Thanks to the author and his colleagues. Two notes only:
1. Figure 2 is a sagittal, not a coronal MRI view.
2. The addition of "T2-weighted" to the phrases of both figures would
be helpful; the surrounding CSF signal is hyper-intense. Many doctors
don't know how to interpret the brain MRI images and we should deliver the
information as complete as possible.
Thanks to the author and his colleagues. Two notes only:
1. Figure 2 is a sagittal, not a coronal MRI view.
2. The addition of "T2-weighted" to the phrases of both figures would
be helpful; the surrounding CSF signal is hyper-intense. Many doctors
don't know how to interpret the brain MRI images and we should deliver the
information as complete as possible.
Reply to reader's observation:
The serotonin syndrome is a clinical diagnosis based on a broad spectrum
of certain clinical signs and symptoms after the intake of serotonergic
agents. Diagnosis of our case was based on the Hunter Criteria.1 Other
sets of diagnostic criteria have been studied for the definition of the
serotonin syndrome.2,3 However the Hunter Criteria were more accurate,
sensitive (84 per cent vs. 75 per...
Reply to reader's observation:
The serotonin syndrome is a clinical diagnosis based on a broad spectrum
of certain clinical signs and symptoms after the intake of serotonergic
agents. Diagnosis of our case was based on the Hunter Criteria.1 Other
sets of diagnostic criteria have been studied for the definition of the
serotonin syndrome.2,3 However the Hunter Criteria were more accurate,
sensitive (84 per cent vs. 75 per cent), specific (97 per cent vs. 96 per
cent) and simpler compared to the original Sternbach Criteria.1,4
Diagnostic Hunter Criteria include spontaneous clonus; inducible clonus
and agitation or diaphoresis; ocular clonus and agitation or diaphoresis;
tremor and hyperreflexia; hypertonia and temperature above 38*C and ocular
or inducible clonus.1,4,5 Not all clinical findings might be present in a
single patient. Presentation depends on mild, moderate or severe
toxicity.4-6 Our patient was on a dual serotonergic drug regimen of a
normal dose of venlafaxine and an overdose of sumatriptan, when he
developed spontaneous clonus resulting in head shaking with only mild
symptoms of serotonin toxicity (confer video in the full text).7 Signs of
neuromuscular hyperreactivity such as clonus (spontaneous or inducible)
with serial involuntary, rhythmic, muscular contractions and relaxations
are the most important diagnostic findings also to distinguish from the
neuroleptic malignant syndrome, anticholinergic and sympathomimetic
toxicity, or CNS infections.4,6 Bilateral occurrence of clonus is not
mandatory for the diagnosis of serotonin toxicity, however bilateral
Babinski signs may occur.4 Clonus is typically more pronounced in the
lower extremities in contrast to our patient's twitching of the head.4-6
However, previous observations described a "peculiar head-turning behavior
characterized by repetitive rotation of the head" in patients with
serotonin syndrome.5 Moreover animal studies found a link between head
movements and the serotonin system, where the head-twitch response is
induced by activation of serotonergic 5-ht receptors in rodents.8-10
Other mild cases of serotonin toxicity were found to be "afebrile but
tachycardic and with twitching or tremor".6,11 Fever higher than 38*C was
not as strongly associated with the diagnosis of the serotonin syndrome.1,
5 Otherwise temperature increase over 38.5*C usually caused by muscular
hyperactivity indicated severe life-threatening cases of serotonin
toxicity.1,4,5 In our patient with mild symptoms and low muscular
hyperactivity the temperature was not elevated.
Symptoms in our patient started shortly after increase of sumatriptan
dosage and typically resolved within 24 hours after the discontinuation of
serotonergic drugs and the initiation of symptomatic therapy with
benzodiazepines.
Synoptical with the timing of onset and resolution of symptoms, the
pattern of illness, and the results of investigations to rule out
alternative causes we established the diagnosis of a serotonin syndrome
aka serotonin toxicity. We did not rechallenge the patient with the drug
as a last option to attribute causality to the suspected adverse drug
reaction.12
References
1. Dunkley EJ, Isbister GK, Sibbritt D, et al. The Hunter Serotonin
Toxicity Criteria: simple and accurate diagnostic decision rules for
serotonin toxicity. QJM 2003; 96:635.
