This case report about aortic dissection is a good reminder to always
consider this condition in acute chest pain particularly in patients with
hypertension or a connective tissue disorder such as Marfans,
SInce using this blood test as a rule out investigation in recent years we
have made the diagnosis increasingly early in our institution.. A Google
search revealed 5040 hits. Doctors have been missing this diagnodis for...
This case report about aortic dissection is a good reminder to always
consider this condition in acute chest pain particularly in patients with
hypertension or a connective tissue disorder such as Marfans,
SInce using this blood test as a rule out investigation in recent years we
have made the diagnosis increasingly early in our institution.. A Google
search revealed 5040 hits. Doctors have been missing this diagnodis for
decades.
I suspect you will receive further correspondence regarding this.
The present report (1) of dengue shock syndrome raises many important questions.It is estimated that at least 10% of dengue fever cases evolve to severe and eventually lethal forms of the disease and a negative serology does not rule out dengue (2). In such cases one has to rely on early clinical features to prevent complications. One such presentation that emerges is Opsoclonus Myoclonus Syndrome (3)(4) A one year old patient pr...
The present report (1) of dengue shock syndrome raises many important questions.It is estimated that at least 10% of dengue fever cases evolve to severe and eventually lethal forms of the disease and a negative serology does not rule out dengue (2). In such cases one has to rely on early clinical features to prevent complications. One such presentation that emerges is Opsoclonus Myoclonus Syndrome (3)(4) A one year old patient presented with fever with leukopenia and a platelet count of 2,41,000 and in a days time the platelets fell to 1,34,000 and the liver was palpable with a rise in SGOT and hematocrit. The child presented with a opsoclonus myoclonus kind of seizure which was diagnosed as febrile convulsion prior to derangement of the platelet count and liver enzyme. The opsoclonus myoclonus and the recent reports of association of these with dengue prompted the doctors to recheck the hematocrit, platelets and liver enzymes which were initially normal. This points out the importance of clinical features like opsoclonus myoclonus which alerts the treating doctor and it is important to recognise this syndrome as a marker of severe form of dengue and differentiate it from typical febrile convulsions which may occur in any febrile illness including dengue.
References
1) Linda Aurpibul,Punyawee Khumlue, Satja Issaranggoon na ayuthaya,Peninnah Oberdorfer. Dengue shock syndrome in an infant. BMJ Case Reports 2014
2) Osorio L(1), Ramirez M, Bonelo A, Villar LA, Parra B. Comparison of the diagnostic accuracy of commercial NS1-based diagnostic tests for early dengue infection.Virol J. 2010 Dec 6;7:361. doi: 10.1186/1743-422X-7-361.
3)Tan AH, Linn, Ramli NM, Hlaing CS, Aye AM, Sam IC, Ng CG, Goh KJ, Tan CT, Lim SY. Opsoclonus-myoclonus-ataxia syndrome associated with dengue virus infection.Parkinsonism Relat Disord. 2014 Sep 16. pii: S1353-8020(14)00324-1. doi:10.1016/j.parkreldis.2014.09.002.
4) Verma R(1), Sharma P, Garg RK, Atam V, Singh MK, Mehrotra HS.Neurological complications of dengue fever: Experience from a tertiary center of
north India.Ann Indian Acad Neurol. 2011 Oct;14(4):272-8. doi: 10.4103/0972-2327.91946.
A very interesting case report but a common omission seen again
in this report as is seen in real life in the wards . Any x -ray for an
acute abdomen should always include both the domes of diaphragm which I
cannot see in the AP view in figure A (only left dome visible) as
compared to B where both domes are clearly visible ( unless it was done
originally but cut off in the view shown here in this report) whic...
