To the Editor: I read with interest the article by Liu A et al (1). The authors have described the management of asymptomatic patient with electrocardiographic (ECG) evidence of pre-excitation. Certain aspects of this report needs to be highlighted.
Asymptomatic patients with ECG evidence of pre-excitation of the ventricles are labelled as Wolf-Parkinson-White (WPW) pattern. On the contrary patients with documented tachyarrhythmia...
To the Editor: I read with interest the article by Liu A et al (1). The authors have described the management of asymptomatic patient with electrocardiographic (ECG) evidence of pre-excitation. Certain aspects of this report needs to be highlighted.
Asymptomatic patients with ECG evidence of pre-excitation of the ventricles are labelled as Wolf-Parkinson-White (WPW) pattern. On the contrary patients with documented tachyarrhythmias with pre-excited ECG are diagnosed as WPW syndrome (2). It is preferable to use these terminologies which are recommended by European society of cardiology.
The crucial factor which determines the risk of developing tachyarrhythmias in patients with WPW pattern is the refractory period of the accessory pathway. If the refractory period of the accessory pathway exceeds 250 ms, the risk of tachyarrhythmias is extremely low (2). Pointers to significantly prolonged refractory period of accessory pathway are abrupt disappearance of delta wave on the surface ECG at rest or during exercise stress test (3). Though the guidelines do not recommend non-invasive risk stratification, exercise testing is a simple, non-invasive tool to identify low risk individuals. In patients with WPW ECG pattern who are not ready to undergo EPS, exercise test may identify individuals at low risk of precipitating ventricular fibrillation. This can be reassuring to both the asymptomatic patient and treating physician.
References:
1. Liu A, Pusalkar P. Asymptomatic Wolff-Parkinson-White syndrome: incidental ECG diagnosis and a review of literature regarding current treatment. BMJ Case Reports 2011;10.1136
2. Blomstrom-Lundqvist C, Scheinman MM, Aliot E, e t al. Supraventricular Arrhythmias (ACC/AHA/ESC Guidelines for the Management of Patients with) ESC Clinical Practice Guidelines EHJ 2003;24:1857 - 97
3. Jezior MR, Kent SM, Atwood JE Exercise testing in Wolff-Parkinson-White syndrome: case report with ECG and literature review Chest 2005;127:1454-7
A very interesting case report but a common omission seen again
in this report as is seen in real life in the wards . Any x -ray for an
acute abdomen should always include both the domes of diaphragm which I
cannot see in the AP view in figure A (only left dome visible) as
compared to B where both domes are clearly visible ( unless it was done
originally but cut off in the view shown here in this report) whic...
A very interesting case report but a common omission seen again
in this report as is seen in real life in the wards . Any x -ray for an
acute abdomen should always include both the domes of diaphragm which I
cannot see in the AP view in figure A (only left dome visible) as
compared to B where both domes are clearly visible ( unless it was done
originally but cut off in the view shown here in this report) which may
lead to loss of very valuable sign of gas under the diaphragm . A
decubitus film is a valuable view but if both domes of diaphragm
specially the right are visible in an AP view , it could avoid a
decubitus view specially in a very sick patient ( as in ventilated sick
newborn babies ) where it may not be possible. A lateral 'shoot
through' is done to diagnose perforation in such cases if needed,
specially if the air leak is not a lot which can even easily disappear
in a repeat x ray after few hours or at laparotomy.
So the take home message is to always insist on complete view of both
domes of diaphragm in an abdominal x ray for acute abdomen by clearly
mentioning on the request form otherwise it does not happen ( as in
this case reported ), resulting in repeat x rays or additional views on
some occasions.
This case report about aortic dissection is a good reminder to always
consider this condition in acute chest pain particularly in patients with
hypertension or a connective tissue disorder such as Marfans,
SInce using this blood test as a rule out investigation in recent years we
have made the diagnosis increasingly early in our institution.. A Google
search revealed 5040 hits. Doctors have been missing this diagnodis for...
