The presented case of bilateral recurrent parotitis is unique and
interesting. I would like to bring to your notice that such presentation
of recurring bilateral parotid infections could be a classic presentation
of rare autosomal recessive genodermatosis known as 'lipoid protenosis'
or hyalinosis cutis et mucosae. It is characterized by wide spread
deposition of homogenous hyaline like material in the skin, submucosal...
The presented case of bilateral recurrent parotitis is unique and
interesting. I would like to bring to your notice that such presentation
of recurring bilateral parotid infections could be a classic presentation
of rare autosomal recessive genodermatosis known as 'lipoid protenosis'
or hyalinosis cutis et mucosae. It is characterized by wide spread
deposition of homogenous hyaline like material in the skin, submucosal
connective tissue, primarily of mouth, pharynx, larynx and often salivary
glands. Clinical manifestations depend on the organs involved and extend
of hyaline accumulations. However, features like hoarseness of
voice,thickening of skin and oral mucosal changes will clinch the
diagnosis.
Although the incidence of amoebiasis intestinal as well as
extraintestinal has gone down substantially even in devloping countries
the complication of intestinal amoebiasis in the form of amoebiac
hepatitis before developing hepatic abscess is quite common. With the most
conservative management with Metranidazol the chances of the patient
developing hepatic abscess are far less unless the patient happens to be
immunocomp...
Although the incidence of amoebiasis intestinal as well as
extraintestinal has gone down substantially even in devloping countries
the complication of intestinal amoebiasis in the form of amoebiac
hepatitis before developing hepatic abscess is quite common. With the most
conservative management with Metranidazol the chances of the patient
developing hepatic abscess are far less unless the patient happens to be
immunocompromised or there is secondary bacterial infection. In this
patient there has been no mention about the immunological status of the
patient although it is mentioned that the patient had lost weight. The
hepatic abscess can ofcourse burst in the neighbouring cavities and organs
if it is not drained early. Most of the patients will respond favourably
to the medical management and drainage whenever required sometimes more
than once.
Hopkins et al have presented and interesting and important case
highlighting the need to look for organic aetiology in new onset
psychosis. Psychiatrists are medically trained doctors and GMC good medical
practice requires them to keep up to date with the latest knowledge and
evidence. Unfortunately very little
attention is being paid in the NHS to this aspect and developing skills like
leadership, management, innovations...
Hopkins et al have presented and interesting and important case
highlighting the need to look for organic aetiology in new onset
psychosis. Psychiatrists are medically trained doctors and GMC good medical
practice requires them to keep up to date with the latest knowledge and
evidence. Unfortunately very little
attention is being paid in the NHS to this aspect and developing skills like
leadership, management, innovations are overemphasised, which undoubtedly
are important skills but should not be at the expense of forgetting or
losing clinical skills. Losing clinical skills renders clinicians less
confident and defensive which increase the rate of referrals to other
specialities for minor problems.
During my on call a 47 year old patient was referred for
mental health act assessment with new onset behavioural change and
psychotic symptoms. The patient was seen by A&E consultant and declared
medically fit. Due to the unusual presentation and some catatonic signs I
insisted on further medical investigations to rule out organic aetiology.
Having read a recent article and being aware of the specific causes for
such presentations like space occupying lesions, haemorrhages and
encephalitis helped me persuade the medical team for further
investigations. The patient was treated for viral encephalitis with
intravenous acyclovir and his psychotic symptoms resolved. This was an
unforgettable lesson and further strengthened my resolve to keep my
clinical skills up to date to provide the best and safe care to my
patients.
I was reading with interest the manuscript of Hidekazu Takeuchi's
[1]. The author believed that dabigatran dissolved the thrombus. As a
consultant hematologist, I have noticed that many people including
patients and practicing physicians believe that anticoagulants dissolve
the clot. In reality, this is not the case. Anticoagulants never dissolve
the thrombus.