A very interesting case report but a common omission seen again
in this report as is seen in real life in the wards . Any x -ray for an
acute abdomen should always include both the domes of diaphragm which I
cannot see in the AP view in figure A (only left dome visible) as
compared to B where both domes are clearly visible ( unless it was done
originally but cut off in the view shown here in this report) which may
lead to loss of very valuable sign of gas under the diaphragm . A
decubitus film is a valuable view but if both domes of diaphragm
specially the right are visible in an AP view , it could avoid a
decubitus view specially in a very sick patient ( as in ventilated sick
newborn babies ) where it may not be possible. A lateral 'shoot
through' is done to diagnose perforation in such cases if needed,
specially if the air leak is not a lot which can even easily disappear
in a repeat x ray after few hours or at laparotomy.
So the take home message is to always insist on complete view of both
domes of diaphragm in an abdominal x ray for acute abdomen by clearly
mentioning on the request form otherwise it does not happen ( as in
this case reported ), resulting in repeat x rays or additional views on
some occasions.
As a clinical neurologist with interest in laterality of motor
control and consciousness, 1, 2 I read the contribution by Simonin and
colleagues and have the following clinical and neurophysiological comments
on their interpretation of the findings in their remarkable (presumably
right handed) patient. Thus, a spontaneously breathing patient with a non-
traumatic left subdural hematoma displayed bilate...
As a clinical neurologist with interest in laterality of motor
control and consciousness, 1, 2 I read the contribution by Simonin and
colleagues and have the following clinical and neurophysiological comments
on their interpretation of the findings in their remarkable (presumably
right handed) patient. Thus, a spontaneously breathing patient with a non-
traumatic left subdural hematoma displayed bilateral hemiplegia with an
ostensibly diminished level of consciousness. The EEG, however, indicated
absence of epileptiform discharges and presence of "reactive waveforms,"
indicating a wakeful state. The patient's consciousness improved
significantly after two weeks but he remained with a left hemiparesis six
months after discharge. The authors ascribed the presenting feature of the
patient, i.e. left hemiplegia ipsilateral to the lesion, to a Kernohan-
Woltman phenomenon in the absence of the same in the initial CT scans.
This interpretation, however, ignores the fact that only 50 % of Kernohan
and Woltman's patients with notching of contralateral peduncles (17/35
with supratentorial lesions) displayed the dreaded ipsilateral pyramidal
signs; raising doubt about the original belief of Kernohan and Wolman as
to the role of notching in causing the ipsilateral phenomenon they
described. 3, 4 Meanwhile, there are plenty of case reports describing
ipsilateral paralysis in subdural hematoma in the absence of any Kernohan
notch (one of those being case 1 reported by Moon et al and by the
authors). 1, 3, 4 As detailed elsewhere, 5-7 the abovementioned two
classes of exceptions make the case that ipsilateral paralysis is a
laterality indexed diaschitic phenomenon based on the withdrawal of the
excitatory signals arising from the major hemisphere and destined for the
minor for movements occurring on the nondominant side of the body (i.e.
ipsilateral to the lesion). This circuitry explains the temporary nature
of the nondominant side weakness after the initial complete paralysis seen
in the patient, with the remaining weakness indicating incomplete
resolution of the initial insult within the major hemisphere. It also
explains the association between the laterality of motor control and
consciousness housed within the executive hemisphere. 7-9 Hallmarks of
lesions affecting the minor hemisphere are contralateral paralysis in the
absence of awareness of the same (anosognosia) and the conjugate deviation
of the eyes toward that hemisphere. 10 This is because sensory signals
arising from the nondominant side cannot reach consciousness before their
arrival to the major hemisphere via the posterior callosum. Bilateral
absence of sensory evoked potentials upon stimulation of the left side is
the electrodiagnostic confirmation of the above described explanation. 11
The role of callosum in underpinning dominance of the major hemisphere
over the minor (slave) hemisphere is manifested by the faster speed of the
dominant hand in bimanual simultaneous movements upon using a pencil and
paper or an etch-a-sketch device or while employing a straightedge as
described by Hall and Hartwell in Mind in 1884. 6, 7, 12
Acknowledgement: This note is dedicated to the tender memories of my
sister Farkhondeh Derakhshan
References:
1. Simonin A, Levivier M, Nistor S, Diserens K. Kernohan's notch and
misdiagnosis
of disorders of consciousness. BMJ Case Rep 2014, 17; 2014
2. Derakhshan I, Binder DK, Lyon R, Manley GT . Transcranial motor
evoked potential recording in a case of Kernohan's notch syndrome: case
report. Neurosurgery 2005; 56: E1166.