2. Sternbach H. The serotonin syndrome. Am J Psychiatry 1991; 148:
705-13.
3. Hegerl U, Bottlender R, Gallinat J, Kuss HJ, Ackenheil M, M?ller
HJ. The serotonin syndrome scale: first results on validity. Eur Arch
Psychiatry Clin Neurosci 1998; 248: 96-103.
4. http://www.uptodate.com/contents/serotonin-syndrome (accessed
October 21, 2013).
5. Boyer EW, Shannon M. The serotonin syndrome. N Engl J Med
2005;352:1112-20.
6. Iqbal MM, Basil MJ, Kaplan J, Iqbal MT. Overview of serotonin
syndrome. Ann Clin Psychiatry 2012; 24: 310-8.
7. Weiler S, Offinger A, Exadaktylos AK. Shaking head means "no". BMJ
Case Rep 2013 Sep 10;2013.
8. Darmani NA, Zhao W. Production of serotonin syndrome by 8-OH DPAT
in Cryptotis parva. Physiol Behav 1998; 65:327-31.
9. Reissig CJ, Eckler JR, Rabin RA, Rice KC, Winter JC. The stimulus
effects of 8-OH-DPAT: evidence for a 5-HT2A receptor-mediated component.
Pharmacol Biochem Behav 2008; 88:312-7.
10. Fantegrossi WE, Simoneau J, Cohen MS, Zimmerman SM, Henson CM,
Rice KC, Woods JH. Interaction of 5-HT2A and 5-HT2C receptors in R(-)-2,5-
dimethoxy-4-iodoamphetamine-elicited head twitch behavior in mice. J
Pharmacol Exp Ther 2010; 335:728-34.
11. Radomski JW, Dursun SM, Reveley MA, Kutcher SP. An exploratory
approach to the serotonin syndrome: an update of clinical phenomenology
and revised diagnostic criteria. Med Hypotheses. 2000; 55:218-24.
12. Edwards IR, Aronson JK. Adverse drug reactions: definitions,
diagnosis, and management. Lancet 2000; 356:1255-9.
We thank the reader for the interesting comment on our recently
published "Images in..." entitled Alcoholic Cardiomyopathy, describing a
case of severe cardiomegaly found at a chest X-ray in an alcoholic
patient. We agree on the utility of perfusion MRI in the differential
diagnosis of non-ischemic dilated cardiomegaly. Unfortunately, the patient
declined a perfusion MRI, thus we were not able to pe...
We thank the reader for the interesting comment on our recently
published "Images in..." entitled Alcoholic Cardiomyopathy, describing a
case of severe cardiomegaly found at a chest X-ray in an alcoholic
patient. We agree on the utility of perfusion MRI in the differential
diagnosis of non-ischemic dilated cardiomegaly. Unfortunately, the patient
declined a perfusion MRI, thus we were not able to perform it. The rapid
improvement of pulmonary oedema is surely a very important sign. We are
cautious, however, with its diagnostic utility because we cannot attribute
the improvement of ventricular volumes only to the cessation of drinking,
since both abstinence from alcohol use and heart failure pharmacological
treatment were started concurrently. We agree that cardiomegaly in a
patient complaining of exertional dyspnoea, peripheral oedema and reduced
effort tolerance is not specific per se and that obviously a "non dynamic"
exam, such as chest X-ray cannot provide information on the cause of
cardiomyopathy. However, in the reading and clinical interpretation of the
X-ray, we also considered the medical history of this patient, i.e. the
lack of risk factors for or history of cardiovascular disease as well as
the positive history for alcoholism during the last 20 years. As such, it
is reasonable that this chest X-ray connotes a specific image of alcoholic
cardiomyopahty. In summary, while radiology exams may not be diagnostic
per se, on the other hand their interpretation together with a complete
medical history may help the clinician to guide the diagnosis.
