Subacute liver failure secondary to black cohosh leading to liver
transplantation:
A challenging interpretation
Rolf Teschke
Department of Internal Medicine II, Division of Gastroenterology and
Hepatology, Klinikum Hanau, Academic Teaching Hospital of the Medical
Faculty of the Goethe University rankfurt/ Main, Germany
Subacute liver failure secondary to black cohosh leading to liver
transplantation:
A challenging interpretation
Rolf Teschke
Department of Internal Medicine II, Division of Gastroenterology and
Hepatology, Klinikum Hanau, Academic Teaching Hospital of the Medical
Faculty of the Goethe University rankfurt/ Main, Germany
Correspondence to:
rolf.teschke@gmx.de
SUMMARY
Causality assessment in cases of suspected herb induced liver injury
requires clear identification of the incriminated herbal product,
otherwise a causal association cannot be established for a particular
herb. In addition, herbs may erroneously be used for treatment of
misinterpreted and unspecific prodromi of acute liver diseases, which
excludes causality attribution for the incriminated herb.
The report of Lim et al.1 provides a challenging interpretation for
two cases of herb induced liver injury (HILI) by black cohosh (BC) and
raises a number of questions related to case presentation, product
identification, and causality assessment. Discussing these issues,
important clinical lessons are to be learnt to reach at a valid diagnosis.
The 60-year old woman (case 1) had a medical history of
hypothyroidism managed by levothyroxine 100 ?g daily and migraine treated
by propranolol 20 mg daily.1 She experienced symptoms considered by her as
menopause-related, uses black cohosh (BC) for two weeks, and required a
liver transplant due to subacute liver failure. However, the past medical
history is otherwise poorly documented but essential for assessing
causality in suspected herb induced liver injury (HILI). In this patient
with 60 years of age, the last menstrual date is clinically important but
this actual question neither was addressed nor answered presently.1
Menopausal symptoms are multifaceted,2 need specifications, and require
clear differentiation from migraine symptoms and other ones related to
diseases of various organs including the liver. Perceived as menopausal
and likely being misinterpreted, the unspecified symptoms could well have
been attributed to unspecific prodromi of an emerging acute liver disease,
a diagnosis easily missed in its initial course. BC may be helpful for
treatment of menopausal symptoms but not of incipient acute liver disease.
Considering the rarity of assumed menopausal symptoms in a 60-year old
patient, assessment of the time course and specification of previous
menopausal symptoms of the would have assisted to arrive at the correct
diagnosis.
Other shortcomings include information gaps with lacking results of
laboratory values at first presentation to her general practitioner and
subsequently until admission.1 In addition, dates are missing on which BC,
propranolol, and levothyroxine were discontinued. There are also no data
on alanine aminotransferase (ALT) activities at admission and on liver
values following admission until liver transplantation three weeks later,
hampering a valid assessment of dechallenge features.
The BC product used in this case remained unnamed and undefined
regarding ingredients and possible warnings, which precluded valid
causality assessment. In particular, there is uncertainty whether BC was
consumed as a licensed drug or unlicensed herbal mixture with potentially
hepatotoxic herbal ingredients unrelated to BC. Authentication of the
product and daily dose were not reported, leaving the question of
adulterants, herbal misidentification, impurities, and daily overdose.
Credit is given1 to Bernal et al.,3 another group of King's College
Hospital, who described the complexity and challenging issues of acute
liver failure, with unknown causes in up to 38% of cases despite thorough
investigations. In reference to cases with seronegative liver failure
described in the literature, clinical features and associated
haematological abnormalities can suggest viral infection, but serological
testing for established and putative hepatotropic viruses can be negative.
In the report under discussion,1 methodological details for parameters
used for individual serological testing for viruses were not provided.