3. Moon KS, Lee JK, Joo SP, Kim TS, Jung S, Kim JH, Kim SH, Kang SS.
Kernohan's
notch phenomenon in chronic subdural hematoma: MRI findings. J Clin
Neurosci 2007;14: 989-992.
4. De Oliveira-Souza R, Benchimol M. Coma and transtentorial
herniation syndrome
due to acute non-expansive hemispheric lesion. Arq Neuropsiquiatr 1995;
53: 815-820.
5. Derakhshan I. Lateralities of motor control and the alien hand
always coincide: further observations on directionality in callosal
traffic underpinning handedness. Neurol Res 2009; 31: 258-264.
6. Derakhshan I. Right sided weakness with right subdural hematoma:
motor deafferentation of left hemisphere resulted in paralysis of the
right side. Brain Inj 2009; 23: 770-774.
7. Derakhshan I. Bimanual simultaneous movements and hemispheric
dominance:
Timing of events reveals hard-wired circuitry for action, speech, and
imagination. Psychol Res Behav Manag 2008; 1: 1-9.
8. Derakhshan I. Voluntary brain processing in disorders of
consciousness. Neurology 2009 17; 73:1712; author reply 1712-1713.
9. Derakhshan I. Laterality of motor control and consciousness share
the same hemisphere. Anesthesiology 2013;119:727-728.
10. Derakhshan I. Lateralization of cognitive functions in aphasia
after right brain amage. Yonsei Med J. 2013; 54:1070-1071.
11. Green JB, Hamilton WJ. Anosognosia for hemiplegia: somatosensory
evoked
potential studies. Neurology 1976; 26:1141-1144.
12. Willford JA, Chandler LS, Goldschmidt L, Day NL. Effects of
prenatal tobacco, alcohol and marijuana exposure on processing speed,
visual-motor coordination, and interhemispheric transfer. Neurotoxicol
Teratol 2010; 32: 580-588. (see Page 2 and Figure 1)
To the Editor: I read with interest the article by Liu A et al (1). The authors have described the management of asymptomatic patient with electrocardiographic (ECG) evidence of pre-excitation. Certain aspects of this report needs to be highlighted.
Asymptomatic patients with ECG evidence of pre-excitation of the ventricles are labelled as Wolf-Parkinson-White (WPW) pattern. On the contrary patients with documented tachyarrhythmia...
To the Editor: I read with interest the article by Liu A et al (1). The authors have described the management of asymptomatic patient with electrocardiographic (ECG) evidence of pre-excitation. Certain aspects of this report needs to be highlighted.
Asymptomatic patients with ECG evidence of pre-excitation of the ventricles are labelled as Wolf-Parkinson-White (WPW) pattern. On the contrary patients with documented tachyarrhythmias with pre-excited ECG are diagnosed as WPW syndrome (2). It is preferable to use these terminologies which are recommended by European society of cardiology.
The crucial factor which determines the risk of developing tachyarrhythmias in patients with WPW pattern is the refractory period of the accessory pathway. If the refractory period of the accessory pathway exceeds 250 ms, the risk of tachyarrhythmias is extremely low (2). Pointers to significantly prolonged refractory period of accessory pathway are abrupt disappearance of delta wave on the surface ECG at rest or during exercise stress test (3). Though the guidelines do not recommend non-invasive risk stratification, exercise testing is a simple, non-invasive tool to identify low risk individuals. In patients with WPW ECG pattern who are not ready to undergo EPS, exercise test may identify individuals at low risk of precipitating ventricular fibrillation. This can be reassuring to both the asymptomatic patient and treating physician.
