47 e-Letters

published between 2020 and 2023

  • Incidence of mucormycosis is in raise in India due to covid-19 in second wave of2021

    Dear Editor,
    Mucormycosis is a fatal fungal infections that mainly affects people who are on medications for other health problems that reduces their ability to fight for environmental pathogens.India is a known to have high burden of mucormycosis cases especially in those with un controlled type 2DM and prevalence of mucormycosis has gone this time up to 2.1times to 3 times during second wave of covid 19 pandemic in India. This may be termed as Covid Associated Mucormycosis or CAM.Prvalance of CAM amongst the covid-19 patients is 0.27/%,and in ICU or in CCU is 1.6% when they are treated with steroid and to those in patients who had high level of blood sugar due to covid- 19 or have high level of ferritin.Occasionally in patients with unconrolled DM ( whose neutrophils functions is impaired in diabetic and those who have neutropenia or altered NL ratio as in covid 19 , as primary defence of mucormycosis is done with neutrophils attached with hyphae ) or in hematlogical malignancies, or in hemopoietic stem cells transplant or in solid organ transplant or in patient's with vercanzole therapy or with immunomodulatory drugs or other immunosuppressive drugs develop fatal mucormycosis.
    In covid 19 wards or in SARI wards mucormycosis may develop due to 1) That NL ratio is altered 2) from treatment of steroid dexamethasone injection 3) use of tocilizumab therapy 4) uses of Immunomodulatory drugs like Baricitinib ,tofacitinib and usually found in later pa...

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  • Response from authors

    The association between heart failure and energy drink consumption is based on the entire clinical course rather than the presentation alone. The patient remains in renal failure with renal biochemistry similar to presentation and has not received renal replacement therapy for some time. Despite this, the patient is no longer in heart failure with a significant improvement in cardiac function occurring prior to the introduction of heart failure medications - carvedilol, hydralazine and isosorbide dinitrite. The clinical course of spontaneous recovery was similar to the cited case report from Belzile and colleagues and hence our reason for bringing this to attention and contributing to greater awareness. We welcome the comments and debate as there is no test to confirm the relationship to energy drink intake and therefore extensive clinical characterisation is required to exclude alternative causes of severe heart failure. Severe heart failure which improves spontaneously to this magnitude - LVEF 9% to 51% is particularly rare.

  • Response from authors

    Dear Sir/Madam,

    Thank you for your comments

    Please see below for clarification to your queries:

    1) What was Central Venous Pressure:

    The CVP pressure was not measured as the patient was relatively well. Are you perhaps referring to JVP which was unremarkable.

    2) If patient was, presumably Conscious, Oriented, able to take Food and Fluids by Mouth, could the Intravenous Administration of Fluids be avoided?

    It is possible that IV fluids could have been avoided but in view of his AKI it was felt prudent to rehydrate with IV fluids. We appreciate that management in this scenario will differ.

    3) How did the Elevated Blood Pressure evolved during Hospitalization, either with or without Medications.

    He had only one dose of amlodipine as inpatient and didn’t require any further doses for BP control. On discharge his Blood pressure was within normal limits and his GP was advised to continue monitoring his blood pressure as he had previously been doing.

    4) What was Patient's Diet and Fluid Intake Both Quantitative and Qualitative during the Hospitalization?

    AKI resolved within 24 hours of admission so exact fluid intake, urinary output and diet were not documented.

    5) Whether the Patient took any Formal or Alternative Medicines or Home Remedies for Coryza he had Two Weeks before Episode of Shortness of Breath, that could have caused Autoimmune Hemolysis?

    The patient had not...

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  • Therapeutic strategy of Malignant glioma and the fetal-maternal wellbeing

    Dear Dr. Biswas,
    In their recent article ‘Anaplastic astrocytoma during pregnancy: the importance of an effective multidisciplinary approach’, Filippi and colleagues described the therapeutic strategy for a pregnant patient whose left parietal glioma was discovered after a new-onset generalized seizure [1]. Following the multidisciplinary conference, they planned to attain a full-term pregnancy with staged tumor resection. First, the mass reduction was performed with neuronavigation and fluorescence-guided surgery using 5-aminolevulinic acid (5-ALA) under general anesthesia. Then awake craniotomy was planned for the residual tumor removal after delivery. Although the authors have provided excellent perioperative care for this complicated case, we have some reservations about the therapeutic strategy for malignant glioma in a pregnant patient.
    The guidelines for the diagnosis and treatment of gliomas, released by the European Association for Neuro-Oncology, present the following management options for newly diagnosed malignant glioma: resection or biopsy, followed by radiotherapy or chemotherapy (or combined modality treatment) [2]. In pregnant patients, the neurosurgical intervention for a malignant tumor is recommended regardless of gestational age, although the 32 week gestation point is generally used as the cutoff [3]. The extent of glioma resection is a decisive prognosis factor irrespective of tumor subtype [4]. In view of the absence of information on th...

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  • 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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  • Treat all Caffeinated Beverages Equally

    The authors implicate caffeine as the causative agent of the cardiomyopathy in this case, caffeine being the main active ingredient within energy drinks. They ask that we enquire about energy drinks within our social histories; consumption of caffeinated products indeed not part of a standard cardiovascular history (1).

    It is therefore conspicuous that within the article there are no calls to enquire about other, more widely used caffeine containing products, specifically tea and coffee. Dare I say, we would be unlikely to baulk at the idea of a patient drinking three or four coffees in a day. In fact, on the wards we offer patients tea or coffee eight times a day, yet think little of the caffeine burden we are imposing upon them. This almost tacit caffeine consumption is unlikely to make it into the medical notes, yet these patients would potentially be consuming levels of caffeine far in excess of the quantity consumed in this case report.

    We seem to apply different value judgements to different drinks, assuming those drinking excess caffeine from expensive coffee machines are doing so knowingly, and as part of a healthy lifestyle. Yet we don’t afford those choosing to consume energy drinks with the same level of ability to make an informed choice. We medicalise the consumption of such drinks, assuming those using them must be doing so for sinister reasons.

    We should treat all caffeinated products equally, given there is no pharmacological differen...

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  • 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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  • 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.

  • 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.

  • Consistent messaging in airway emergencies

    We thank Dr Yap and colleagues for describing clearly the successful management of an unexpectedly challenging airway.1 We agree that the index case highlights the need for vigilance in all patients requiring airway management, particularly where an atypical presentation of a respiratory condition may indicate occult airway pathology.2 However, the case raises a number of important issues for airway assessment, intubation-related laryngeal pathology and the management of ‘can’t intubate, can’t ventilate’ scenarios which warrant further discussion, considered below.

    Airway assessment can be encapsulated by the quote, “Hindsight is a wonderful thing but foresight is better, especially when it comes to saving life,” attributed the 19th Century English poet William Blake. Whilst subtle, there were a number of clues in the described case report that could, and perhaps should, have prompted a more thorough evaluation of the airway. It is surprising that the patient did not report their extreme prematurity at birth, or the fact that they spent the first year of their life in hospital. This would have almost certainly have involved prolonged ventilation and sequelae into childhood. Respiratory and airway complications are well recognised in premature neonates and may coexist.3 The authors highlight the Difficult Airway Society’s airway algorithms and the fact that any clinician managing an airway should prepare for failure.4-6 This should involve an examination of the front...

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