The authors rightly mention in their case report that it is not an
uncommon finding in normal infants who are referred to the paediatrician
because of large head size or a rapid increase in OFC. My concern is that
the patient 1 in the case report may send a wrong message to the trainees
or other doctors that CT head is the primary mode of imaging in such cases
because of high dose of radiation involved with a CT. Most of...
The authors rightly mention in their case report that it is not an
uncommon finding in normal infants who are referred to the paediatrician
because of large head size or a rapid increase in OFC. My concern is that
the patient 1 in the case report may send a wrong message to the trainees
or other doctors that CT head is the primary mode of imaging in such cases
because of high dose of radiation involved with a CT. Most of them can be
confirmed /recognized by a cranial ultrasound which can be easily
performed even in a district general hospital setting and followed up by
a repeat U/S if necessary, as the anterior fonatenelle is open in a large
number of cases at that age. A CT or MRI should be needed rarely unless
we have a case like patient 2 in the case report with head injury or
suspicion of non accidental injury etc.
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.
Dear Editor,
We read with interest, the case report written by Dr. Magdalani et al.,
"Acute Acalculous cholecystitis in a Lebanese girl with primary Epstein-
Barr viral infection" in the British Medical Journal Case Reports
published on 18 April, 2016.
The authors describe a case of a previously healthy, 16 year old
girl, who presented with history of 10 day fever, sore throat, and upper
abdominal pain. She app...
Dear Editor,
We read with interest, the case report written by Dr. Magdalani et al.,
"Acute Acalculous cholecystitis in a Lebanese girl with primary Epstein-
Barr viral infection" in the British Medical Journal Case Reports
published on 18 April, 2016.
The authors describe a case of a previously healthy, 16 year old
girl, who presented with history of 10 day fever, sore throat, and upper
abdominal pain. She appeared clinically stable, with mild leukocytosis
(predominantly lymphocytic), mild transaminitis and a cholestatic pattern
of direct hyperbilirubinemia.
A diagnosis of EBV associated with acute acalculous cholecystitis
(AAC) was established with sonographic findings of significant gall
bladder wall thickening. Her gall bladder was not dilated, and there was
no pericholecystic fluid. She was treated with antibiotics with resolution
of her symptoms. The authors noted that the benefit of antibiotics is
questionable.
Her symptomology and laboratory findings can also be described as
consistent with EBV hepatitis. GB wall thickening in acute hepatitis is
well known and is attributed to reactive/viral pericholecystitis. The
mechanism is proposed to be due to impaired hepatic function with reduced
secretion of bile, or from immunological/inflammatory damage to hepatic
and biliary cells (1-6).
We believe, like others, that the associated sonographic findings (1, 2,
5, 6) can be attributed to diffuse reactive gall bladder wall thickening
secondary to peritoneal fluid produced as a result of extra biliary
inflammatory process. Management is supportive, with review of literature
in this paper showing resolution in 28 of 29 patients diagnosed with EBV
associated AAC.
AAC carries with it considerable mortality as evidenced by
literature. Epidemiologically, it occurs in a select cohort of patients
who are clinically sick, on prolonged parenteral nutrition, or
immunosuppressed patients. Without intervention (cholecystectomy or
cholecystostomy tube placement, and steroids in autoimmune patients), it
progresses rapidly to gangrenous gall bladder and then perforation (7, 8).
It is usually associated with more serious morbidity and higher mortality
rates than calculous cholecystitis.
The pathophysiology of cystic duct obstruction in AAC is attributed to
ischemia to cystic duct, leading to endothelial injury, gall bladder
stasis, and eventual necrosis.
We and others believe that sonographic findings should not be the
sole diagnostic criteria for AAC (1, 3). Differential diagnoses such as
EBV, CMV, malaria, and other viral hepatides should be taken into
consideration. A diagnosis of AAC should be suspected in the sicker,
hospitalized patient, and mandates an admission to a monitored unit, and
early operative intervention. We suggest obtaining a HIDA scan, in cases
of uncertain diagnosis, with the understanding that the sensitivity and
specificity are slightly decrease, since the obstruction is functional and
not mechanical.
References:
1. Debnath et al. Is it acalculous cholecystitis or reactive/viral
pericholecystits in acute hepatitis? Braz J Infect Dis 2010;14(6):647-648
2. Lee et al. Acalcuous diffuse gall bladder wall thickening in children.
Pediatr Gastroenterol Hepatol Nutr 2014 June 17(2):98-103
3. Shkalim-Zemer et al. Cholestatic Hepatitis Induced by Epstein - Barr
virus in a Pediatric Population. Clinical Pediatrics 2015, Vol. 54(12)
1153-1157
4. Khoo. Acute cholestatic hepatitis induced by Epstein-Barr virus
infection in an adult: a case report. Journal of Medical Case Reports
(2016) 10:75
5. Debnath et al. Post-prandial paradoxical filling of gall bladder in
patients with acute hepatitis: Myth or reality? Medical Journal Armed
Forces of India 68 (2012) 346 e349
6. Poddighe, .Acalculous Acute Cholecystitis in Previously Healthy
Children: General Overview and Analysis of Pediatric Infectious Cases. Int
J Hepatol. 2015; 2015: 459608.
