Rheumatic heart disease leading to mitral stenosis is seen more
often in the developing countries than in the developed world. The
patients are quite asymptomatic at rest until the 2nd or 3rd decade, when
they may present with various signs and symptoms like
dyspnoea on exertion, palpitations, easy fatigebility,
dizziness, coughing up blood, chest pain or discomfort, and swelling in
legs and upto 15% of patients may pr...
Rheumatic heart disease leading to mitral stenosis is seen more
often in the developing countries than in the developed world. The
patients are quite asymptomatic at rest until the 2nd or 3rd decade, when
they may present with various signs and symptoms like
dyspnoea on exertion, palpitations, easy fatigebility,
dizziness, coughing up blood, chest pain or discomfort, and swelling in
legs and upto 15% of patients may present with signs of systemic emboli as
a first sign like transient ischemic attack, stroke, or suddden pain in
abdomen due to gut ischemia or a renal infarct. Embolic phenomenon are
seen in mitral stenosis patients with atrial fibrillation, but sometimes
even patients in sinus rythm may present with clinical features of
sytemic emboli.
In the above case, a young women presented with a history of
parasthesia and dysarthria, for the first time. Given that she was a young
Mexican lady, a high level suspicion should have been on the cardiac
origin of emboli and along with CT brain to rule out
stroke , a 2-D cardiac echo study would have been very useful to rule out
any emboli in the left heart. The echo would have given the appropriate
diagnosis and guided the proper anticoagulation therapy and a further
mitral valve replacement as the final treatment.
In conclusion, a young patient presenting with a TIA/stroke/hemiparesis
needs a thorough assessment of the source of the systemic emboli and thus
a very high level of suspicion for cardiac origin.
I have several points about this interesting case report.
1/ The first point that surprised me is this: apparently, this
patient has had neither at the end of the procedure nor after an
intercostal infiltration with long-acting local anaesthetic drug
2/ Then this could have helped in both diagnosis and treatment. The
disappearing or alleviation of pain would have clearly identified the
intercostal nerv...
I have several points about this interesting case report.
1/ The first point that surprised me is this: apparently, this
patient has had neither at the end of the procedure nor after an
intercostal infiltration with long-acting local anaesthetic drug
2/ Then this could have helped in both diagnosis and treatment. The
disappearing or alleviation of pain would have clearly identified the
intercostal nerve injury and even broken the vicious circle of chronic
pain if it had been done early after the onset. It would have also allowed
an earlier onset of physiotherapy and potentially avoided such a risky and
aleatory end for this chronic pain
3/ About the mechanistic hypothesis
Intercoastal nerve injury in thoracoscopy procedures is dependent on
technique, size of the device and skill of the surgeon. It is a rather
frequent complication of those procedures and prevention is key. It is
mainly based on a surgical approach just at the upper edge of the rib in
order to avoid any damage to the vessels which lead to a haematoma
compressing the nerve or directly to the nerve
4/ chronic pain is a neurobiological issue
(https://www.ncbi.nlm.nih.gov/pubmed/12931188) which is the result of a
persistent lesion of a peripheral nerve. Complex neurologic and epigenetic
mechanisms are at the root of chronic pain and personal traits are
associated to the development of chronic pain
(https://www.ncbi.nlm.nih.gov/pubmed/16355225)(https://academic.oup.com/brain/article/137/3/724/389996).
In my experience, one of the worst treatment for chronic pain in a
thoracic surgical incision is systemic opioids
(https://journals.lww.com/painrpts/Fulltext/2017/03000/Postoperative_pain_from_mechanisms_to_treatment.1.aspx).
In this setting it is probable that strong and fast movements during the
short swim can have released some local fibrous tissue in the wound and
that a severe stress can have interrupted the vicious circle of chronic
pain which is dependent on a central thalamic role
(https://www.jscimedcentral.com/Neuroscience/neuroscience-5-1075.pdf)
5/ Is cold a biting bystander in this case?
We know on the contrary that cold could lead to neuropathy in case of
chronic cold but non-freezing
exposure(https://academic.oup.com/brain/article/140/10/2557/4100656). When
cold is used for neurolysis it is with a cryoprobe and temperatures at the
tip of the probe which is in contact with the nerve (CT guided procedure)
is minus 50 Celsius. It is clear that the swimming episode did not reach
this range of temperature.