Uncommon but well documented viral causes of acute liver failure include
varicella zoster virus and parvovirus B193 that were not considered in the
present case report.1
Lim et al.1 presented a second case of unknown age with assumed HILI
by an unidentified BC product. Information gaps included not only unknown
age and unnamed product lacking authentication, but also undeclared
indication for use and unknown daily dose. Undefined symptoms appeared two
weeks after cessation of the product that had been used for 6 weeks, and
admission was 4 weeks after symptoms had appeared. Exclusion of
alternative causes was fragmentary. Following product cessation, initial
ALT activities decreased from 1119 to 339 U/L over 9 days and then peaked
at 7304 U/L 7 days later for unknown reasons. A recurrent ALT increase
speaks against the role of the incriminated product.4
Considering available and missing data in the two cases,1 causality
for the two unidentified products was possible in the first case and
excluded in the other one (Table), using the Council for International
Organizations of Medical Sciences (CIOMS) scale4 as described in detail
before.5 Lim et al.1 provided for the first case a total score, which
signified the lowest level of a probable causality without presenting
individual scores for each item of the CIOMS scale to be used for further
evaluation; of unknown reasons, CIOMS-based causality for the second case
was not provided.
Lim et al.1 refer to the literature quoting 3 reports6-8 with
assumed BC hepatotoxicity, but there was lack of causality upon further
CIOMS based evaluation in these reported cases9,10 as well in other
cases.9-12 It has also been argued that using the WHO method 14 out of 21
spontaneous reports of the Medicines and Healthcare products Regulatory
Agency (MHRA) were shown to support a relation between BC and liver
damage, but levels of causality were not communicated.1 Most of these
spontaneous MHRA cases likely had been analyzed by the European Medicines
Agency (EMA), but there was lack of causality for BC as assessed with the
CIOMS scale,13 which is liver specific and validated for hepatotoxicity.14
The WHO method used by MHRA is not liver specific, not validated for
hepatotoxicity, and therefore obsolete for assessing hepatotoxicity
cases.15 Finally, there is also no evidence for BC hepatotoxicity by
metaanalysis of randomized controlled clinical trials.16
In conclusion, to assess cases of suspected HILI we need good quality
of case data and liver specific assessment tools such as the CIOMS scale,
in addition to thorough clinical evaluation and clear product
identification. If these conditions are not fulfilled, we are left with
more questions than answers are given.
Learning points
? Causality attribution for a herb in cases of assumed herb induced liver
injury requires clear
identification of the incriminated herbal product used by the patient
and information of the
daily dose.
? Unspecific prodromi of acute liver disease may be misinterpreted and
erroneously be
treated by herbal products, offsetting causality attribution for the
herb under discussion.
? A careful case analysis is mandatory, which includes the use of a liver
specific causality
assessment method such as the CIOMS scale, providing transparency by
listing each
individual and scored item of the scale rather than a total score
that lacks transparency.
REFERENCES
1. Lim TY, Considine A, Quaglia A, et al. Case report: Subacute liver
failure secondary to black cohosh leading to liver transplantation. BMJ
2013. DOI : 10.1136/bcr-2013-009325
2. Nelson HD. Menopause. Lancet 2008; 371: 760-70
3. Bernal W, Auzinger G, Dhawan A, et al. Acute liver failure. Lancet
2010; 376: 190-201
4. Danan G, B?nichou C. Causality assessment of adverse reactions to drugs
- I.
A novel method based on the conclusions of international consensus
meetings:
application to drug-induced liver injuries. J Clin Epidemiol 1993; 46:1323
-30
5. Teschke R, Frenzel C, Schulze J, et al. Herbal hepatotoxicity:
challenges and pitfalls of causality assessment methods. World J
Gastroenterol 2013; 19: 2864-82
6. Whiting PW, Clouston A, Kerlin P. Black cohosh and other herbal
remedies associated
with acute hepatitis. Med J Aust 2002; 177: 432-5
7. Lontos S, Jones RM, Angus PW, et al. Acute liver failure associated
with the use of
herbal preparations containing black cohosh. Med J Aust 2003; 179: 390-1
8. Levitsky J, Alli TA, Wisecarver J, et al. Fulminant liver failure
associated with the
use of black cohosh. Dig Dis Sci 2005; 50: 538-9
9. Teschke R, Schwarzenboeck A. Suspected hepatotoxicity by cimicifugae
racemosae
rhizoma (black cohosh, root): critical analysis and structured causality
assessment.