This case report about aortic dissection is a good reminder to always
consider this condition in acute chest pain particularly in patients with
hypertension or a connective tissue disorder such as Marfans,
SInce using this blood test as a rule out investigation in recent years we
have made the diagnosis increasingly early in our institution.. A Google
search revealed 5040 hits. Doctors have been missing this diagnodis for
decades.
I suspect you will receive further correspondence regarding this.
We should comment on the case report by Liu et al. highlighting the
difficulties in treating patients with Eisenmenger syndrome(1). The
haematological complications of cyanotic congenital heart disease are well
described in literature, since the systematic description of the condition
by Paul Wood in 1958(2). This paradoxical state of affair between bleeding
and thrombotic diathesis continues to puzzle us. Bleeding, typical...
We should comment on the case report by Liu et al. highlighting the
difficulties in treating patients with Eisenmenger syndrome(1). The
haematological complications of cyanotic congenital heart disease are well
described in literature, since the systematic description of the condition
by Paul Wood in 1958(2). This paradoxical state of affair between bleeding
and thrombotic diathesis continues to puzzle us. Bleeding, typically
haemoptysis, is not uncommon and is one of the recognized causes of death
in this population, as it was for the original case described by Viktor
Eisenmenger(2). There are numerous points that should be made with regards
to the description of this case as well as its discussion, which have
important clinical implications.
In recent years, it has been suggested that the term "polycythaemia"
should be avoided when describing secondary erythrocytosis in cyanotic
heart disease(3). The isolated rise in haemoglobin and haematocrit is a
physiological adaptation to chronic hypoxia, i.e. an attempt to enhance
oxygen tissue delivery(3). In fact, in this condition, white cell count is
normal and platelet count is often low, as in this case(3). The
distinction between erythrocytosis and polycythaemia is not academic.
Erythrocytosis secondary to chronic hypoxia differs significantly from
polycythaemia vera in its thrombotic tendency. In the latter, routine
venesections are the mainstay of therapy, with a target to reduce
haematocrit and improve symptoms(3). In contrast, routine phlebotomies do
not have a role in patients with Eisenmenger syndrome, as they compromise
oxygen tissue delivery, increase the risk of stroke, reduce exercise
capacity and induce or augment iron deficiency(2-4). Instead, screening
for iron deficiency and iron supplementation is recommended(3).
It has been suggested that venesections (small volumes) should be
considered for patients with Eisenmenger syndrome with a haematocrit
>65% who present with severe hyperviscosity symptoms in the absence of
iron deficiency and dehydration, or for boosting platelet count before
elective surgery(3). Venesection should always be accompanied by volume
replacement and iron supplementation, if necessary(3). Unfortunately,
routine venesections are still inappropriately practiced in patients with
Eisenmenger syndrome, despite the evidence for the contrary(3). Avoiding
the term polycythaemia in this condition is thus essential for avoiding
inappropriate intervention.
Use of antiplatelet medication and anticoagulants remains controversial in
Eisenmenger syndrome(5). There is currently little evidence for or against
it; most would agree that anticoagulation should be considered in patients
who develop congestive heart failure, sustained arrhythmia, in situ
pulmonary artery thrombosis or other thromboembolic complications(2).
There is little evidence to support dual anti-platelet treatment(5), and
certainly cessation of such therapy in a patient with severe
thombocytopenia, especially after significant bleeding, would be
advisable.
Thrombocytopenia is common in cyanotic patients with congenital heart
disease and is one of many mechanisms by which bleeding can occur(6).
Clotting abnormalities, disseminated intravascular coagulation and
neovascularisation induced by chronic hypoxia, can all contribute to the
bleeding diathesis of these patients(2). Given this background, bone
marrow aspiration is usually not required in these patients. Citrate-
adjusted tubes should be used when performing coagulation studies,
adjusted to haematocrit levels(6).
This patient is likely to have differential cyanosis, i.e. low oxygen
saturation in her toes but not her fingers, as right-to-left shunting
occurs through the patent duct. The shunt is typically (not occasionally)
bidirectional in Eisenmenger syndrome(5). In the presence of low oxygen
saturations, a haemoglobin concentration of 18.7g/dl is very likely to
suggest iron deficiency, especially after significant bleeding. Moreover,
no comment is made on targeted pulmonary hypertension therapies(7).