This case report is clearly mysterious and in absence of imagery and
testing of the nerves, it is at odd to conclude of any direct action of
cold water immersion on neuropathy.
I read with interest Dunne et al's paper kite surfing: epidemiology
of trauma. They state that 'a comprehensive review of EMBASE, PubMed and
Google Scholar was conducted' and that 'the search strategy included
medical subject headings (MeSH) kitesurf/kitesurfing/kitesurfing
hip/kitesurfing pelvis/kitesurfing fracture/kitesurfing injury'. At the
time of writing, (3 April 2018) none of these terms may be found in the
MeSH...
I read with interest Dunne et al's paper kite surfing: epidemiology
of trauma. They state that 'a comprehensive review of EMBASE, PubMed and
Google Scholar was conducted' and that 'the search strategy included
medical subject headings (MeSH) kitesurf/kitesurfing/kitesurfing
hip/kitesurfing pelvis/kitesurfing fracture/kitesurfing injury'. At the
time of writing, (3 April 2018) none of these terms may be found in the
MeSH thesaurus (https://meshb.nlm.nih.gov/search), and MeSH terms would
not, in any case, have helped in a search of EMBASE or of Google Scholar.
Existing papers in MEDLINE on kite surfing injuries have been indexed with
the term Athletic Injuries, and no subordinate terms yet exist. A more
productive strategy might have been to search titles and abstracts using
the strings kite* ADJ3 surf* OR kitesurf*.
A search using these strings on the HDAS interface finds 29 results in
MEDLINE and 33 in EMBASE.
A more elaborate strategy for the other concept in the search, that of
pelvic and acetabular fractures is certainly possible using a combination
of controlled vocabulary and natural language terms.
I greatly appreciate the well-advised comments from the reader on my
case report, ''Fatal air embolism
following local anaesthetisation: does needle size matter?''. (1) They
discuss the significance of proper positioning prior to performing the
biopsy. While having the appropriate hemithorax in ipsilateral-dependent
position certainly minimizes the motion and reduces the risk of air
embolism as the core biopsy needle tra...
I greatly appreciate the well-advised comments from the reader on my
case report, ''Fatal air embolism
following local anaesthetisation: does needle size matter?''. (1) They
discuss the significance of proper positioning prior to performing the
biopsy. While having the appropriate hemithorax in ipsilateral-dependent
position certainly minimizes the motion and reduces the risk of air
embolism as the core biopsy needle traverses the lung parenchyma; our case
report was meant to emphasize the risk of air embolism during the
administration of local anesthetic where the needle typically does not
penetrate any significant portion of lung parenchyma.
Since 25-gauge needle is very small and usually not linked to air
embolisms, we discussed that all the risk factors (including improper
positioning) that are associated with air embolism during core biopsy are
applicable to smaller Lidocaine needle as well. In our patient, it is
likely that positioning in addition to negative intra-thoracic pressure
generated by patient's cough resulted in air embolism.
1. Khalid F, Rehman S, AbdulRahman R, Gupta S. Fatal air embolism
following local anaesthetisation: does needle size matter? BMJ Case Rep.
2018;2018.
We read with interest this case series having seen several nerf gun
eye injuries in our own department. A search of the electronic patient
records revealed 17 such cases since 2014. Of these 12 were male and 5
female with 9 under the age of 18. Analysis of the primary injury revealed
5 hyphemas, 5 cases of traumatic iritis, 2 corneal abrasions, 1 case of
commotio retinae and 1 case of angle recession with the risk of glau...
We read with interest this case series having seen several nerf gun
eye injuries in our own department. A search of the electronic patient
records revealed 17 such cases since 2014. Of these 12 were male and 5
female with 9 under the age of 18. Analysis of the primary injury revealed
5 hyphemas, 5 cases of traumatic iritis, 2 corneal abrasions, 1 case of
commotio retinae and 1 case of angle recession with the risk of glaucoma.
In addition this placed an additional strain on an already stretched
eye casualty as many of the patients required treatment with an average of
3 visits with 1 patient requiring 8 visits.
We therefore support the authors call for patients and parents to be
aware of the types of 'bullets' used and to use eye protection to prevent
significant eye injuries.
