eLetters

332 e-Letters

published between 2018 and 2021

  • Response from authors
    Thank you for your correspondence. 
     
    We reported this case as a possible early association during the first wave when it was impossible to discern whether there was a true connection between COVID and SSNHL, let alone determine the incidence. The paper was clear that direct causation wasn’t proven, but it served to highlight the importance of prompt treatment of SSNHL which is often associated with viral aetiologies. 
     
    The case report was written to create early awareness of a possible link. Since then, a BRC funded team in Manchester have published a systematic review linking the two and are also undertaking a year-long study into the association. An NIHR/BRC team in Nottingham are doing similarly. 
     
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  • Association or coincidence?

    The authors describe a single patient who tested positive for SARS-Cov-2 and had sensorineural hearing loss.
    In their article they mention that the annual incidence of sudden sensorineural hearing loss (SSNHL) is between 5 and 160 patients per 100,000.
    The current population of the UK is 67.866.011 according to the latest data (https://www.worldometers.info/demographics/uk-demographics/, accessed 18th October 2020).
    This therefore suggests that there will be between 3,393 and 108,585 patients presenting with SSNHL in the UK this year. Accepting that we have not completed the year we can expect around 80% of the above figures to represent the expected incidence so far i.e. somewhere between 2,714 and 86,868 patients experiencing SSNHL.
    The estimated incidence of Covid in the UK population is 0.62%, or 1 in 160 people have so far had Covid.
    Therefore, purely by statistics alone, the number of patients with both Covid and SSNHL should lie somewhere between 17 and 543.
    Whilst the authors make no claim that in their presented case the Covid was directly responsible for the SSNHL it seems surprising that this article was published by the BMJ as it stands without the authors making any attempt to discern the true incidence of SSNHL in patients with Covid.

  • Response to eletter
    Thanks for the comments on our manuscript entitled "Plexiform neurofibromatosis of penis: a rare presentation of type 1 neurofibromatosis."
     
    We think that this is a very good suggestion for treating such cases. Selumetinib has been found to be effective to treat neurofibromatosis type 1 in children 2 years of age and older. It is an inhibitor of mitogen-activated protein kinase and has been recommended as a first-line therapy approved for paediatric neurofibromatosis patients who have inoperable and bulky lesions. 
    Selumetinib therapy was a good option for this particular child but there were several reasons to choose surgery for this patient. Firstly the deformity was unsightly and grotesque considering the almost double length of the penis was leading to social discrimination, peer pressure and solitary life for this child. The patient has been rehabilitated with just one surgical operation in which after debulking the penile size is within socially acceptable limits. S...
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  • Selumetinib should be preferred to a surgical approach in case of extensive plexiform neurofibromas

    Dear Editor,
    we found the case report of Banthia et al. extremely interesting. First of all, penile plexiform neurofibromas are quite infrequent. Secondly, the subject described did not have a former clinical diagnosis of neurofibromatosis type I prior to the identification of this tumor, which is even rarer. However, we take exception to the therapeutic approach chosen by the authors. In fact, the surgical treatment of deep and extended plexiform neurofibromas is generally unsatisfactory, since their complete resection is frequently unattainable, allowing the masses to grow back (1-2). A partial tumor debulking should be considered only in case of high-risk conditions, such as a urethral or ureteral compression or a bowel obstruction. Apart from these scenarios, a medical approach should always be preferred, at least as a first attempt.
    Selumetinib, an inhibitor of MEK 1 and 2 kinase, has demonstrated to be effective in reducing the size of plexiform neurofibromas in pediatric patients (3-4). The drug is generally well tolerated and safe in the pediatric population. Only few patients failed to show a clinical response to the treatment and even fewer had to stop it due to the appearance of severe adverse events.
    In a recent study, we reported a cohort of nine patients with inoperable plexiform neurofibromas treated with selumetinib (5). Eight of them showed a partial response to the drug, i.e. a reduction of the tumor size by more than 20%. Remarkably, on...

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  • Lets call EVALI what it is: THC VALI

    To the editor,
    The authors of this article appear to be unaware that the cause of "EVALI" was identified almost a year ago. To quote Dr Ann Schuchat, Principal Deputy Director of CDC in December, 2019: "we can conclude that what I call the explosive outbreak of cases of EVALI can be attributed to exposure to THC-containing vaping products that also contained Vitamin E acetate." (1). This followed publication in NEJM of a study which noted that "Vitamin E acetate was identified in BAL fluid obtained from 48 of 51 case patients (94%) in 16 states but not in such fluid obtained from the healthy comparator group." It also noted that "47 of 50 (94%) had detectable tetrahydrocannabinol (THC) or its metabolites in BAL fluid or had reported vaping THC products." It is widely known that people who have become ill due to use of illicit products, such as THC vapes, do not always tell the truth about the illegal products they used. The NEJM study also reported that "9 of 11 patients who reported no use of THC-containing e-cigarette products in the 90 days before the onset of illness had detectable THC or its metabolites in their BAL fluid." These and numerous other studies have clarified that EVALI is caused by vaping THC products contaminated by vitamin E Acetate. Since the cause became clear in December 2019, identification of new cases of this disease dropped markedly, and in February 2020 CDC stopped reporting new cases. We...