In the middle age, Asian Caucasian males frequently present with the
complaints of (1) penile retraction into pelvis leaving glans penis at
pubic arch, (2) feeling of mass or heaviness in pelvic urethra, (3)
discomfort requiring the patient to repeatedly pick the glans under
garments to pullout the penis to get relieved. Examinations in such cases
show evidence of prostate enlargement (80% cases) with o...
In the middle age, Asian Caucasian males frequently present with the
complaints of (1) penile retraction into pelvis leaving glans penis at
pubic arch, (2) feeling of mass or heaviness in pelvic urethra, (3)
discomfort requiring the patient to repeatedly pick the glans under
garments to pullout the penis to get relieved. Examinations in such cases
show evidence of prostate enlargement (80% cases) with or without
prostatitis and some cases presenting additional anal inflammatory
problem. In the case report where psychiatric patients present with Koro-
like symptoms, prostate findings need be described even if unequivocal.
Dear editor please delete the previous letter which I submitted one
hour ago and consider this new letter for response to the article
THE LETTER:
Very nice case and I read with much attention the article "
Alcoholic cardiomyopathy" by Antonio Mirijello, et al published in BMJ
Case Reports 2013 :doi:10.1136/bcr-2013-201449.
I think that the most important sign is the rapidity of myocardial
recovery during absti...
Dear editor please delete the previous letter which I submitted one
hour ago and consider this new letter for response to the article
THE LETTER:
Very nice case and I read with much attention the article "
Alcoholic cardiomyopathy" by Antonio Mirijello, et al published in BMJ
Case Reports 2013 :doi:10.1136/bcr-2013-201449.
I think that the most important sign is the rapidity of myocardial
recovery during abstinence of drinking with the rapidity of disappearing
of the signs: "cardiomegaly and pulmonary edema" in chest x-ray after
cessation of drinking.
Perfusion MRI can play a role in differential diagnosis of non ischemic
dilated cardiomegaly.
It will be great if the authors can explain in more details the meaning of
"typical signs of alcoholic cardiomyopathy" in one non dynamic chest x-ray
and what is the difference from other chest x-ray signs of other causes of
dilated hypertrophic cardiomyopathy?
Best regards
Suheil Artul
EMMS Hospital Nazareth Israel, Radiology Department
26-10-2013
Wijeyaratne and co-authors report on a case with fatal pulmonary
embolism of polyvinyl alcohol particles following therapeutic embolisation
of a peripherial arteriovenous malformation(1).
The citation that there is one other report of acute 'pulmonary
hypertension' following transcatheter embolisation is not total correct.
It was a circulatory arrest ( pulmonary embolism grade IV) which requir...
Wijeyaratne and co-authors report on a case with fatal pulmonary
embolism of polyvinyl alcohol particles following therapeutic embolisation
of a peripherial arteriovenous malformation(1).
The citation that there is one other report of acute 'pulmonary
hypertension' following transcatheter embolisation is not total correct.
It was a circulatory arrest ( pulmonary embolism grade IV) which required
mechanical resuscitation for about 50 minutes and veno-arterial
extracorporeal membrane oxygenation support was preformed until
hemodynamic stability was regained (2).
(1) Wijeyaratne SM, Ubayasiri RA, Weerasinghe C. Fatal pulmonary
embolism of polyvinyl alcohol particels following therapeutic embolisation
of a peripheral arteriovenous malformation. BMJ Case Reports 2009;
doi:10.1136/bcr.02.2009.1635
(2) Haller I, Kofler A, Lederer W, Chemelli A, Wiedermann FJ. Acute
pulmonary artery embolism during transcatheter embolization: successful
resuscitation with veno-arterial extracorporeal membrane oxygenation.
Anesth Analg. 2008 Sep;107(3):945-7
Hereby, we would like to comment on the case report, you published
earlier this year entitled "Histological diagnosis of cardiac lipoma in an
adult with tuberous sclerosis complex" (1). The authors state that they
presented the first case of an adult with tuberous sclerosis complex,
where a histological diagnosis of cardiac lipoma was made. Therefore, we
would like to draw your attention to the Atlas of Tumor Pathology
p...
