this end, our protocols (and laws) state that both procedures should independently be performed by different teams. The best way and timing of discussing all possibilities with patients is probably highly personal and require further study how to optimize the procedures of ODE from both a patient and doctors’ perspective beyond expert opinion.

References
1. Maes G, Oude Voshaar R, Bollen J, Marijnissen R. Burden of organ donation after euthanasia in patients with psychiatric disorder. BMJ Case Rep. 2022 Jul 4;15(7):e246754. doi: 10.1136/bcr-2021-246754. PMID: 35787499; PMCID: PMC9255367.
2. https://www.ama-assn.org/delivering-care/ethics/withholding-information-...
3. Vandenbroucke JP. Observational research, randomised trials, and two views of medical science. PLoS Med. 2008 Mar 11;5(3):e67. doi: 10.1371/journal.pmed.0050067.
4. Mulder J, Sonneveld H, Healey A, Van Raemdonck D. The first international roundtable on "organ donation after circulatory death by medical assistance in dying" demonstrates increasing incidence of successful patient-driven procedure. Am J Transplant. 2022 Mar;22(3):999-1000. doi: 10.1111/ajt.16879. Epub 2021 Nov 6. PMID: 34706144.