Malignancy of the prostate is very well known to liberate lots of
tissue factors controlling the coagulation process. This patient must have
developed some sort of Disseminated intra vascular coagulation which was
enhanced by the simultaneous administration of Aspirin. Most of the tests
used to diagnose a particular coagulation deficiency have a considerable
overlap in clinical setting.
To say that this patient has develo...
Malignancy of the prostate is very well known to liberate lots of
tissue factors controlling the coagulation process. This patient must have
developed some sort of Disseminated intra vascular coagulation which was
enhanced by the simultaneous administration of Aspirin. Most of the tests
used to diagnose a particular coagulation deficiency have a considerable
overlap in clinical setting.
To say that this patient has developed haemophilia A at the age of seventy
plus years and to call it as acquired haemohilia is not justified. The
aspirin of course had contributed to the bleeding problems in this
patient. It is fortunate that the patient improved with the appropriate
effective management.
A 4 year old patient with a known diagnosis of a brainstem glioma,
ventriculo-peritoneal shunt and ventricular access device was referred to
our paediatric district general ward for review following a head injury.
She had been knocked over at nursery by her brother on a bicycle and
sustained an occipital head injury. Following this, the nursery staff
noticed that her pupils were asymmetrical. Mum had collected her from...
A 4 year old patient with a known diagnosis of a brainstem glioma,
ventriculo-peritoneal shunt and ventricular access device was referred to
our paediatric district general ward for review following a head injury.
She had been knocked over at nursery by her brother on a bicycle and
sustained an occipital head injury. Following this, the nursery staff
noticed that her pupils were asymmetrical. Mum had collected her from
nursery and brought her to the ward. There was no history of loss of
consciousness or vomiting.
On examination she was very well, bright and playful with a heart rate of
104 and blood pressure 99/56. There was a small, non boggy swelling to her
occiput. Her right pupil was a size 6, fixed and dilated. Her left pupil
was size 2 with an intact direct and consensual response to light. The
accommodation reflex was intact and eye movements were also normal.
Fundoscopy showed a slightly blurred optic disc on the right and was
difficult to visualise on the left. Neurological examination was otherwise
normal for this patient and mum described her as 'the best she has been in
ages'.
On further discussion of current medication it transpired that the
hyoscine patch which had been applied that morning was missing from behind
her right ear. The clinical impression was that the head injury was
coincidental and that given how clinically well she was, the right sided
pupillary findings were most in keeping with topical contamination of the
eye with hyoscine presumably by fingertip innoculation.
In our literature search for the half life of hyoscine we came across the
above BMJ case report. In this report, Hannon et al very helpfully
summarise an easy clinical test involving the instillation of Pilocarpine
eye drops to establish if a pharmacological blockade is the cause for the
underlying pupillary dilatation. We therefore administered pilocarpine and
reviewed. Our patient continued to have one fixed and dilated pupil at 30
minutes, confirming pharmacological blockade as the cause of her dilated
pupil. This avoided an hour long journey to a tertiary centre, possible
general anaesthetic for a CT scan and potential aspiration of ventricular
access device.
This case reinforces the need for a detailed medication history and the
management was significantly improved by the BMJ case report. Case reports
remain a very helpful resource for patient management and we were
exceptionally grateful to these authors for their thorough and helpful
discussion.
Sarah Alexander, Locum Paediatric Consultant
Clare Irving, Consultant Paediatrician, Borders General Hospital
We thank Dr. Boyd and Dr. Moodambail for their recent article in BMJ
Case Reports, which describes the case of a four-year old boy with
hypercalcaemia and hypervitaminosis D that was possibly attributed to the
inappropriate prescribing of nutrient supplements. The case was
complicated by the fact that the parent failed to disclose the use of
these supplements until several days into the child's admission.