Finally, we find it surprising that the chest x-ray in this 35-year-old
patient was "normal". Typically, significant dilatation of the pulmonary
arteries, peripheral "pruning" of pulmonary vessels and cardiomegaly are
present(5). Moreover, calcification of the patent duct is commonly
identified on plain radiography(6). We would advise computed tomography
(CT) scanning in all patients with Eisenmenger syndrome presenting with
suspected haemoptysis, as chest x-ray alone may not be sufficient to
delineate areas of pulmonary haemorrhage(5).
Patients with Eisenmenger syndrome should be followed-up in tertiary
centers where such complex issues on secondary erythrocytosis and the
balance between thrombosis and bleeding diathesis can be addressed and
advanced therapy for pulmonary arterial hypertension can be considered(7).
References
1. Liu A, Saman H, Pusalkar P. Massive epistaxis in a patient with
Eisenmenger syndrome: illustrating the clot-versus-bleed conundrum. BMJ
Case Reports 2011; doi:10.1136/bcr.02.2011.3812
2. Diller GP, Dimopoulos K, Broberg CS, et al. Presentation, survival
prospects, and predictors of death in Eisenmenger syndrome: a combined
retrospective and case-control study. Eur Heart J. 2006;27:1737-42.
4. Ammash N, Warnes CA. Cerebrovascular events in adult patients with
cyanotic congenital heart disease. J Am Coll Cardiol 1996 ; 28:768-72.
5. Dimopoulos K, Giannakoulas G, Wort SJ, et al. Pulmonary arterial
hypertension in adults with congenital heart disease: distinct differences
from other causes of pulmonary arterial hypertension and management
implications. Curr Opin Cardiol 2008 ; 23: 545-54.
6. Warnes CA, Williams RG, Bashore TM, et al. ACC/AHA 2008 Guidelines
for the Management of Adults with Congenital Heart Disease: Executive
Summary: a report of the American College of Cardiology/American Heart
Association Task Force on Practice Guidelines (writing committee to
develop guidelines for the management of adults with congenital heart
disease). Circulation 2008 ; 118: 2395-2451.
7. Dimopoulos K, Inuzuka R, Goletto S, Giannakoulas et al. Improved
survival among patients with Eisenmenger syndrome receiving advanced
therapy for pulmonary arterial hypertension. Circulation 2010;121:20-5.
I read with interest the recently published case report by Frazer and
coworker.1 History of decompensated alcoholic liver disease with gross
ascites and presence of right sided pleural effusion raise the clinical
suspicion of hepatic hydrothorax. The transudative nature of pleural fluid
confirms this diagnosis. In absence of any cytological analysis of pleural
fluid (total and differential count) it is difficult to understa...
I read with interest the recently published case report by Frazer and
coworker.1 History of decompensated alcoholic liver disease with gross
ascites and presence of right sided pleural effusion raise the clinical
suspicion of hepatic hydrothorax. The transudative nature of pleural fluid
confirms this diagnosis. In absence of any cytological analysis of pleural
fluid (total and differential count) it is difficult to understand why the
authors thought about the alternative differential diagnosis i.e.
parapneumonic effusion.
BTS guideline had recommended to put the chest tube in "safe triangle".2
In the present case, X-ray showed that the chest tube was placed at lower
level and the end of tube can be identified below the dome of diaphragm.
Draining of 7.0 l fluids from pleural cavity and followed by
development of hypotension, raise the suspicion that part of chest
tube was in the abdominal cavity. Re expansion pulmonary edema following
drainage of large effusion is rare but well documented.2 BTS guideline
suggested not to drain more than 1.5 l at one time or 500 ml per hour.
In this present case 2.0 l fluid was drained over initial 2 hours 45
minutes. So this case may be an example of near miss by the physician.