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  • Cheiro-oral syndrome secondary to thalamic infarction: a clinical syndrome a physician should know

    Dear editor,
    The case report of published in BMI Case Reports 2020 Oct 29;13(10):e236017 by Ong et al. further expanded the knowledge of cheiro-oral syndrome, an incomplete sensory disorder, in clinical practice. Regarding to the classification of cheiro-oral syndrome, authors cited for Satpute et al. (2013), who clearly described the vascular anatomy of thalamus relating to the clinical picture of sensory and other neurological deficits, including some incomplete sensory syndromes. Bogousslavsky et al. (1988) had reported similar results before. However, to my understanding, the four types of cheiro-oral syndrome was firstly suggested by Chen WH (2009).

    1.Bogousslavsky J, Regli F, Uske A. Thalamic Infarcts: clinical syndromes, etiology, and prognosis. Neurology. 1988;38:837–848.
    2.Chen WH. Cheiro-Oral Syndrome: A Clinical Analysis and Review of Literature. Yonsei Med J. 2009;50(6):777–783.
    3.Satpute S, Bergquist J, Cole JW. Cheiro-Oral syndrome secondary to thalamic infarction: a case report and literature review. Neurologist 2013;19:22–5.

  • Utilization of the Brighton Collaboration consensus case definition for the standardized assessment of sensorineural hearing loss in COVID-19 related hearing loss

    To the authors:
    We read with interest the article entitled “Sudden irreversible hearing loss post COVID-19”.1 In this article, the authors presented an unusual case of a 45 year-old gentleman with sudden-onset sensorineural hearing loss (SNHL) after COVID-19 infection and treatment. In their literature review, five other case reports were cited with hearing loss noted after COVID-19.2-6 The patient in the case report experienced a decrease in his left sided hearing 1 week after his intensive care unit stay for COVID-19 treatment. His initial hearing loss was evaluated at the bedside with a tuning fork examination showing negative Rinne’s test on the side of reported hearing loss, and Weber’s test lateralizing to the side opposite to his hearing loss, which is consistent with SNHL of the affected side. He then had a 7 day treatment course of 60mg oral Prednisone daily in addition to a series of intratympanic steroid injection. His hearing loss was documented with elevated hearing thresholds of 65, 75, 75, and 85 dB at 2, 3, 4, and 6 kHz.
    As multiple countries across all continents are facing the effects of the pandemic, our understanding of the various immediate and long-term complications of COVID-19 is evolving. SNHL is one of these complications. The Coalition for Epidemic Preparedness Innovations (CEPI) has developed a Brighton Collaboration case definition of SNHL to be utilized in the evaluation of adverse events following immunization, which can also be...

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  • A Ticking Time Bomb – incidental finding of a giant thoracoabdominal aneurysm

    Dear Editor,

    Giant aortic aneurysm is a rare clinical entity. They may present with typical features of chest pain or abdominal pain, or most feared complications with dissection and rupture. However, an asymptomatic and unruptured giant thoracic aneurysm is extremely rare with only two case reports in the literature.

    I had a similar case which an 80-year-old lady admitted to a local district general hospital with a 5 day history of productive cough with shivers, which she was tested positive for COVID-19 on admission.

    Diagnostic workup demonstrated an incidental finding of a giant TAAA. Her case was referred to a tertiary hospital for vascular Multidisciplinary Team (MDT) discussion and planning.

    It was decided that for her to have pre-operative assessment and MDT discussion after her recovery from infection to have a definitive management of the TAAA. The patient is currently being managed supportively in hospital.

    According to National Institute for Health and Care Excellence (NICE), asymptomatic and 5.5 cm or larger aneurysm should be considered for repair. The case should be discussed in terms of the overall balance of benefits and risks with repair and conservative management, based on the current status of health and the expected future health. In this case, it was deemed that the risk of proceeding with repair at present outweighed the benefits.

    Incidental finding of a giant AAA/TAAA is rare. It emphasises the importance...

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  • Aza induced hyperglycemia

    The author proposes two possible mechanisms for Aza induced hyperglycemia 1. Impaired beta cell function in pancreas via epigenetic mechanism 2. Increased secretion of cortisol. I suggest another possibility. A recent paper by Strand et al reports that Aza, a DNMT1 inhibitor, is a potent inducer of PTEN (this work done in vascular smooth muscle cells). It is well known that PTEN is an inhibitor of downstream elements of the insulin pathway, specifically PI3K-AKT-mTOR pathway and this results in insulin resistance. I suggest that the hyperglycemic activity of Aza is by PTEN induction of insulin resistance.
    Strand KA, Lu S, Mutryn MF, et al. High Throughput Screen Identifies the DNMT1 (DNA Methyltransferase-1) Inhibitor, 5-Azacytidine, as a Potent Inducer of PTEN. Arterioscler Thromb Vasc Biol. 2020;40:1854–1869.

  • Additional ST elevation in V1 and mild inferolateral ST depression

    A close comparison of baseline and exercise ECGs show mild ST elevation in V1 and mild inferolateral ST depression. Though the ST depression is mostly slow upsloping type, in lead I and V6 it is almost horizontal. The magnified view of the ECG makes ST elevation in V1 quite clear.

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