I was reading with interest the manuscript of Hidekazu Takeuchi's
[1]. The author believed that dabigatran dissolved the thrombus. As a
consultant hematologist, I have noticed that many people including
patients and practicing physicians believe that anticoagulants dissolve
the clot. In reality, this is not the case. Anticoagulants never dissolve
the thrombus.
The aims of the anticoagulant therapy in the treatment of acute
venous thrombosis are; (a) to stabilize the thrombus, (b) to prevent
thrombus extension thereby preventing pulmonary embolism, (c) to prevent
recurrent thrombosis, and (d) to limit late complications such as post-
thrombotic syndrome [2]. While anticoagulant therapy tries to achieve
those aims, it allows the endogenous fibrinolytic system to dissolve the
thrombus gradullay over time. Depending on the rate of fibrinolysis, some
thrombus may dissolve within a few weeks or a few months. Some are left
with residual chronic thrombus [3-4]. If rapid dissolution of the thrombus
is desired to quickly restore vascular patency and improve hemodynamics,
we use thrombolytics such as tissue plasminogen activator [5].
In this case, I believed that dabigatran did not dissolve the
thrombus. Dabigatran just stabilized the thrombus, prevented thrombus
extension and thereby allowing the patient's endogenous fibrinolytic
system to dissolve the thrombus over time. It is prime time that
practicing physicians should disgard the idea that anticoagulants dissolve
the thrombus and to realize that it is the fibrinolytic system which
dissolves the thrombus eventually.
Thein H Oo, MD
Associate Professor of Medicine/Consultant Hematologist
The University of Texas M.D. Anderson Cancer Center
Houston, Texas
USA
References:
1. Takeuchi H. Floating thrombus in the left upper pulmonary vein
dissolved by dabigatran. BMJ Case Rep 2013. Doi:10.1136/bcr-2013-200836
2. Landaw SA, Bauer KA. Approach to the diagnosis and therapy of
lower extremity deep vein thrombosis. www.uptodate.com, accessed November
1, 2013
3. Leung LLK. Overview of hemostasis. www.uptodate.com, accessed
November 1, 2013
4. Kearon C. Natural history of venous thromboembolism. Circulation
2003;107(23 Suppl 1):122-130
5. Tapson VF. Fibrinolytic (thrombolytic) therapy in acute pulmonary
embolism and lower extremity deep vein thrombosis. www.uptodate.com,
accessed November 1, 2013
This is a very important case report as it feeds into our
understanding of how to interpret test results. If the pre-test
probability is high (eg. features of meningism in acute febrile illness)
then negative results should be treated with an index of suspicion. No
test is perfect, with both pathophysiological (eg. delayed movement of
WBCs from inflamed meninges into CSF), statistical (occasional
representatives from...
This is a very important case report as it feeds into our
understanding of how to interpret test results. If the pre-test
probability is high (eg. features of meningism in acute febrile illness)
then negative results should be treated with an index of suspicion. No
test is perfect, with both pathophysiological (eg. delayed movement of
WBCs from inflamed meninges into CSF), statistical (occasional
representatives from the end of the bell curve) and technical (operator
dependency) limitations. The clinical team did well to exclude all other
possibilities. This case also provides further support for efforts to
expand the panel of CNS virus PCR tests to pick up currently
underrepresented viral pathogens in the CSF.
Propranolol has now become the main stay for treatment of infantile
hemangiomas even in developed countries unless it fails or the drug could
not be used because of complications.This has been a matter of great
relief not only for the parents/patients but the practicing doctors as
well everywhere .
Pancytopenia is a rare expression of Lyme Disease.My worry is that
the patient may have been co-infected with a virus for which, at this
time, there is no form of positive identification. Such a virus could be
related to one of the other viral scourges the vector of which are hard
ticks.
Dear Mr. Latimer
Thanks you for your response to my case report.
Fasciotomy and debridement in the presence of crush syndrome is a
controversial topic. As far as evidence is concerned there are proponents
and opponents of fasciotomy in the presence of rhabdomyolysis. Although
there is a theoretical risk of worsening the renal function and
electrolyte imbalance, leaving the compartment closed in the presence of
clinical...