7. Owen et al. Acute Acalculous Cholecystitis. Curr Treat Options
Gastroenterol. 2005 Apr;8(2):99-104.
8. Barie et al. Acute acalculous cholecystitis. Gastroenterol Clin North
Am. 2010 Jun;39(2):343-57.
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.
I read this article with interest as we too made a diagnosis of post-streptococcal acute disseminated encephalomyelitis with basal ganglia swelling in a female aged 11, who had presented with altered conscious level and dystonia, with similar distribution of basal ganglia lesions on MR brain imaging. However, a diagnosis of Biotin-Thiamine-Responsive Basal Ganglia Disease was considered, and homozygous SLC19A3 mutation was conf...
I read this article with interest as we too made a diagnosis of post-streptococcal acute disseminated encephalomyelitis with basal ganglia swelling in a female aged 11, who had presented with altered conscious level and dystonia, with similar distribution of basal ganglia lesions on MR brain imaging. However, a diagnosis of Biotin-Thiamine-Responsive Basal Ganglia Disease was considered, and homozygous SLC19A3 mutation was confirmed. This is a treatable condition requiring lifelong biotin and thiamine, and I urge the authors to consider testing their patient for this condition promptly.
Many thanks for the opportunity to share this potentially important piece of clinical information.
Your sincerely,
Katharine Forrest
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.
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.
The spleen can become infected as a result of septicemia, especially in immunodeficient patients. On some occasions, it can also get infected in immunologically competent patients. The spleen is known to undergo infarction in situ and may subsequently become infected. In addition, it could undergo sequestration and get infected under a variety of situations, without producing any significant symptoms and clinical findings. It...
The spleen can become infected as a result of septicemia, especially in immunodeficient patients. On some occasions, it can also get infected in immunologically competent patients. The spleen is known to undergo infarction in situ and may subsequently become infected. In addition, it could undergo sequestration and get infected under a variety of situations, without producing any significant symptoms and clinical findings. It is therefore not surprising to note that there was no palpable splenic mass before the radiological investigations revealed an abscess in the splenic region. The repeat admission and drainage of the collection of pus occurred because the patient may have been discharged too early and could have been avoided. Most of these patients require treatment with high doses of broad spectrum antibiotics for a sufficient duration. A possibility of accessory spleen also needs to be considered. A primary source of infection needs to be established. The prognosis is good for most immunologically competent patients as long as the usual precautions are taken after splenectomy.
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.
The combination of trimethoprim and sulafamethoxole has been used for the prophylaxis of malaria for over several decades. While the development of vitamin K deficiency due to this drug combination is theoretically possible, it is not very common. There are many risk factors for vitamin K deficiency, such as diet, interactions with other drugs and basic liver function.
To state that this drug combination caused vitamin K...
The combination of trimethoprim and sulafamethoxole has been used for the prophylaxis of malaria for over several decades. While the development of vitamin K deficiency due to this drug combination is theoretically possible, it is not very common. There are many risk factors for vitamin K deficiency, such as diet, interactions with other drugs and basic liver function.
To state that this drug combination caused vitamin K deficiency in the patient is presumptive. Other factors may have lead to reduced levels of vitamin K in this patient. Furthermore, to state that the patient developed GI bleeding secondary to vitamin K deficiency is speculative. The use of this drug combination for the prevention of malaria is important for those residing in these endemic areas and for those intending to travel to these areas.
The authors rightly mention in their case report that it is not an uncommon finding in normal infants who are referred to the paediatrician because of large head size or a rapid increase in OFC. My concern is that the patient 1 in the case report may send a wrong message to the trainees or other doctors that CT head is the primary mode of imaging in such cases because of high dose of radiation involved with a CT. Most of...
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...
Dear Editor, We read with interest, the case report written by Dr. Magdalani et al., "Acute Acalculous cholecystitis in a Lebanese girl with primary Epstein- Barr viral infection" in the British Medical Journal Case Reports published on 18 April, 2016.
The authors describe a case of a previously healthy, 16 year old girl, who presented with history of 10 day fever, sore throat, and upper abdominal pain. She app...
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...
I read this article with interest as we too made a diagnosis of post-streptococcal acute disseminated encephalomyelitis with basal ganglia swelling in a female aged 11, who had presented with altered conscious level and dystonia, with similar distribution of basal ganglia lesions on MR brain imaging. However, a diagnosis of Biotin-Thiamine-Responsive Basal Ganglia Disease was considered, and homozygous SLC19A3 mutation was conf...
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...
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.
...
The spleen can become infected as a result of septicemia, especially in immunodeficient patients. On some occasions, it can also get infected in immunologically competent patients. The spleen is known to undergo infarction in situ and may subsequently become infected. In addition, it could undergo sequestration and get infected under a variety of situations, without producing any significant symptoms and clinical findings. It...
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 combination of trimethoprim and sulafamethoxole has been used for the prophylaxis of malaria for over several decades. While the development of vitamin K deficiency due to this drug combination is theoretically possible, it is not very common. There are many risk factors for vitamin K deficiency, such as diet, interactions with other drugs and basic liver function. To state that this drug combination caused vitamin K...
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