Phytomedicine 2009; 16: 72-84
10. Teschke R, Bahre R, Fuchs J, et al. Black cohosh hepatotoxicity:
quantitative
causality evaluation in nine suspected cases. Menopause 2009; 16: 956-65
11. Teschke R, Schmidt-Taenzer W, Wolff A. Spontaneous reports of assumed
herbal hepatotoxicity by black cohosh: Is the liver unspecific Naranjo
scale precise enough to ascertain causality? Pharmacoepidemiol Drug Saf
2011; 20: 567-82
12. Teschke R. Black cohosh and suspected hepatotoxicity -
inconsistencies, confounding variables, and prospective use of a
diagnostic causality algorithm: A critical review. Menopause 2010; 17: 426
-40
13. EMA (European Medicines Agency): Assessment of case reports connected
to herbal medicinal products containing cimicifugae racemosae rhizoma
(black cohosh, root). Issued May 8, 2007. Available at:
http://www.ema.europa.eu/docs/en_GB/document_library/Herbal_-
_HMPC_assessment_report/2010/02/WC500074167.pdf
Accessed 14 July 2013
14. B?nichou C, Danan G, Flahault A. Causality assessment of adverse
reactions to
drugs - II. An original model for validation of drug causality assessment
methods: case reports with positive rechallenge. J Clin Epidemiol 1993;
46: 1331-6
15. Teschke R, Eickhoff A, Wolff A, et al. Herbal hepatotoxicity and WHO
global introspection method. Ann Hepatol 2013; 12: 11-21
16. Naser B, Schnitker J, Minkin MJ, et al. Hepatotoxicity suspected by
black cohosh: No evidence by metaanalysis of randomized controlled
clinical trials for isopropanolic black cohosh extract. Menopause 2011;
18: 366-75
Table: Case scoring with the CIOMS scale
Items for hepatocellular injury Possible
Score Patient 1
Score Patient 2
Score
Time to onset from the beginning of the herb
5-90 days (rechallenge: 1-15 days) +2 +2
< 5 or > 90 days (rechallenge: > 15 days) +1
Alternative assessment: Time to onset from cessation of the herb
? 15 days (except for slowly metabolized chemicals: > 15 days)
+1
+1
Course of ALT after cessation of the herb
Percentage difference between ALT peak and N
Decrease ? 50% within 8 days +3
Decrease ? 50% within 30 days +2
No information or continued herb use 0 0
Decrease ? 50% after day 30 0
Decrease < 50% after day 30, or recurrent increase -2 -2
Risk factors
Alcohol use (drinks/day: > 2 for women, > 3 for men) +1
Alcohol use (drinks/day: ? 2 for women, ? 3 for men) 0 0
Age ? 55 years +1 +1
Age < 55 years 0
Concomitant drug(s) or herbs(s)
None, or no information
0
Concomitant drug or herb with incompatible time to onset 0
Concomitant drug or herb with compatible or suggestive time to onset
-1 -1
Concomitant drug or herb known as hepatotoxin and with compatible or
suggestive time to onset -2
Concomitant drug or herb with evidence for its role in this case
(positive
re-challenge or validated test) -3
Search for non herb causes
Group I (6 causes)
Anti-HAV IgM - -
HBsAg, anti-HBc IgM, HBV-DNA - -
Anti-HCV, HCV-RNA - -
Hepatobiliary sonograph /colour Doppler sonography of liver
vessels/endosonography/CT/MRC -
Alcoholism (AST/ALT ? 2)
Acute recent hypotension history (particularly if underlying heart
disease present) -
Group II (6 causes) -
Complications of underlying disease(s) such as sepsis, autoimmune
hepatitis, chronic hepatitis B or C, primary biliary cirrhosis or
sclerosing
cholangitis, genetic liver diseases -
Infection suggested by PCR and titer change for
CMV (anti-CMV IgM, anti-CMV IgG)
-
EBV (anti-EBV IgM, anti-EBV IgG) -
HEV (anti-HEV IgM, anti-HEV IgG) -
HSV (anti-HSV IgM, anti-HSV IgG) -
VZV (anti-VZV IgM, anti-VZV IgG)
Evaluation of groups I and II
All causes groups I and II reasonably ruled out +2
The 6 causes of group I ruled out +1
5 or 4 causes of group I ruled out 0 0
< 4 causes of group I ruled out -2 -2
Non-drug/herb cause highly probable -3
Previous information on hepatotoxicity of the herb
Reaction labelled in the product characteristics +2
Reaction published but unlabelled +1 +1 +1
Reaction unknown 0
Response to re-administration
Doubling of ALT with the herb alone, provided ALT< 5N before re-
exposure +3
Doubling of ALT with the drug(s) and herb(s) already given at the
time of
first reaction +1
Increase in ALT but < N under the same conditions as for the first
administration -2
Other situations 0
Total score for patient +3 -2
CIOMS based causality assessment for the two cases of the report of
Lim et al.1 The compilation of individual items is derived from the
updated CIOMS scale,5 which is based on the original CIOMS scale.4 The -
sign indicates that the parameter was assessed with a negative result.