Dear Mr. Latimer
Thanks you for your response to my case report.
Fasciotomy and debridement in the presence of crush syndrome is a
controversial topic. As far as evidence is concerned there are proponents
and opponents of fasciotomy in the presence of rhabdomyolysis. Although
there is a theoretical risk of worsening the renal function and
electrolyte imbalance, leaving the compartment closed in the presence of
clinical evidence of compartment syndrome is not advisable.
I have reference some recent evidence that suggest that the most
appropriate treatment for crush syndrome is on going resuscitation to
restore renal function and electrolyte balance but if there is an
associated compartment syndrome, the compartments have to be surgically
released.
In our case if the compartment hadn't been released it could have led to
permanent damage to the sciatic nerve. Secondly, leaving dead muscle in a
patient who is already immunocompromised can lead to life threatening
sepsis.
Therefore, the management of crush syndrome with compartment syndrome
should consist of continuous medical management along with surgical
release of compartment, the decision is however clinical and should be
tailored to the individual patient.
References:
1. Shaikh N. Complication of crush injury, but a rare compartment syndrome. J Emerg Trauma Shock 2010 Apr;3(2):177-81.
2. Mrsi V1, Nesek Adam V, Grizelj Stojc E, Rasi Z, Smiljani A, Turci I. Acute rhabdomyolysis: a case report and literature review Acta Med Croatica 2008 Jul;62(3):317-22.
3. Genthon A, Wilcox SR. Crush syndrome: a case report and review of the
literature J Emerg Med 2014 Feb;46(2):313-9.
I wish to commend the efforts of the authors of this interesting
article being the first of its kind in the literature.
I would like them to share with us the duration of therapy in this case
and follow up information.
Thank you.
The occurrence of phaeochromocytoma in pregnancy is extraordinarily
rare, with a frequency of 1 in 54, 000 (0.002%) (1-2). Due to the
potentially devastating consequences to the mother and foetus it is
essential to consider phaeochromocytoma in the differential diagnosis of
uncontrollable hypertension.
In order to do this the appropriate initial biochemical
investigation(s) are vital. Memon et el (3) rightly hi...
The occurrence of phaeochromocytoma in pregnancy is extraordinarily
rare, with a frequency of 1 in 54, 000 (0.002%) (1-2). Due to the
potentially devastating consequences to the mother and foetus it is
essential to consider phaeochromocytoma in the differential diagnosis of
uncontrollable hypertension.
In order to do this the appropriate initial biochemical
investigation(s) are vital. Memon et el (3) rightly highlighted that in
healthy pregnant women, plasma and urinary catecholamine concentrations
are not or only slightly increased. As a consequence it is not recommended
that plasma or urinary catecholamines are measured in the evaluation of a
pregnant patient under investigation for uncontrollable hypertension.
Moreover it is not appropriate to measure urinary vanillylmandelic acid
due to its poor diagnostic sensitivity (4). Recommendations for the
initial evaluation of phaeochromocytoma include measurement of total
fractionated urine metadrenalines and or plasma metadrenalines (5). The
initial test used in the initial evaluation of phaeochromocytoma should
have the strongest power to exclude the tumour as reliably as possible so
that no tumour is missed. Metadrenalines have this power as they have the
highest sensitivity and highest negative predictive value (4). It is
therefore the authors recommendation that metadrenalines are measured in
the initial biochemical evaluation of phaeochromocytoma during pregnancy.
References:
1. Harrington JL, Farley DR, van Heerden JA & Ramin KD. Adrenal
tumours and pregnancy. World Journal of Surgery 1999 23 182-186.
2. Harper MA, Murnaghan GA, Kennedy L, Hadden DR, Atkinson AB.
Phaeochromocytoma in pregnancy. Five cases and a review of the literature.
British Journal of Obstetrics and Gynaecology 1989 96 594-606.