1. Frazer R, Deane C, Sabit R. A simple chest drain gone wrong: a near
miss! BMJ Case Reports 2011; doi:10.1136/bcr.12.2010.3563
2. Laws D et al, on behalf of BTS. BTS guidelines for the insertion of a
chest drain.Thorax 2003;58:ii53-ii59
Thank you to the authors for providing an interesting case study
suggesting an association between Roth spots and pyridoxine dependent
epilepsy. The documented causes of Roth spots include severe anaemia,
leukaemias, dysproteinaemia, HIV retinopathy and endocarditis (Kanski,
2002).
Within the manuscript, infection has been ruled out as the cause of
Roth spots. However, details on tests regarding the other diff...
Thank you to the authors for providing an interesting case study
suggesting an association between Roth spots and pyridoxine dependent
epilepsy. The documented causes of Roth spots include severe anaemia,
leukaemias, dysproteinaemia, HIV retinopathy and endocarditis (Kanski,
2002).
Within the manuscript, infection has been ruled out as the cause of
Roth spots. However, details on tests regarding the other differential
diagnoses for Roth spots are not available. The authors should consider
providing at least a full blood count to rule out gross anaemia and
leukaemias to strengthen their case, and other investigations as
clinically indicated.
Reference:
Kanski, J. Clinical Ophthalmology, a Test yourself Atlas. Butterworth-
Heinemann 2002.
Historically, the use of novel treatments, sometimes still in clinical trials, has led to significant breakthroughs in the management of incurable conditions. Highly active antiretroviral therapy (HAART) for HIV is a success story of modern medicine. But in the not so distant past (1988), HIV patients faced with certain death, campaigned for the fast-tracking of public access for drugs still in clinical trials at an attempt to sa...
Historically, the use of novel treatments, sometimes still in clinical trials, has led to significant breakthroughs in the management of incurable conditions. Highly active antiretroviral therapy (HAART) for HIV is a success story of modern medicine. But in the not so distant past (1988), HIV patients faced with certain death, campaigned for the fast-tracking of public access for drugs still in clinical trials at an attempt to save their lives. This, in turn, helped the development of HAART for HIV.
_(new paragraph)_One can draw a corollary between HIV treatments in 1988 with some targeted therapies at present. Targeted therapies represent a novel form of treatment for many oncological conditions, which are minimally responsive to current standard treatment regimes. One example is V600E metastatic melanoma and BRAF kinase inhibitor. Metastatic melanoma is notoriously resistent to standard chemotherapy, with around 5% response rate with dacarbazine. Compared to dacarbazine, the BRAF kinase inhibitor vemurafenib has a response rate of 48%.1 This gives hope for many patients with incurable metastatic melanoma.
_(new paragraph)_The place for bevacizumab in oncology is the subject of ongoing research. However, the careful observation that oncology patients receiving bevacizumab had improvement in their wet age related macular degeneration (ARMD) has led to a major breakthrough in ophthalmology. Now intravitreal bevacizumab and other anti-VEGF agents are the standard therapy for wet ARMD.
_(new paragraph)_The number of targeted therapies is only going to increase over time. Some will lead to major success, some will find soem specific targets, and some will be failures. Ethically, neither the regulatory bodies nor doctors should deny patients with incurable conditions from novel agents that are potentially life-saving. The challenge for clinicians here is to accept the inherent uncertainties with any novel therapies, and to carefully monitor and look out for the side effects (however rare) and potentially unexpected benefits for these agents.
_(new paragraph)_
1. Chapman PB, Hauschild A, Robert C, et al. Improved Survival with Vemurafenib in Melanoma with BRAF V600E Mutation. N Engl J Med 2011.
I would like to congratulate the authors on the publication of this
case report. Long term treatment of giant cell arteritis (GCA) with
prednisone in elderly patients is problematic with significant side
effects. An effective steroid sparing agent will help clinicians in the
long term management of GCA patients.
Although this case report provides compelling evidence that TCZ is
likely to be beneficial in the tr...
I would like to congratulate the authors on the publication of this
case report. Long term treatment of giant cell arteritis (GCA) with
prednisone in elderly patients is problematic with significant side
effects. An effective steroid sparing agent will help clinicians in the
long term management of GCA patients.