We thank Dr. Boyd and Dr. Moodambail for their recent article in BMJ
Case Reports, which describes the case of a four-year old boy with
hypercalcaemia and hypervitaminosis D that was possibly attributed to the
inappropriate prescribing of nutrient supplements. The case was
complicated by the fact that the parent failed to disclose the use of
these supplements until several days into the child's admission.
Patient underreporting of complementary and alternative medicine
(CAM) use during clinical encounters with conventional health care
providers is a well-documented concern. It is estimated that 50% to 77% of
people consuming CAM do not inform their medical practitioner (1-5), which
is alarming. Drs. Boyd and Moodambail suggest that the issue of non-
disclosure could be resolved if medical practitioners routinely gathered
information about CAM use as part of the history taking process. This
proposed solution is underpinned by a rather simplistic view of a complex
problem.
Myriad factors undoubtedly determine whether a patient divulges the
use of CAM to a medical practitioner or other health care provider. Drs.
Boyd and Moodambail allude to just one of these factors - 'opportunity' -
highlighting that the health care provider should at least ask the patient
if they are taking any CAM. Evidence suggests that communication is merely
one of many factors impacting patient disclosure of CAM use. Yet another
reason for non-disclosure are patient concerns regarding a potential
negative response (such as being judged) by a medical practitioner (4).
What this means is that even if the appropriate questions are posed by the
medical practitioner, the patient may not divulge relevant information
about CAM use because of fear.
Given the complexity underpinning this issue, we propose a
multifaceted strategy to overcome barriers associated with the disclosure
of CAM use. In addition to improving communication, strategies to improve
the disclosure of CAM use should draw attention to shared decision making
between patient and medical practitioner (6), and to fostering positive
relationships between patient and health care provider (5). Medical
practitioners would also benefit from seeking relevant and unbiased
information about CAM and to have a greater respect for patient decision
making (7). This is especially poignant given the emergence of patient-
centered and consumer-directed care, where the patient plays the role of
an active and informed decision maker. The onus is not just on the medical
practitioner and patient, however; CAM practitioners also need to be aware
of their limitations and the potential adverse effects of their
treatments, and to encourage patients to share relevant details with other
health care providers such as medical professionals and pharmacists.
Ultimately, all health care providers, conventional and
complementary, should work towards ensuring that their patients receive
timely, quality and safe health care. This can only be achieved if
conventional and complementary health care providers: (1) communicate
effectively with each other and with the patient, (2) openly and
respectfully discuss each other's roles in the patient's care, and (3)
acknowledge the patient's right to privacy, respect, access to all forms
of health care, and their own personal belief system. By adopting a multi-
faceted approach to such a complex issue, it is more likely that patients
- the primary stakeholders in health care - would have the opportunity and
confidence to disclose CAM usage to their health care providers.
References
1. MacLennan A, Myers S, Taylor A. The continuing use of
complementary and alternative medicine in South Australia: costs and
beliefs in 2004. Medical Journal Australia. 2006;184(1):27-31.
2. World Health Organization. WHO traditional medicine strategy 2002-2005.
Geneva World Health Organization; 2002.
3. Crawford NW, Cincotta DR, Lim A, Powell CVE. A cross-sectional survey
of complementary and alternative medicine use by children and adolescents
attending the University Hospital of Wales. BMC Complementary and
Alternative Medicine. 2006;6.
4. Robinson A, McGrail MR. Disclosure of CAM use to medical practitioners:
a review of qualitative and quantitative studies. Complementary Therapies
in Medicine. 2004;12(2-3):90-8.
5. Faith J, Thorburn S, Tippens KM. Examining CAM use disclosure using the
Behavioral Model of Health Services Use. Complementary Therapies in
Medicine. 2013;21(5):501-8.
6. Wallen GR, Brooks AT. To Tell or Not to Tell: Shared Decision Making,
CAM Use and Disclosure Among Underserved Patients with Rheumatic Diseases.
Integrative Medicine Insights. 2012;7:15-22.