Hereby, we would like to comment on the case report, you published
earlier this year entitled "Histological diagnosis of cardiac lipoma in an
adult with tuberous sclerosis complex" (1). The authors state that they
presented the first case of an adult with tuberous sclerosis complex,
where a histological diagnosis of cardiac lipoma was made. Therefore, we
would like to draw your attention to the Atlas of Tumor Pathology
published by the Armed Forces Institute of Pathology in 1978 (2) in which
three adult TSC-patients with multiple lipomas in the myocardium were
presented. Furthermore, in 2011 the Journal of Clinical Pathology
published a report in which the histopathological findings of areas of
mature fat cells in the myocardium of two adult TSC-patients were
presented (3). The before mentioned areas of mature fat cells in the
myocardium showed no associated inflammation, no associated fibrosis, no
entrapped myocardial cells, and no capsule. As far as we can judge from
Figure 1 in the BMJ case report, the presented area of adipocytes
resembles the figures presented in the Journal of Clinical Pathology.
Therefore, it would be interesting to know whether the authors of the BMJ
case report can confirm that the presented solid population of adipocytes
in their adult TSC-patient showed no associated inflammation, no
associated fibrosis, and no capsule in keeping with the suggested unique
finding for tuberous sclerosis complex of areas of mature fat cells in the
myocardium presented in 2011.
1. Jabir S, Al-Hyassat S. Histological diagnosis of cardiac lipoma in
an adult with tuberous sclerosis complex. BMJ Case Rep. 2013 Jan 3;2013.
2. McAllister HA, Fenoglio JJ. Tumors of the cardiovascular system.
In: Atlas of Tumor Pathology. Armed Forces Institute of Pathology, editor.
Washington D.C. 1978:40-46
3. Adriaensen ME, van Oosterhout MF, Feringa HH, Schaefer-Prokop CM,
Zonnenberg BA, Prokop M. Mature fat cells in the myocardium of patients
with tuberous sclerosis complex. J Clin Pathol. 2011 Mar;64(3):244-5
To; Artemis Igoumenou, Maria G Turri, Raana Din, and Harvey Gordon
As I can see that this patient has been with long standing history of
multiple axis diagnosis which is been used in DSM diagnosis ,he is been
treated with various medications. He is currently 56 years which means
that his care plan should be in line with his current health ,age and
presentations. As he is clearly presenting with early changes in his
int...
To; Artemis Igoumenou, Maria G Turri, Raana Din, and Harvey Gordon
As I can see that this patient has been with long standing history of
multiple axis diagnosis which is been used in DSM diagnosis ,he is been
treated with various medications. He is currently 56 years which means
that his care plan should be in line with his current health ,age and
presentations. As he is clearly presenting with early changes in his
intellectual functions along with his history of autistic disorder
associated with unpredictable and violence behaviour this increase the
concerns regarding this man condition .The current concerns about
community care of the mentally disordered patients focus on the level of
risk of unacceptable behaviour, particularly inappropriate aggressive or
sexual acts. It is clear that such behaviour occurs in patients suffering
from mental disorders, and might be expected to be more common in
psychotic states, when provocation from delusional and hallucinatory
perceptions is present. The presence of concurrent personality disorder or
history of previous violent or antisocial behaviour increases the risk of
people with psychotic disorders committing violent offences. The
methodology of most of studies on which these conclusions are based has
been flawed, with selection bias, lack of diagnostic precision and results
often based upon criminal records rather than clearly defined ratings of
behaviours. The issue of unreported and non-criminal aggressive behaviour,
including inappropriate sexual behaviour, particularly in the context of
family or residential care has been studied less extensively. Furthermore
the course of this misconduct and the effects of continued community
treatment have been seldom examined. One excellent study compared the
course of aggressive behaviour in a cohort of patients after discharge
from acute psychiatric hospital care. In one centre a comparison group of
people living in the same neighbourhoods indicated that after the initial
10 weeks of follow-up there was no difference in the prevalence of
violence by patients and that of their neighbours, when substance abuse
was absent in both groups. Violence in both groups was usually committed
at home and targeted at family and friends. The context of this violence
was not explored in detail, although it is evident that severely mentally
disordered patients are often themselves the victims of violent behaviour
. It is probable that a substantial proportion of aggressive acts may be
provoked by aggression and coercion towards the patients themselves.