Abbreviations: ALT, Alanine aminotransferase; AST, Aspartate
aminotransferase; CIOMS, Council for International Organizations of
Medical Sciences; CMV, Cytomegalovirus; CT, Computed tomography; EBV,
Epstein-Barr virus; HAV, Hepatitis A virus; HBc, Hepatitis B core; HBsAg,
Hepatitis B surface antigen; HBV, Hepatitis B virus; HCV, Hepatitis C
virus; HEV, Hepatitis E virus; HSV, Herpes simplex virus; MRC, Magnetic
resonance cholangiography; N, upper limit of normal; VZV, Varicella zoster
virus.
Total score and resulting causality grading: ? 0, excluded; 1-2, unlikely;
3-5, possible; 6-8, probable; ? 9, highly probable.
In 2013 Gadit stated "A 54-year-old woman presented to a community-
based psychiatric clinic with unique problem of persistent genital arousal
disorder. ... this case has become a clinical challenge in terms of
treatment" [1].
The clitoris is an external organ ("internal" clitoris does not exist) and
has three erectile tissue parts, in the free part of the organ, is
composed of the body and the glans located inside of the p...
In 2013 Gadit stated "A 54-year-old woman presented to a community-
based psychiatric clinic with unique problem of persistent genital arousal
disorder. ... this case has become a clinical challenge in terms of
treatment" [1].
The clitoris is an external organ ("internal" clitoris does not exist) and
has three erectile tissue parts, in the free part of the organ, is
composed of the body and the glans located inside of the prepuce; the
hidden part of the clitoris are the roots or crura, they are covered by
the ischiocavernosus muscles. Their contraction results in a surge of
blood in the crura toward the corpora cavernosa of the clitoris and
compression of the deep dorsal veins, contributing to erection of the
clitoris. Studies by Dickinson, in 1949, identified a small number of
reports showing that pronounced erection can occur. In fact, as in males,
in females, it is possible to have the priapism of the clitoris, a rare
condition associated with prolonged painful erection of the corpora
cavernosa lasting for more than 6 hr and unassociated with sexual arousal,
not associated with sexual stimulation. It causes engorgement, swelling,
pain of the clitoris and of its immediate adjacent area [2-4].
Female priapism treatment depends on aetiology. The cause of priapism, in
male and female, is impaired outflow of blood from the corpora cavernosa
because of venous obstruction or because of failure of the alpha-
adrenergic relaxation system. ''Most reported cases of female priapism
describe the association with the use of antidepressant and other
psychotropic drugs, all with alphaadrenergic blocking potential, such as
trazodone, buproprion citalopram and nefazodone. Treatment consisted of
discontinuing the offending medication or providing symptomatic pain
relief. Serious permanent damage where treatment has been delayed has been
reported in men but not in women. Furthermore, the association between
congenital clitoromegaly and priapism has also not been reported
previously. With this concern in mind, we felt justified to resort to
management options described for male priapism but hitherto not for female
priapism, i.e. the direct injection with epinephrine and heparin, followed
by aspiration to provide immediate decompression''[4,5].
The etiology of PGAD is not completely understood, it is described as
spontaneous, intrusive, and unwanted genital arousal in the absence of
sexual interest and desire. PGAD definition is equal to that of
clitoral/female priapism. PGAD is not a newly recognized condition. In
addition, if the "genital arousal" is unwanted, why to use "arousal"? This
term could suggests that women should, may end up feeling "abnormal" from
sexuality viewpoint.
Restless Genital Syndrome includes restless legs and/or overactive
bladder, and it may include PGAD: it cannot be defined how PGAD.
The term clitoral, or female, priapism is a more accurate term than
persistent genital arousal disorder or Restless genital syndrome.