References:
1. Liu A, Pusalkar P. Asymptomatic Wolff-Parkinson-White syndrome: incidental ECG diagnosis and a review of literature regarding current treatment. BMJ Case Reports 2011;10.1136
2. Blomstrom-Lundqvist C, Scheinman MM, Aliot E, e t al. Supraventricular Arrhythmias (ACC/AHA/ESC Guidelines for the Management of Patients with) ESC Clinical Practice Guidelines EHJ 2003;24:1857 - 97
3. Jezior MR, Kent SM, Atwood JE Exercise testing in Wolff-Parkinson-White syndrome: case report with ECG and literature review Chest 2005;127:1454-7
I read with interest your recent paper in BMJ Case Reports. Based on
the single case, you concluded that long-term Li treatment might cause
cortical atrophy. Without pre-Li MRI or evidence for increases in GM
following discontinuation of Li, this conclusion seems tentative. Even if
this was the case, perhaps the brain changes were not related to the
duration of use. We detected positive asso...
I read with interest your recent paper in BMJ Case Reports. Based on
the single case, you concluded that long-term Li treatment might cause
cortical atrophy. Without pre-Li MRI or evidence for increases in GM
following discontinuation of Li, this conclusion seems tentative. Even if
this was the case, perhaps the brain changes were not related to the
duration of use. We detected positive association between brain gray
matter and Li use even in patients with an average of >10 years of Li
treatment (1-3). Importantly, these patients have had regular Li
monitoring. The frequency and quality of monitoring may well determine,
whether Li would show neuroprotective effects or not, especially with long
term use.
Lithium is neurotoxic above a relatively narrow therapeutic range
and/or in combination with certain medications (haloperidol). In addition,
treatment with NSAIDs, ACE inhibitors, diuretics may yield toxic Li
levels, same as renal disease or even acute gastrointestinal problems or
dehydration.
The above-mentioned issues obviously become more likely with the
duration of treatment, especially if there is no regular monitoring and no
adjustments of the dose. Chronic and unmonitored use of Li may lead to
repeated intoxications, due to interactions with other medications,
changes in Li clearance with age, increase in rates of comorbid conditions
with age.
Based on the available literature, the long duration of treatment may
in fact be a pre-requisite for the putative neuroprotective effects to
occur - see the studies in amnestic mild cognitive impairment (4) and
Alzheimer dementia (5), as well as the pharmacoepidemiological studies
showing association between Li treatment and lower risk of dementia, but
only with repeated use (6). However, without careful and regular
monitoring, long-term Li treatment may be problematic.
Sincerely, Tomas Hajek
Reference List
1. Hajek T, Cullis J, Novak T, Kopecek M, Hoschl C, Blagdon R et al.
(2012): Hippocampal volumes in bipolar disorders: opposing effects of
illness burden and lithium treatment. Bipolar Disorders 14: 261-270.
2. Hajek T, Bauer M, Pfennig A, Cullis J, Ploch J, O'donovan C et
al. (2012): Large positive effect of lithium on prefrontal cortex N-
acetylaspartate in patients with bipolar disorder: 2-centre study. Journal
of Psychiatry and Neuroscience 37: 185-192.
3. Hajek T, Bauer M, Simhandl C, Rybakowski J, O'donovan C, Pfennig
A et al. (2013): Neuroprotective effect of lithium on hippocampal volumes
in bipolar disorder independent of long-term treatment response. Psychol
Med : 1-11.
5. Nunes MA, Viel TA, Buck HS (2013): Microdose lithium treatment
stabilized cognitive impairment in patients with Alzheimer's disease. Curr
Alzheimer Res 10: 104-107.
6. Kessing LV, Sondergard L, Forman JL, Andersen PK (2008): Lithium
treatment and risk of dementia. Arch Gen Psychiatry 65: 1331-1335.
I read with interest the case report on complications of trans
thoracic lung biopsy. Only a few studies have systematically evaluated
risk factors for pneumothorax and pulmonary haemorrhage in computed
tomographically (CT)-guided transthoracic lung biopsy (TLB). One study
looking into the factors affecting diagnostic yield and complication
rates, by Heyer CM and colleagues in 2008, showed that the...