Although this case report provides compelling evidence that TCZ is
likely to be beneficial in the treatment of an acute exacerbation of GCA,
it is not clear from the information provided whether TCZ has a
significant steroid sparing effect in its long term management. The
patient continued to receive oral prednisone at 3.5 mg daily despite five
infusions of TCZ, 9 months after the initial flare up. Also, the dose of
prednisone before the patient's acute excerbation was not available, and
one cannot establish whether the prednisone dose after TCZ is any lower
than her pre exacerbation dose.
This case report shows that TCZ is probably beneficial in the
treatment of steorid refractory GCA. However, further studies should be
performed prior to the use of TCZ in uncomplicated GCA cases.
Editor Madam, it is very interesting case where the Lymphoblasts
appeared to cross over the blood brain barrier to appear in the CSF or a
leak from adjoining bone or capillary contributed it, and more
interestingly blast cells in CSF spared rest of the brain and nerves while
preferentially deposited in retinal layers formed by optic nerve, like of
the previous cases cited in the report. If any other significant reason
ap...
Editor Madam, it is very interesting case where the Lymphoblasts
appeared to cross over the blood brain barrier to appear in the CSF or a
leak from adjoining bone or capillary contributed it, and more
interestingly blast cells in CSF spared rest of the brain and nerves while
preferentially deposited in retinal layers formed by optic nerve, like of
the previous cases cited in the report. If any other significant reason
appeared than per chance juxta papillary deposit of lymphoblasts in
recurred leukaemia, authors may better comment.
A very interesting case report but a common omission seen again in this report as is seen in real life in the wards . Any x -ray for an acute abdomen should always include both the domes of diaphragm which I cannot see in the AP view in figure A (only left dome visible) as compared to B where both domes are clearly visible ( unless it was done originally but cut off in the view shown here in this report) whic...
A quick review of the condition helps keep the condtion in mind and help decision making
Conflict of Interest:
None declared
This case report about aortic dissection is a good reminder to always consider this condition in acute chest pain particularly in patients with hypertension or a connective tissue disorder such as Marfans, SInce using this blood test as a rule out investigation in recent years we have made the diagnosis increasingly early in our institution.. A Google search revealed 5040 hits. Doctors have been missing this diagnodis for...
We should comment on the case report by Liu et al. highlighting the difficulties in treating patients with Eisenmenger syndrome(1). The haematological complications of cyanotic congenital heart disease are well described in literature, since the systematic description of the condition by Paul Wood in 1958(2). This paradoxical state of affair between bleeding and thrombotic diathesis continues to puzzle us. Bleeding, typical...
I read with interest the recently published case report by Frazer and coworker.1 History of decompensated alcoholic liver disease with gross ascites and presence of right sided pleural effusion raise the clinical suspicion of hepatic hydrothorax. The transudative nature of pleural fluid confirms this diagnosis. In absence of any cytological analysis of pleural fluid (total and differential count) it is difficult to understa...
Thank you to the authors for providing an interesting case study suggesting an association between Roth spots and pyridoxine dependent epilepsy. The documented causes of Roth spots include severe anaemia, leukaemias, dysproteinaemia, HIV retinopathy and endocarditis (Kanski, 2002).
Within the manuscript, infection has been ruled out as the cause of Roth spots. However, details on tests regarding the other diff...
I would like to congratulate the authors on the publication of this case report. Long term treatment of giant cell arteritis (GCA) with prednisone in elderly patients is problematic with significant side effects. An effective steroid sparing agent will help clinicians in the long term management of GCA patients.
Although this case report provides compelling evidence that TCZ is likely to be beneficial in the tr...
Editor Madam, it is very interesting case where the Lymphoblasts appeared to cross over the blood brain barrier to appear in the CSF or a leak from adjoining bone or capillary contributed it, and more interestingly blast cells in CSF spared rest of the brain and nerves while preferentially deposited in retinal layers formed by optic nerve, like of the previous cases cited in the report. If any other significant reason ap...
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