Treatment described for male priapism must be divulged to the sexual
medicine experts [4,5]: it must be a therapy also for clitoral/female
priapism.
Sexologists and sexual medicine experts use questionnaires for the
prevalence, etiology, diagnosis and treatment of female sexual
dysfunctions (FSD). Female Sexual Function Index (FSFI) questionnaire is
the most widely used scale to assess sexual dysfunction in women.
Physiologically the FSFI questionnaire does not provide an assessment of
female sexual function, but primarily assesses vaginal intercourse: many
questions seem to assess the degree of lubrication and ease of
penetration, while very little attention is paid to clitoral sensation.
Questionnaires for women's sexual function must mainly assess the presence
or absence of orgasm with masturbation and in the questions there must not
be the words "intercourse" and "satisfaction"[6]. As a matter of fact
female sexual dysfunctions are popular because they are based on something
that doesn't exist, i.e. the vaginal orgasm[2,3,6]. Clitoral/female
priapism is not a sexological disease, but a gynecological/urological
disease.
I warn colleagues to maintain a high level of professionalism and not to
be use nonmedical or not scientific definition, terms and questionnaires.
References
[1] Gadit A. Persistent genital arousal disorder: a clinical
challenge. BMJ Case Rep. May 21; 2013. doi:10.1136/bcr-2013-009098
[2] Puppo V. Anatomy and Physiology of the Clitoris, Vestibular
Bulbs, and Labia Minora With a Review of the Female Orgasm and the
Prevention of Female Sexual Dysfunction. Clin Anat 2013; 26: 134-52.
[3]Puppo V. Embryology and anatomy of the vulva: The female orgasm
and women's sexual health. Eur J Obstet Gynecol Reprod Biol 2011; 154:3-8.
[4] Arntzen BW, de Boer CN. Priapism of the clitoris. BJOG 2006; 113:
742-43.
[5] Montague DK, Jarow J, Broderick GA, Dmochowski RR, Heaton JP, Lue
TF, et al. American Urological Association guideline on the management of
priapism. J Urol 2003; 170(4 Pt 1): 1318-24.
[6] Puppo V. Female sexual function index (FSFI) does not assess
female sexual function. Acta Obstet Gynecol Scand 2012; 91:759.
The potential value of NPIS data for surveillance has increasingly
been recognised by official government bodies.1
During the year 2011/12, the NPIS answered telephone enquiries
relating to drugs of abuse, constituting 2.6% of the overall telephone
workload. Over the same period there were accesses to drugs of abuse
monographs on TOXBASE, representing 4.0% of the total TOXBASE activity. As
with all NPIS activi...
The potential value of NPIS data for surveillance has increasingly
been recognised by official government bodies.1
During the year 2011/12, the NPIS answered telephone enquiries
relating to drugs of abuse, constituting 2.6% of the overall telephone
workload. Over the same period there were accesses to drugs of abuse
monographs on TOXBASE, representing 4.0% of the total TOXBASE activity. As
with all NPIS activity data, these figures are not a direct measure of the
frequency of toxicity or hospital admission with drugs of abuse, but give
an indirect indication of the substances being encountered by the NHS
clinicians. It should be noted that analytical confirmation of exposure is
rarely available and the statistics reported here reflect what has been
reported as being taken by the recreational drug users involved.
Cocaine, amphetamines, MDMA ('ecstasy'), heroin, cannabis, methadone,
mephedrone and ketamine all feature in the top ten telephone enquiries and
TOXBASE accesses for drugs of abuse.
The NPIS continues to monitor activity relating to newer recreational
drugs. Those most frequently involved in telephone enquiries over the last
three years have been mephedrone, 'legal highs' (not otherwise specified),
naphyrone, methcathinone, 6-APB, 'Ivory Wave' products (not otherwise
specified, but reported to contain desoxypipradrol) and methoxetamine.
For mephedrone 2 the previously reported substantial reduction in
enquiry numbers following legal control in April 2010 has been maintained
for telephone enquiries, although there has been a small increase in
TOXBASE hits over the last year. Reductions in activity following legal
control have also been maintained for 'Ivory Wave' products and naphyrone.