7. Saxe GA, Madlensky L, Kealey S, Wu DP, Freeman KL, Pierce JP.
Disclosure to physicians of CAM use by Breast cancer patients: Findings
from The women's healthy eating and living study. Integrative Cancer
Therapies. 2008;7(3):122-9.
We would like to thank Petrin et al for an informative case report[1]
on an important injury sustained in athletes and service personnel. We
agree that a high degree of suspicion for stress fractures should be
maintained as we have previously reported the problems with a missed
femoral neck stress fracture[2], and the more literature that is available
highlighting these training injuries is useful for medical staff lookin...
We would like to thank Petrin et al for an informative case report[1]
on an important injury sustained in athletes and service personnel. We
agree that a high degree of suspicion for stress fractures should be
maintained as we have previously reported the problems with a missed
femoral neck stress fracture[2], and the more literature that is available
highlighting these training injuries is useful for medical staff looking
after athletes and servicemen[3].
We note and thank you, that you reference our paper a couple of times
in your article[4]. However, we believe that you have inadvertently
slightly miss represented our work and we would like to take this
opportunity to correct it.
We do not state that "surgical fixation with percutaneous nail
fixation is the treatment of choice in the management of tension type
femoral neck fractures", as whilst we strongly believe that operative
management is the most appropriate treatment for these fractures, we also
think that the fracture should be treated with the most appropriate device
available, as in our case report[2], where the patient was treated with a
dynamic hip screw. Whilst in some cases an inter-medullary device would
be appropriate, there is a higher cost and periprosthetic fracture risk
using these devices. To our knowledge there is no evidence supporting the
use of an inter-medullary device over a dynamic hip screw in the treatment
of tension-type femoral stress fractures. We would also draw your
attention to our paper Femoral Neck Stress Fractures in Sport: A Current
Concepts Review[5] which details this type of stress fracture further.
We thank the authors for an excellent case report and are grateful
for the opportunity to clarify our stance on internal fixation of these
fractures.
References:
1. Petrin Z, Sinha A, Gupta S, Patel MK. Young man with sudden
severe hip pain secondary to femoral neck stress fracture. BMJ Case Rep
2016. doi:10.1136/bcr-2016-216820
2. Thomas R, Wood AM, Watson J, Arthur CHC, Nicol AM. Delay in
Diagnosis of Neck of Femur Stress Fracture in a female military recruit. J
Royal Naval Medical Service 2012, Vol 98.2 27-29
3. Wood AM, Keenan ACM, Arthur C, Wood IM. Common Training Injuries
Concerning Potential Royal Marine Applicants. J Royal Naval Medical
Service 2011, 97.3 106-109
4. Wood AM, Hales R, Keenan A, et al. Incidence and time to return to
training for stress fractures during military basic training. J Sports Med
2014;2014:282980.
5. Robertson G, Wood AM. Femoral Neck Stress Fractures in Sport: A
Current Concepts Review. Under Consideration Sports Medicine
International SMIO-10-2016-0014-re
The case report from Dr. Boyd and Dr. Moodambail highlights the
potential for over-zealous administration of vitamin D to result in
toxicity (1). However, we contend that it is very unlikely that the
reported daily dose of 3,000 IU (75 micrograms) vitamin D would elevate
serum 25-hydroxyvitamin D (25[OH]D) concentrations to over 2000 nmol/L in
a 4-year-old child. The US Institute of Medicine specifies a safe Upper
Level...
The case report from Dr. Boyd and Dr. Moodambail highlights the
potential for over-zealous administration of vitamin D to result in
toxicity (1). However, we contend that it is very unlikely that the
reported daily dose of 3,000 IU (75 micrograms) vitamin D would elevate
serum 25-hydroxyvitamin D (25[OH]D) concentrations to over 2000 nmol/L in
a 4-year-old child. The US Institute of Medicine specifies a safe Upper
Level Intake of 3000 IU vitamin D per day for children aged 4-8 years (2),
and vitamin D intoxication in children typically arises when very much
larger doses of vitamin D (240,000 IU to 4,500,000 IU) are administered
(3). Mutations in genes encoding enzymes in the vitamin D metabolic
pathway have been associated with hypercalcaemia in individuals with
relatively modest vitamin D intakes, but circulating 25(OH)D
concentrations in these cases are below the thresholds associated with
toxicity (4). It is therefore likely that the dose of vitamin D taken by
this child was far in excess of the reported 3,000 IU per day;
determination of the vitamin D content of the supplements that he was
taking would be instructive.