3. Memon MA, Aziz W, Abbas F. Surgical management of pheochromocytoma
in a 13-week pregnant woman. British Medical Journal Case Report 2014.
doi:10.1136/bcr-2013-202838.
4. Lenders JW, Pacak K, Walther MM, Linehan WM, Mannelli M, Friberg P
et al. Biochemical diagnosis of phaeochromocytoma: which test is best?
Journal of American Medical Association 2002;287:1427-1434.
5. Pacak K, Eisenhofer G, Ahlman H, Bornstein SR, Gimenez-Roqueplo
AP, Grossman AB et al. Pheochromocytoma: recommendations for clinical
practice from the First International Symposium, October 2005. Nature
Clinical Practice Endocrinology Metabolism 2007;3:92-102.
The presented case of bilateral recurrent parotitis is unique and interesting. I would like to bring to your notice that such presentation of recurring bilateral parotid infections could be a classic presentation of rare autosomal recessive genodermatosis known as 'lipoid protenosis' or hyalinosis cutis et mucosae. It is characterized by wide spread deposition of homogenous hyaline like material in the skin, submucosal...
Although the incidence of amoebiasis intestinal as well as extraintestinal has gone down substantially even in devloping countries the complication of intestinal amoebiasis in the form of amoebiac hepatitis before developing hepatic abscess is quite common. With the most conservative management with Metranidazol the chances of the patient developing hepatic abscess are far less unless the patient happens to be immunocomp...
Hopkins et al have presented and interesting and important case highlighting the need to look for organic aetiology in new onset psychosis. Psychiatrists are medically trained doctors and GMC good medical practice requires them to keep up to date with the latest knowledge and evidence. Unfortunately very little attention is being paid in the NHS to this aspect and developing skills like leadership, management, innovations...
Dear Editor
I was reading with interest the manuscript of Hidekazu Takeuchi's [1]. The author believed that dabigatran dissolved the thrombus. As a consultant hematologist, I have noticed that many people including patients and practicing physicians believe that anticoagulants dissolve the clot. In reality, this is not the case. Anticoagulants never dissolve the thrombus.
The aims of the anticoagulan...
This is a very important case report as it feeds into our understanding of how to interpret test results. If the pre-test probability is high (eg. features of meningism in acute febrile illness) then negative results should be treated with an index of suspicion. No test is perfect, with both pathophysiological (eg. delayed movement of WBCs from inflamed meninges into CSF), statistical (occasional representatives from...
Propranolol has now become the main stay for treatment of infantile hemangiomas even in developed countries unless it fails or the drug could not be used because of complications.This has been a matter of great relief not only for the parents/patients but the practicing doctors as well everywhere .
Conflict of Interest:
None declared
Pancytopenia is a rare expression of Lyme Disease.My worry is that the patient may have been co-infected with a virus for which, at this time, there is no form of positive identification. Such a virus could be related to one of the other viral scourges the vector of which are hard ticks.
Conflict of Interest:
None declared
Dear Mr. Latimer Thanks you for your response to my case report. Fasciotomy and debridement in the presence of crush syndrome is a controversial topic. As far as evidence is concerned there are proponents and opponents of fasciotomy in the presence of rhabdomyolysis. Although there is a theoretical risk of worsening the renal function and electrolyte imbalance, leaving the compartment closed in the presence of clinical...
I wish to commend the efforts of the authors of this interesting article being the first of its kind in the literature. I would like them to share with us the duration of therapy in this case and follow up information. Thank you.
Conflict of Interest:
None declared
The occurrence of phaeochromocytoma in pregnancy is extraordinarily rare, with a frequency of 1 in 54, 000 (0.002%) (1-2). Due to the potentially devastating consequences to the mother and foetus it is essential to consider phaeochromocytoma in the differential diagnosis of uncontrollable hypertension.
In order to do this the appropriate initial biochemical investigation(s) are vital. Memon et el (3) rightly hi...
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