On the advice of the Advisory Council on Misuse of Drugs (ACMD), ketamine
analogue methoxetamine ('mexxy'or 'MXE') was subject to a Temporary Drug
Class Order coming into effect on 5 April 2012. The impact of this on
enquiries to the NPIS will continue to be monitored.
During the year 2011/12 the NPIS has developed its working
relationship with the UK Focal Point Early Warning System (EWS) on new
psychoactive substances or 'legal highs', which is managed by the
Department of Health. Data were provided on NPIS activity relating to
methoxetamine and this formed some of the evidence provided to the ACMD
and the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA).
Further discussions with the UK Focal Point EWS are planned with a view to
developing a chapter for the exchange of data and information, but, in the
meantime, the NPIS has been listed by the EMCDDA as part of the UK early
warning system national profile.
2. James D, Adams R, Spears R, Cooper G et al. Clinical
characteristics of mephedrone toxicity reported to the UK National Poisons
Information Service. Emerg Med J 2011; 28(8): 686-9.
We read with interest the case report "Extensively drug resistant
tuberculosis in a 7-year-old child with interferon-gamma and interleukin-
12 deficiency" by Kulkarni et al [1]. The reports of XDR-TB hold an
important epidemiological implication and need to be defined accurately.
We would like to clarify the definition used for extensively drug
resistant tuberculosis (XDR-TB) in the report.
We read with interest the case report "Extensively drug resistant
tuberculosis in a 7-year-old child with interferon-gamma and interleukin-
12 deficiency" by Kulkarni et al [1]. The reports of XDR-TB hold an
important epidemiological implication and need to be defined accurately.
We would like to clarify the definition used for extensively drug
resistant tuberculosis (XDR-TB) in the report.
The case presented above reported the drug resistance pattern of the
M. tuberculosis isolate for the second line anti-tuberculosis drugs to be:
sensitive to para-aminosalicylic acid, ofloxacin and kanamycin but
resistant to amikacin, cycloserine and ethionamide. The isolate cannot be
labeled as XDR-TB based on the above sensitivity pattern as it was
sensitive to ofloxacin. XDR-TB is correctly defined as MDR-TB plus
resistance to a fluoroquinolone and at least one second-line injectable
agent: amikacin, kanamycin and/or capreomycin [2], based on which it is
necessary for the MDR-TB isolate to be resistant to a fluroquinolone to be
termed as a XDR-TB, which is not present in the present case. Hence, the
isolate may be termed as MDR-TB at best, and not XDR-TB.
The risk factors for acquisition of extensive drug resistance in TB
include inappropriate use of second-line drugs in a patient for whom first
-line drugs are failing [3]. This child was treated with the first line
anti-tuberculosis drugs earlier, but had no exposure to the second line
drugs, which does not make a strong case of the acquisition of resistance
to second line drugs. The global threat of XDR tuberculosis has great
significance for the public health field, as the the existence of XDR-TB
is a reflection of weaknesses in tuberculosis management programmes [3].
Moreover, there is a need for universal definitions for the various
degrees of antimicrobial resistance in bacteria [4], and international
norms should be used to avoid confusion in the medical literature.
References
1. Kulkarni K, Singh M, Soneja P, Mathew J, Marwaha RK. Extensively
drug resistant tuberculosis in a 7-year-old child with interferon-gamma
and interleukin-12 deficiency. BMJ Case Rep. 2009;2009. pii:
bcr06.2008.0293.
2. World Health Organization: Multidrug and extensively drug-
resistant TB (M/XDR-TB): 2010 global report on surveillance and response.
[Available:
http://www.who.int/tb/publications/mdr_surveillance/en/index.html].
Accessed 22 January, 2012.
3. Raviglone MD, Smith IM. XDR Tuberculosis - Implications for Global
Public Health. N Engl J Med 2007;356:656-659.
4. Falagas ME, Karageorgopoulos DE. Pandrug resistance (PDR),
extensive drug resistance (XDR), and multidrug resistance (MDR) among Gram
-negative bacilli: need for international harmonization in terminology.
Clin Infect Dis. 2008;46:1121-2;author reply 1122.
I have found using a "Sharpie" marker over the site, then cleaning it
off with an alcohol pad, (a method described in Habiff's Dermatology to
stain burrows), makes the "delta wing pattern" which can be subtle,
obvious. I use a usb polarizing dermatoscope and a laptop at bedside to
diagnose and show the patient multiple linear aggregations of the delta
patterns and find this method useful in my every day practice. The
p...