1. Boyd C, Moodambail A. Severe hypercalcaemia in a child secondary
to use of alternative therapies. BMJ Case Reports. 2016; 2016.
2. Institute of Medicine. Dietary Reference Intakes for Calcium and
Vitamin D. Washington, DC: National Academy Press; 2011.
3. Vogiatzi MG, Jacobson-Dickman E, DeBoer MD. Vitamin D supplementation
and risk of toxicity in pediatrics: a review of current literature. J Clin
Endocrinol Metab. 2014; 99(4): 1132-41.
4. Schlingmann KP, Kaufmann M, Weber S, Irwin A, Goos C, John U, et al.
Mutations in CYP24A1 and idiopathic infantile hypercalcemia. N Engl J Med.
2011; 365(5): 410-21.
Dear Sir,
We have read your impressive article "Neurosarcoidosis presenting as a
large dural mass lesion" published in BMJ Case report on 8 November 2016.
I have read about neurosarcoidosis thoroughly because of my previous
exposure with few patients who were recovered as per diagnosis and
prognosis.
First, your esteem has mentioned that the biopsy confirmed the
diagnosis while the diagnosis of sarcoidosis depe...
Dear Sir,
We have read your impressive article "Neurosarcoidosis presenting as a
large dural mass lesion" published in BMJ Case report on 8 November 2016.
I have read about neurosarcoidosis thoroughly because of my previous
exposure with few patients who were recovered as per diagnosis and
prognosis.
First, your esteem has mentioned that the biopsy confirmed the
diagnosis while the diagnosis of sarcoidosis depends on multiple factors.
Infact, histopayhology is only one of the diagnostic steps that we totally
agreed to be included in the investigative process but histopathological
changes are non-specific because of unidentified molecular and cellular
events.
Indeed, Sarcoidosis has neither distinctive clinical features [1]
exclusive changes in pulmonary function studies, diagnostic labarotary
investigations,[2] definite disease activity marker,[3] special imaging
findings nor specific histological picture.[4-6]
Consequently, the diagnosis of sarcoidosis is based on clinico-
radiographic ?ndings which are supported by histologic evidence of the
presence of noncaseating granulomatous in?ammation with the exclusion of
similar presenting diseases such as tuberculosis, brucellosis, lymphoma,
and lung cancer,[7] autoimmunity disorders (primary biliary cirrhosis and
Wegener's granulomatosis), drug reactions, occupational and environmental
exposures (e.g. beryllium, talc), farmer's lung disease (hypersensitivity
pneumonitis) and infections.[4-6]
So, when the diagnosis of sarcoidosis is considered, stains and
culture for fungi and mycobacteria should always be obtained.[6]
Approching patient with sarcoidosis is based on the following criteria:[8]
1) a compatible clinical and/or radiological picture;
2) histological evidence of non-caseating granulomas; and
3) exclusion of other diseases capable of producing a similar histological
or clinical picture.
Second, your esteem has mentioned that your case has been treated
with steroids and as you now there is no global / international consensus
about the dose and duration. Most recommend prednisolone 20 - 40 mg for
not less than 12 months. [9]
While we have treated ourpatient with prednisolone tablet orally started
with 40 mg daily in divided doses and tapered for as short as two months.
We are egger to know what type of steroids you have prescribed and more
importantly what was the dose and for how long was the treatment spectrum
of this neurosarcoidosis case?