I read with interest the case report on complications of trans
thoracic lung biopsy. Only a few studies have systematically evaluated
risk factors for pneumothorax and pulmonary haemorrhage in computed
tomographically (CT)-guided transthoracic lung biopsy (TLB). One study
looking into the factors affecting diagnostic yield and complication
rates, by Heyer CM and colleagues in 2008, showed that the rate of
pneumothorax was influenced by the size and depth of the lesion. This
study was done on 172 CT guided TLBs which were performed on 159 patients
using a 16 gauge core biopsy needle. There was higher frequency of
pneumothorax in smaller lesions and of greater depth. Haemorrhage was
associated with CT signs of emphysema. The high diagnostic yield of CT-
guided TLB was not affected by lesion characteristics or emphysema.
Another study on CT-guided transthoracic fine needle aspiration of
pulmonary lesions: accuracy and complications in 134 cases by Uskul BT and
colleagues in 2009 suggested that the most important factor increasing the
risk of pneumothorax is an increase in the depth of aerated lung traversed
for sampling.
These population-based data should help patients and physicians make
more informed choices about whether to perform biopsy of a pulmonary
lesion.
References
1.Acad Radiol. 2008 Aug;15(8):1017-26.
Computed tomography-navigated transthoracic core biopsy of pulmonary
lesions: which factors affect diagnostic yield and complication rates?
Heyer CM, Reichelt S, Peters SA, Walther JW, M?ller KM, Nicolas V.
2. CT- guided transthoracic fine needle aspiration of pulmonary
lesions: accuracy and complications in 294 patients.
Arslan S, Yilmaz A, Bayramg?rler B, Uzman O, Nver E, Akkaya E.
Med Sci Monit. 2002 Jul;8(7):CR493-7.
3 Accuracy and complications in computed tomography fluoroscopy-guided
needle biopsies of lung masses. Eur Radiol. 2006 Jun;16(6):1387-92. Epub
2006 Mar 16.
Heck SL, Blom P, Berstad A.
Eur Radiol. 2006 Jun;16(6):1387-92. Epub 2006 Mar 16.
4 CT-guided transthoracic fine needle aspiration of pulmonary lesions:
accuracy and complications in 134 cases.
Usk?l BT, T?rker H, G?k?e M, Kant A, Arslan S, Turan FE.
This patient probably had coagulase negative staphylococcal infection
somewhere on his body which probably went unnoticed. We have not been
informed about the other investigations carried out for this patient. At
least the Blood Cultures should have been sent early in the course of the
disease. The extent of the spinal cord compression is rather unusual.
Although the immediate decompression is the way of prefered line of...
This patient probably had coagulase negative staphylococcal infection
somewhere on his body which probably went unnoticed. We have not been
informed about the other investigations carried out for this patient. At
least the Blood Cultures should have been sent early in the course of the
disease. The extent of the spinal cord compression is rather unusual.
Although the immediate decompression is the way of prefered line of
management high doses of appropriate antibiotics along with administration
of immunoglobulins would have helped the patient.
Sarcoidosis most of the times mimics tuberculosis symptomatically as
well as radiologically and poses diagnostic dilemma. It is nice to see
case report on Sarcoidosis with caseating granuloma as biopsy usually
differentiate it from tuberculosis as tuberculosis produces caseating
granuloma and sarcoidosis non caseating type. Anergy produced by
sarcoidosis can lead to loss of induration in PPD testing. As bronchoscopy
was...