I have found using a "Sharpie" marker over the site, then cleaning it
off with an alcohol pad, (a method described in Habiff's Dermatology to
stain burrows), makes the "delta wing pattern" which can be subtle,
obvious. I use a usb polarizing dermatoscope and a laptop at bedside to
diagnose and show the patient multiple linear aggregations of the delta
patterns and find this method useful in my every day practice. The
procedure takes 1-2 minutes. I am a family practice doctor in an urgent
care setting. The dermatoscope I use is less than $300 online.
this is a very interesting case report.
I just had the same 2 hours ago in the O.R!
60 y.o.lady, on L-thyroxin after a surgical thyroidectomy,she has no
cardiac symptoms but described a short breath on exercise,( though she
runs a farm) She was scheduled for a coelioscopy because of abdominal
pain.She received for the induction: propofol 200mg, sufentanyl 15 mcg,
atracurium 50 mg.She then received the usual analgesic regi...
this is a very interesting case report.
I just had the same 2 hours ago in the O.R!
60 y.o.lady, on L-thyroxin after a surgical thyroidectomy,she has no
cardiac symptoms but described a short breath on exercise,( though she
runs a farm) She was scheduled for a coelioscopy because of abdominal
pain.She received for the induction: propofol 200mg, sufentanyl 15 mcg,
atracurium 50 mg.She then received the usual analgesic regimen in our
institution.
(acetaminophen 1 g, ketoprofen 100mg , nefopam 20 mg and tramadol 100 mg)
without any EKG change.
15 minutes later,immediately after the gas-insufflation in the peritoneum,
the EKG changed without any hemodynamic compromise, the operation went on
successfully,( salpingectomy) and in the Recovery room , the EKG showed
all the signs you described : narrow PR interval, Delta wave, and
alteration of the repolarization in V1 to V4( negative T wave)
she had no chest pain,the troponin , the ionogram, the thyroid hormons
were normal, as was the bedside echocardiography ,.
After an IV perfusion with 3 g of magnesium sulfate in 1 hour, the EKG
returned normal.
The patient has been informed with what happened, and will be scheduled
for a cardiac assessment.
It is surprising that the authors blame malaria for illness in this
patient who presented with an acute febrile illness and confusion. To put
it mildly, the diagnosis of Cerebral Malaria is questionable. The evidence
the authors cite in support of diagnosis is weak: hyponatremia can occur
in a myriad of
conditions including any CNS infection, and that the patient responded to
quinine is also questionable as the patient wa...
It is surprising that the authors blame malaria for illness in this
patient who presented with an acute febrile illness and confusion. To put
it mildly, the diagnosis of Cerebral Malaria is questionable. The evidence
the authors cite in support of diagnosis is weak: hyponatremia can occur
in a myriad of
conditions including any CNS infection, and that the patient responded to
quinine is also questionable as the patient was on other drugs including
ceftriaxone
and acyclovir. There are number of features which point against malaria as
the possible etiology: absent parasite on smears, negative PCR and antigen
tests,leukocytosis, and the fact that patient took some prophylaxis. On
the contrary the authors provide no evidence that they have rule out viral
encephalitis or similar illness.
Gluten intolerance is an autoimmune enteropathy cased by
heterogeneous mixture of wheat storage proteins. Malabsorption symptoms
imply diarrhoea, abdominal pain/bloating, and weight loss. This case
describes a 22 years old female subject, who suffered chronic headache,
joint pain, urticaria, and long period of amenorrhea. Skin prick tests
revealed a sensitization to ?-gliadin, while neurological, gynaecological,
endocrin...
Gluten intolerance is an autoimmune enteropathy cased by
heterogeneous mixture of wheat storage proteins. Malabsorption symptoms
imply diarrhoea, abdominal pain/bloating, and weight loss. This case
describes a 22 years old female subject, who suffered chronic headache,
joint pain, urticaria, and long period of amenorrhea. Skin prick tests
revealed a sensitization to ?-gliadin, while neurological, gynaecological,
endocrine and clinical-laboratory examinations did not justify the above-
mentioned symptoms. Gluten-free diet resolved chronic symptoms and re-
established the menstrual cycle, whereas a temporary gliadin daily diet re
-exacerbated all clinical symptoms. Urticaria occurred 20 minutes and the
chronic headache the next day after exposure to the gliadin-rich diet. In
addition, it was observed the missing of the expected menstrual bleeding.