References
1. Baughman RP, Drent M, Kavuru M, Judson MA, Costabel U, Du BR, Albera C,
Brutsche M, Davis G, Donohue JF, et al. In?iximab therapy in patients with
chronic sarcoidosis and pulmonary involvement. Am J Respir Crit Care Med
2006;174:795-802.
2. Keir G, Wells AU. Assessing pulmonary disease and response to therapy:
which test? Semin Respir Crit Care Med 2010;31:409-418.
3. Chesnutt AN. Enigmas in sarcoidosis. West j Med 1995; 162:519-526.
4. Nunes H, Bouvry D, Soler P, Valeyre D. Sarcoidosis. Orphanet J Rare Dis
2007; 2: 46.
5. Warshauer DM, Lee JKT. Imaging manifestations of abdominal sarcoidosis.
AJR 2004; 182: 15-28.
6. Jundson MA. Sarcoidosis: clinical presentation, diagnosis and approach
to treatment. Am J Med Sci 2008; 335: 26-33.
7. Iannuzzi MC, Rybicki BA, Teirstein AS. Sarcoidosis. N Engl J Med.
2007;357(21):2153-2165.
8. U. Costabel. Sarcoidosis: clinical update. Eur Respir J 2001; 18:
Suppl. 32, 56s-68s.
9. Eishi Y, Suga M, Ishige I, Kobayashi D, Yamada T, Takemura T, Takizawa
T, Koike M, Kudoh S, Costabel U, et al. Quantitative analysis of
mycobacterial and propionibacterial DNA in lymph nodes of Japanese and
European patients with sarcoidosis. J Clin Microbiol 2002;40(1):198-204.
This could possibly be anti-GBM disease, though bloody diarrhoea
isn't a feature of that condition. But there wasn't a renal biopsy to
confirm, or specificity tests on the antibody (e.g. Western blotting with
it) so evidence is only the ELISA result. Most such assays encounter
occasional false positives.
A relevant and very well described case, useful for ongoing
comprehension of sarcoidosis'pathogenesis. The "galaxy sign" summons for
a spreading of causal agents (mineral dusts ? bacteria ? others ?)from a
"mother" lesion to surrounding areas, in coherence with recent
interpretations of sarcoidosis as a peculiar, common reaction to different
xenobiotics, particularly in contexts of "heavy" exposomes. Calcification
is a...
A relevant and very well described case, useful for ongoing
comprehension of sarcoidosis'pathogenesis. The "galaxy sign" summons for
a spreading of causal agents (mineral dusts ? bacteria ? others ?)from a
"mother" lesion to surrounding areas, in coherence with recent
interpretations of sarcoidosis as a peculiar, common reaction to different
xenobiotics, particularly in contexts of "heavy" exposomes. Calcification
is a common feature with silicosis.
It could be really interesting which exposures' profile characterized the
patient.
Please, see a recent paper of mine about a case of lung fibrosis in a
woman occupationally exposed to amorphous silica and expoy rosins vapours.
This is a well written Case Report and helpfully describes some
pathology (as well as the phenomenon of S. aureus disease relapse). It
should be noted, however, that whilst the supporting evidence for i.v.
Linezolid is that it is non-inferior to Vancomycin, it is abundantly clear
in the literature that i.v. Vancomycin is wholly inferior to i.v.
Flucloxacillin. Regarding data on disc penetration, Gibson et al tested
this...
This is a well written Case Report and helpfully describes some
pathology (as well as the phenomenon of S. aureus disease relapse). It
should be noted, however, that whilst the supporting evidence for i.v.
Linezolid is that it is non-inferior to Vancomycin, it is abundantly clear
in the literature that i.v. Vancomycin is wholly inferior to i.v.
Flucloxacillin. Regarding data on disc penetration, Gibson et al tested
this for fluclox in an animal model, but only after a single i.v. bolus.
It is likely that after repeated high doses that fluclox does penetrate,
otherwise there would be thousands of cases in the literature of relapse
with zero cures. Furthermore, the source referenced for penetration of
tissue by Linezolid is actually of skin blisters, not bone, whereas it is
widely accepted that beta-lactams penetrate skin and soft tissue
beautifully.