Finally, although it is clear that psychoactive medication can induce a
substantial reduction in aggressive behaviour , and that non-adherence to
community- based treatment is a predictor of severe violence in
schizophrenia the effects of long-term optimal treatment programmes on the
level of aggressive behaviour have seldom been reported. It may be
concluded that the hypothesis that aggressive and inappropriate behaviour
is more common in people suffering severe schizophrenic disorders,
particularly those characterised by persisting psychotic symptoms, with
impaired decision-making abilities, including difficulties with adherence
to community-based treatment programmes, has not been proven conclusively.
There appears to be an increased risk of misconduct in cases when active
psychotic experiences provoke anger and frustration, particularly when
judgement is further clouded by drugs or alcohol . There is an urgent need
to provide reassurance to the community that efforts to prevent offensive
behaviour by people with schizophrenia are realistic and that offending is
managed according to the same standards of justice expected of all
citizens. Different reports describes the changes in a broad range of
aggressive behaviour and sexual misconduct of chronic patients who were
receiving continued evidence-based biomedical and psychosocial treatment.
It was hypothesized that continued treatment would contribute to a lower
rate of these behaviours over time .I do believe that there are hundreds
of patient who they received inadequate diagnosis either because there
cases started quite earlier in their life or because their symptoms not
fitting any of the international diagnosis, therefore the best we can use
for treating them is to use the bio psycho social model in their care plan
approaches ,using the least restrictive methods in treating them when they
have crisis warrants admissions and to plan ahead for their future
progression into old age psychiatry. One has to liaise with learning
disability team to assess him and to evaluate his need if required.
Dr Osama Hammer
MBBCH. ,MSc., MRCPsych Sussex Partnership trust
We would like to thank the author/s for the comment made above with
regards to our publication in January of 2013 entitled "Histological
diagnosis of cardiac lipoma in an adult with tuberous sclerosis"1. In this
report we alleged, following a review of the current literature, that this
was the first report of its kind where a histological diagnosis of cardiac
lipoma in an adult with tuberous sclerosis was made and that we d...
We would like to thank the author/s for the comment made above with
regards to our publication in January of 2013 entitled "Histological
diagnosis of cardiac lipoma in an adult with tuberous sclerosis"1. In this
report we alleged, following a review of the current literature, that this
was the first report of its kind where a histological diagnosis of cardiac
lipoma in an adult with tuberous sclerosis was made and that we did not
find any such reports previously. We would like to thank the author/s of
the above comment for bringing to our attention two previous sources that
have documented similar pathological findings to ours.
We were surprised to note that this was described as early as 1978 within
the Atlas of Tumor Pathology published by the Armed Forces Institute of
Pathology (although we ourselves have not been able to peruse a copy of
this book). Furthermore, we confirm that the lipomatous lesions within the
myocardium of our patient did not show any associated inflammation,
fibrosis or a capsule surrounding it.
More importantly, this comment brought to our attention a few important
factors, which we believe may be useful for future authors who may believe
theirs is a highly unique case which has not been described previously.
These factors include:
1) A comprehensive literature search involving all possible variations in
terminology. The reason we did not come across the publication in the
Journal of Clinical Pathology referred to above, was because we did not
use the term "fat cells" when performing out database search2. Rather, we
only used the term "lipoma" when performing our search which resulted in
the above study being excluded from our search.
2) When claiming primacy of findings, one should phrase this claim in
"tentative" language. What we mean by this is that one should phrase the
claim in such a way that they concede the possibility of the report having
been made previously. Hence, we recommend using terminology such as "we
believe this to be the first such case" or "the authors' believe this to
be the first such case". This leaves open the possibility of other reports
of a similar nature.
Shehab Jabir
Samir Al-Hyassat
References
1. Jabir S, Al-Hyassat S. Histological diagnosis of cardiac lipoma in
an adult with tuberous sclerosis. BMJ Case Rep. 2013 Jan 3;2013. doi:pii:
bcr2012007484.10.1136/bcr-2012-007484.