Sarcoidosis most of the times mimics tuberculosis symptomatically as
well as radiologically and poses diagnostic dilemma. It is nice to see
case report on Sarcoidosis with caseating granuloma as biopsy usually
differentiate it from tuberculosis as tuberculosis produces caseating
granuloma and sarcoidosis non caseating type. Anergy produced by
sarcoidosis can lead to loss of induration in PPD testing. As bronchoscopy
was done in this patient all the investigations were done including
mycobacterial culture but status of CD4 and CD8 and there ratio is not
mentioned. This CD4/CD8 ratio reverses in bronchoalveolar lavage in
sarcoidosis and disregulation leads to Immune paradox leading to anergy
responsible for no induration in PPD testing1. ACE levels are elevated in
60% of patients with sarcoidosis as Sarcoidal granuloma produce
angiotensin-converting enzyme (ACE). Effective antitubercular treatment
can lead to improvement in symptoms within 2-4 weeks so it was not needed
to follow the patient for 6 months. Hypercalcemia, hypercalciurea usually
occurs in sarcoidosis so 24 hours urinary calcium analysis was indicated
in this patient2. Spontaneous remission occurs in two third of the
patients and in half of the patients remission occurs within three years.
However as patient responded very well to steroid diagnosis of necrotising
sarcoid granuloma is justifiable and further research is needed to
establish a definitive diagnosis as sarcoidosis is still not very well
understood and still it is diagnosed by exclusion.
References:-
1. Miyara M, Amoura Z, Parizot C, et al. The immune paradox of sarcoidosis
and regulatory T cells. J Exp Med 2006;203:359-370[Erratum, J Exp Med
2006;203:477.]
2. Berliner AR, Haas M, Choi MJ. Sarcoidosis: the nephrologist's
perspective. Am J Kidney Dis 2006;48:856-870
This case report about aortic dissection is a good reminder to always consider this condition in acute chest pain particularly in patients with hypertension or a connective tissue disorder such as Marfans, SInce using this blood test as a rule out investigation in recent years we have made the diagnosis increasingly early in our institution.. A Google search revealed 5040 hits. Doctors have been missing this diagnodis for...
A quick review of the condition helps keep the condtion in mind and help decision making
Conflict of Interest:
None declared
A very interesting case report but a common omission seen again in this report as is seen in real life in the wards . Any x -ray for an acute abdomen should always include both the domes of diaphragm which I cannot see in the AP view in figure A (only left dome visible) as compared to B where both domes are clearly visible ( unless it was done originally but cut off in the view shown here in this report) whic...
Dear Sir:
As a clinical neurologist with interest in laterality of motor control and consciousness, 1, 2 I read the contribution by Simonin and colleagues and have the following clinical and neurophysiological comments on their interpretation of the findings in their remarkable (presumably right handed) patient. Thus, a spontaneously breathing patient with a non- traumatic left subdural hematoma displayed bilate...
Dear Dr. Evrensel,
I read with interest your recent paper in BMJ Case Reports. Based on the single case, you concluded that long-term Li treatment might cause cortical atrophy. Without pre-Li MRI or evidence for increases in GM following discontinuation of Li, this conclusion seems tentative. Even if this was the case, perhaps the brain changes were not related to the duration of use. We detected positive asso...
Dear Editors,
I read with interest the case report on complications of trans thoracic lung biopsy. Only a few studies have systematically evaluated risk factors for pneumothorax and pulmonary haemorrhage in computed tomographically (CT)-guided transthoracic lung biopsy (TLB). One study looking into the factors affecting diagnostic yield and complication rates, by Heyer CM and colleagues in 2008, showed that the...
This patient probably had coagulase negative staphylococcal infection somewhere on his body which probably went unnoticed. We have not been informed about the other investigations carried out for this patient. At least the Blood Cultures should have been sent early in the course of the disease. The extent of the spinal cord compression is rather unusual. Although the immediate decompression is the way of prefered line of...
Sarcoidosis most of the times mimics tuberculosis symptomatically as well as radiologically and poses diagnostic dilemma. It is nice to see case report on Sarcoidosis with caseating granuloma as biopsy usually differentiate it from tuberculosis as tuberculosis produces caseating granuloma and sarcoidosis non caseating type. Anergy produced by sarcoidosis can lead to loss of induration in PPD testing. As bronchoscopy was...
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