My conclusion is that whilst this is a helpful addition to the
literature, there are currently no grounds for withholding i.v.
flucloxacillin in invasive MSSA disease and that Linezolid (a
bacteriostatic agent) is a long way from having been validated for this
setting.
Hello Mam,
I would gladly like to know that the site of metastasis was in the upper
extremity or in the lower extremity?
and if it was upper extremity then at what site?
Malignancy of the prostate is very well known to liberate lots of tissue factors controlling the coagulation process. This patient must have developed some sort of Disseminated intra vascular coagulation which was enhanced by the simultaneous administration of Aspirin. Most of the tests used to diagnose a particular coagulation deficiency have a considerable overlap in clinical setting. To say that this patient has develo...
A 4 year old patient with a known diagnosis of a brainstem glioma, ventriculo-peritoneal shunt and ventricular access device was referred to our paediatric district general ward for review following a head injury. She had been knocked over at nursery by her brother on a bicycle and sustained an occipital head injury. Following this, the nursery staff noticed that her pupils were asymmetrical. Mum had collected her from...
We thank Dr. Boyd and Dr. Moodambail for their recent article in BMJ Case Reports, which describes the case of a four-year old boy with hypercalcaemia and hypervitaminosis D that was possibly attributed to the inappropriate prescribing of nutrient supplements. The case was complicated by the fact that the parent failed to disclose the use of these supplements until several days into the child's admission.
Pati...
We would like to thank Petrin et al for an informative case report[1] on an important injury sustained in athletes and service personnel. We agree that a high degree of suspicion for stress fractures should be maintained as we have previously reported the problems with a missed femoral neck stress fracture[2], and the more literature that is available highlighting these training injuries is useful for medical staff lookin...
The case report from Dr. Boyd and Dr. Moodambail highlights the potential for over-zealous administration of vitamin D to result in toxicity (1). However, we contend that it is very unlikely that the reported daily dose of 3,000 IU (75 micrograms) vitamin D would elevate serum 25-hydroxyvitamin D (25[OH]D) concentrations to over 2000 nmol/L in a 4-year-old child. The US Institute of Medicine specifies a safe Upper Level...
Dear Sir, We have read your impressive article "Neurosarcoidosis presenting as a large dural mass lesion" published in BMJ Case report on 8 November 2016. I have read about neurosarcoidosis thoroughly because of my previous exposure with few patients who were recovered as per diagnosis and prognosis.
First, your esteem has mentioned that the biopsy confirmed the diagnosis while the diagnosis of sarcoidosis depe...
This could possibly be anti-GBM disease, though bloody diarrhoea isn't a feature of that condition. But there wasn't a renal biopsy to confirm, or specificity tests on the antibody (e.g. Western blotting with it) so evidence is only the ELISA result. Most such assays encounter occasional false positives.
Conflict of Interest:
None declared
A relevant and very well described case, useful for ongoing comprehension of sarcoidosis'pathogenesis. The "galaxy sign" summons for a spreading of causal agents (mineral dusts ? bacteria ? others ?)from a "mother" lesion to surrounding areas, in coherence with recent interpretations of sarcoidosis as a peculiar, common reaction to different xenobiotics, particularly in contexts of "heavy" exposomes. Calcification is a...
This is a well written Case Report and helpfully describes some pathology (as well as the phenomenon of S. aureus disease relapse). It should be noted, however, that whilst the supporting evidence for i.v. Linezolid is that it is non-inferior to Vancomycin, it is abundantly clear in the literature that i.v. Vancomycin is wholly inferior to i.v. Flucloxacillin. Regarding data on disc penetration, Gibson et al tested this...
Hello Mam, I would gladly like to know that the site of metastasis was in the upper extremity or in the lower extremity? and if it was upper extremity then at what site?
Conflict of Interest:
None declared
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