2. Adriaensen ME, van Oosterhout MF, Feringa HH, Schaefer-Prokop CM,
Zonnenberg BA, Prokop M. Mature fat cells in the myocardium of patients
with tuberous sclerosis complex. J Clin Pathol. 2011 Mar;64(3):244-5.
doi:10.1136/jcp.2010.087676
Thanks to the author and his colleagues. Two notes only:
1. Figure 2 is a sagittal, not a coronal MRI view.
2. The addition of "T2-weighted" to the phrases of both figures would be helpful; the surrounding CSF signal is hyper-intense. Many doctors don't know how to interpret the brain MRI images and we should deliver the information as complete as possible.
Conflict of Interest:
...Reply to reader's observation: The serotonin syndrome is a clinical diagnosis based on a broad spectrum of certain clinical signs and symptoms after the intake of serotonergic agents. Diagnosis of our case was based on the Hunter Criteria.1 Other sets of diagnostic criteria have been studied for the definition of the serotonin syndrome.2,3 However the Hunter Criteria were more accurate, sensitive (84 per cent vs. 75 per...
Hi Dr Wu and Dr Mueller,
Thanks for your excellent case report. I have a patient of proven refractory reflux pain even after fundoplication .
Do you think coeliac plexus or other blocks may help in such situations? What other such interventions may help to relieve his reflux pain?
What happened to your patient's pain after 11 weeks?
Would be grateful for your response to these queri...
Dear Editor,
We thank the reader for the interesting comment on our recently published "Images in..." entitled Alcoholic Cardiomyopathy, describing a case of severe cardiomegaly found at a chest X-ray in an alcoholic patient. We agree on the utility of perfusion MRI in the differential diagnosis of non-ischemic dilated cardiomegaly. Unfortunately, the patient declined a perfusion MRI, thus we were not able to pe...
Editor Sir:
In the middle age, Asian Caucasian males frequently present with the complaints of (1) penile retraction into pelvis leaving glans penis at pubic arch, (2) feeling of mass or heaviness in pelvic urethra, (3) discomfort requiring the patient to repeatedly pick the glans under garments to pullout the penis to get relieved. Examinations in such cases show evidence of prostate enlargement (80% cases) with o...Dear editor please delete the previous letter which I submitted one hour ago and consider this new letter for response to the article THE LETTER:
Very nice case and I read with much attention the article " Alcoholic cardiomyopathy" by Antonio Mirijello, et al published in BMJ Case Reports 2013 :doi:10.1136/bcr-2013-201449. I think that the most important sign is the rapidity of myocardial recovery during absti...
Dear Sir,
Wijeyaratne and co-authors report on a case with fatal pulmonary embolism of polyvinyl alcohol particles following therapeutic embolisation of a peripherial arteriovenous malformation(1).
The citation that there is one other report of acute 'pulmonary hypertension' following transcatheter embolisation is not total correct. It was a circulatory arrest ( pulmonary embolism grade IV) which requir...
Hereby, we would like to comment on the case report, you published earlier this year entitled "Histological diagnosis of cardiac lipoma in an adult with tuberous sclerosis complex" (1). The authors state that they presented the first case of an adult with tuberous sclerosis complex, where a histological diagnosis of cardiac lipoma was made. Therefore, we would like to draw your attention to the Atlas of Tumor Pathology p...
To; Artemis Igoumenou, Maria G Turri, Raana Din, and Harvey Gordon As I can see that this patient has been with long standing history of multiple axis diagnosis which is been used in DSM diagnosis ,he is been treated with various medications. He is currently 56 years which means that his care plan should be in line with his current health ,age and presentations. As he is clearly presenting with early changes in his int...
We would like to thank the author/s for the comment made above with regards to our publication in January of 2013 entitled "Histological diagnosis of cardiac lipoma in an adult with tuberous sclerosis"1. In this report we alleged, following a review of the current literature, that this was the first report of its kind where a histological diagnosis of cardiac lipoma in an adult with tuberous sclerosis was made and that we d...
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