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.
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.
Hopefully these studies will provide further clarification and answer the questions posed in your letter which our case report was never designed to do.”
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.
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...
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. Secondly, there were financial issues in procuring the drug as the treatment is expensive considering the high monthly costs that are involved in therapy with this particular drug. Thirdly medical treatment with this drug if available would have taken some time for the lesion to regress and the patient's parents were looking for a treatment that could immediately restore normalcy to the deformity.
We will definitely consider drug therapy with Selumetinib for this patient in the follow-up period as it has been shown to be quite effective in treating extensive neurofibromatosis as was seen in this paediatric patient.
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...
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, one of them, a five-year-old boy, had a giant plexiform neurofibroma similar to the one described in this clinical case, extended from the abdomen to the pelvis and scrotum. The mass was causing abdominal and scrotal pain, so that the boy couldn’t even sit on a chair. The patient had originally been treated in another institution with a partial debulking procedure, but after twelve months the plexiform neurofibroma grew back to its original size. Furthermore, the surgical excision resulted in the necessity of placing a colostomy, which the boy still has and that will probably be impossible to remove in future, since the plexiform neurofibroma further grew around the distal colic stump. After two years of treatment with selumetinib, a radiological decrease of the mass by more than 20% was noticed, and the boy stopped complaining of abdominal and scrotal pain. Nowadays he’s 10 years old and in good clinical conditions.
In conclusion, we suggest that selumetinib should be preferred to a surgical approach in presence of an extended plexiform neurofibroma, due to the well-known risk or the tumor regrowth after surgery.
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.
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...
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 do a disservice to the public and to our patients by being imprecise about this. EVALI is not caused by nicotine e-cigarettes, just as the epidemic of lethal overdoses associated with addictive pain medication use is not caused by Ibuprofen. We are correct to call that the "opioid epidemic", rather than the "analgesic epidemic". A THC vape is not the same as a nicotine e-cigarette, just as Vicodin is not the same as Tylenol and a joint is not the same as a cigarette. Lets call this serious respiratory disease what it is: THC-Vaping Associated Lung Injury (THCVALI) caused by vaping THC products contaminated by vitamin E acetate. We should inform our at-risk patients and the public tha tit is dangerous to use THC vapes, from the United States that came from informal sources (i.e. not directly from a licensed dispensary or via a doctor's prescription), and we should not confuse our patients or professional colleagues by referring to this illness as if it is caused by nicotine e-cigarettes. It is not. We should therefore call it THCVALI..
(2) Blount BC et al, For the Lung Injury Response Laboratory Working Group. Vitamin E Acetate in Bronchoalveolar-Lavage Fluid Associated with EVALI. N Engl J Med 2020; 382:697-705 DOI: 10.1056/NEJMoa1916433
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...
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 of MDT approach to direct and achieve appropriate management for a complex case. Care treatment prioritisation, surgical planning and full complement expertise are required in complex cases such as this.
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.
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...
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 used in the study of COVID-19 complications.7 The American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS), the National Institute of Deafness and Other Communication Disorders (NIDCD) and the American Speech-Language-Hearing Association (ASHA) endorse the definition of Sensorineural hearing loss (SNHL) as hearing loss of at least 30 decibels (dB) in three sequential frequencies in the standard pure tone audiogram. However, this definition is not universally utilized, and variations of the definition area used in various publications. The audiometry can be a limiting factor for a definitive diagnosis when adequate equipment and appropriately trained personnel are not available. The Brighton Collaboration case definition suggests the classification of SNHL cases in various levels of diagnostic certainty based on the availability and utilization of adequate diagnostic tools in addition to the clinical evaluation (see reference 7, Table 1). This case ascertainment and classification then allows for data comparability across hospitals, countries, and surveillance systems. In this case report, a level 1 of diagnostic certainty was achieved as the patient had a physical examination excluding a cause for conductive hearing loss (CHL) in addition to an audiometry result consistent with SNHL.
In light of this report, and in the context of the active development of COVID-19 vaccines, SNHL should be evaluated as an event of interest in post-infection complications and post-immunization safety assessments. The Brighton Collaboration provides a consensus case definition for the standardized assessment of SNHL. It is our hope that the use of a standard definition will facilitate data interpretation and promote the scientific understand of SNHL following COVID-19.
Reference
1. Koumpa FS, Forde CT, Manjaly JG. “Sudden irreversible hearing loss post COVID-19.” BMJ Case Rep. 2020 Oct 13;13(11):e238419.
2. Kilic O, Kalcioglu MT, Cag Y, et al. Could sudden sensorineural hearing loss be the sole manifestation of COVID-19? An investigation into SARS-COV-2 in the etiology of sudden sensorineural hearing loss. Int J Infect Dis 2020;97:208–11.
3. Degen C, Lenarz T, Willenborg K. Acute profound sensorineural hearing loss after COVID-19 pneumonia. Mayo Clin Proc 2020;95:1801–3.
4. Rhman SA, Wahid AA. COVID-19 and sudden sensorineural hearing loss: a case report. Otolaryngol Case Reports 2020;16:100198.
5. Mustafa MWM. Audiological profile of asymptomatic Covid-19 PCR-positive cases. Am J Otolaryngol 2020;41:102483.
6. Sriwijitalai W, Wiwanitkit V. Hearing loss and COVID-19: a note. Am J Otolaryngol 2020;41:102473.
7. Liu YC, Ibekwe T, Kelso JM, et al. Sensorineural hearing loss (SNHL) as an adverse event following immunization (AEFI): Case definition & guidelines for data collection, analysis, and presentation of immunization safety data. Vaccine. 2020;38(30):4717-4731. doi:10.1016/j.vaccine.2020.05.019
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.
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.
Dear Editor,
Show Morewe 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...
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.
To the editor,
Show MoreThe 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...
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...
Show MoreA 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.
To the authors:
Show MoreWe 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...
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.
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