This case demonstrates that gliadin intake can induce not only
malabsorption but also "idiopathic" neuronal or gynaecological symptoms.
This is a prime example of a situation where it would be easy for
someone to say "this isn't possible" but when you offer irrefutable proof,
all one can say is "WOW!!"
Vitamin C deficiency can lead to bleeding and swollen gums in an
adolescent girl if she is a fussy eater. Diet history, x-ray and blood
levels can exclude/ confirm Vitamin C deficiency.
Letter to the Editor
Subacute liver failure secondary to black cohosh leading to liver transplantation: A challenging interpretation
Rolf Teschke Department of Internal Medicine II, Division of Gastroenterology and Hepatology, Klinikum Hanau, Academic Teaching Hospital of the Medical Faculty of the Goethe University rankfurt/ Main, Germany
Correspondence to: rolf.teschke@gmx.de
SUM...
In 2013 Gadit stated "A 54-year-old woman presented to a community- based psychiatric clinic with unique problem of persistent genital arousal disorder. ... this case has become a clinical challenge in terms of treatment" [1]. The clitoris is an external organ ("internal" clitoris does not exist) and has three erectile tissue parts, in the free part of the organ, is composed of the body and the glans located inside of the p...
The potential value of NPIS data for surveillance has increasingly been recognised by official government bodies.1
During the year 2011/12, the NPIS answered telephone enquiries relating to drugs of abuse, constituting 2.6% of the overall telephone workload. Over the same period there were accesses to drugs of abuse monographs on TOXBASE, representing 4.0% of the total TOXBASE activity. As with all NPIS activi...
Dear Sir,
We read with interest the case report "Extensively drug resistant tuberculosis in a 7-year-old child with interferon-gamma and interleukin- 12 deficiency" by Kulkarni et al [1]. The reports of XDR-TB hold an important epidemiological implication and need to be defined accurately. We would like to clarify the definition used for extensively drug resistant tuberculosis (XDR-TB) in the report.
...
I have found using a "Sharpie" marker over the site, then cleaning it off with an alcohol pad, (a method described in Habiff's Dermatology to stain burrows), makes the "delta wing pattern" which can be subtle, obvious. I use a usb polarizing dermatoscope and a laptop at bedside to diagnose and show the patient multiple linear aggregations of the delta patterns and find this method useful in my every day practice. The p...
this is a very interesting case report. I just had the same 2 hours ago in the O.R! 60 y.o.lady, on L-thyroxin after a surgical thyroidectomy,she has no cardiac symptoms but described a short breath on exercise,( though she runs a farm) She was scheduled for a coelioscopy because of abdominal pain.She received for the induction: propofol 200mg, sufentanyl 15 mcg, atracurium 50 mg.She then received the usual analgesic regi...
It is surprising that the authors blame malaria for illness in this patient who presented with an acute febrile illness and confusion. To put it mildly, the diagnosis of Cerebral Malaria is questionable. The evidence the authors cite in support of diagnosis is weak: hyponatremia can occur in a myriad of conditions including any CNS infection, and that the patient responded to quinine is also questionable as the patient wa...
Gluten intolerance is an autoimmune enteropathy cased by heterogeneous mixture of wheat storage proteins. Malabsorption symptoms imply diarrhoea, abdominal pain/bloating, and weight loss. This case describes a 22 years old female subject, who suffered chronic headache, joint pain, urticaria, and long period of amenorrhea. Skin prick tests revealed a sensitization to ?-gliadin, while neurological, gynaecological, endocrin...
This is a prime example of a situation where it would be easy for someone to say "this isn't possible" but when you offer irrefutable proof, all one can say is "WOW!!"
It's never too late to learn something new!
Conflict of Interest:
None declared
Vitamin C deficiency can lead to bleeding and swollen gums in an adolescent girl if she is a fussy eater. Diet history, x-ray and blood levels can exclude/ confirm Vitamin C deficiency.
Conflict of Interest:
None declared
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