I deeply appreciated the excellent description and discussion of the case in this paper. I would suggest one more piece of information to be given to the readers; not only genetic factors play a relevant role in the male breast cancers' web of causation but some, mainly occupational, exposures do too. I would therefore find it useful to know which work the patient practised, and if this occupation involved exposure to high le...
I deeply appreciated the excellent description and discussion of the case in this paper. I would suggest one more piece of information to be given to the readers; not only genetic factors play a relevant role in the male breast cancers' web of causation but some, mainly occupational, exposures do too. I would therefore find it useful to know which work the patient practised, and if this occupation involved exposure to high levels of heat (e.g. in consequence of being assigned to an industrial oven). Yours sincerely Roberto
Varying sizes and quality of clots are seen in severe rheaumatic
mitral valve stenosis, especially in Asian subcontinent.
LA clots are also found in patients with non-valvular atrial
fibrillation, but to a lesser extent as compared to rheumatic valvular
disesase and are seen more in the advanced world.
The clots can be fresh ones or multilayered organised clots or a mixture of the two.
In severe mitral stenosis, because...
Varying sizes and quality of clots are seen in severe rheaumatic
mitral valve stenosis, especially in Asian subcontinent.
LA clots are also found in patients with non-valvular atrial
fibrillation, but to a lesser extent as compared to rheumatic valvular
disesase and are seen more in the advanced world.
The clots can be fresh ones or multilayered organised clots or a mixture of the two.
In severe mitral stenosis, because of the obvious stasis of blood in LA,
there are high possibilities of clot formation, and this is seen more so in the
Indian subcontinent due to poor patinet compliance with anticoagulation
therapy and this is a major issue in the management of patients with
rheumatic mitral stenosis.This leads to various complications such as Stroke,
TIA, and embolisation to various other systemic organs and lower limbs
ausing ischemia.
It is important to treat these patients as an urgent case for LA clot
removal and Mitral valve repalcement along with surgical management of
lower limb ischemia.
Zaidi et al conclude that "Dietary supplements, such as curcumin, may
be beneficial for some myeloma patients". This is on the basis of their
single case report; in other words it is an anecdote. In contrast, the
medicinal chemistry of curcumin has been studied in depth for many years.
Nelson et al conclude that, despite over 120 clinical trials, no
beneficial effect has been observed (1).
Zaidi et al conclude that "Dietary supplements, such as curcumin, may
be beneficial for some myeloma patients". This is on the basis of their
single case report; in other words it is an anecdote. In contrast, the
medicinal chemistry of curcumin has been studied in depth for many years.
Nelson et al conclude that, despite over 120 clinical trials, no
beneficial effect has been observed (1).
I am wondering about how rigorous was the peer review of this case
report. Did the reviewers evaluate what was the more likely explanation,
in the light of the published literature?
I note that Zaidi et al cite a review by Aggarwal et al in 2009 (2).
Several papers from this author were withdrawn in or about 2012 as
possibly fraudulent (3), casting doubt on his authority. I do not think
this oversight reflects well on the authors of the present case report, or
on its reviewers.
This case report has recently attracted substantial attention from
the lay media. Exaggerated claims have been made on national radio. Yet
there is good evidence that cancer patients who rely on alternative
treatments such as plant extracts have worse outcomes (4). Was it really
responsible of the BMJ to publish this report in its present form?
References
1. Nelson KM, Dahlin J, Bisson J et al. The Essential Medicinal
Chemistry of Curcumin. J Med Chem. 2017 Mar 9; 60(5): 1620-1637.
2. Aggarwal BB, Harikumar KB. Potential therapeutic effects of
curcumin, the anti-inflammatory agent, against neurodegenerative,
cardiovascular, pulmonary, metabolic, autoimmune and neoplastic diseases.
Int J Biochem Cell Biol 2009;41:40-59.
3. Ackerman T. M.D. Anderson scientist, accused of manipulating data,
retires. Houston Chronicle, March 2, 2016 Updated: March 4, 2016.
http://bit.ly/2AHTN20 (accessed 8th Jan 2018)
4. Johnson SB, Park HS, Gross CP et al. Use of Alternative Medicine
for Cancer and Its Impact on Survival. Journal of the National Cancer
Institute, Volume 110, Issue 1, 1 January 2018
Conflict of Interest:
I have had smouldering myeloma for nine years but have not required treatment.
BMJ approached the authors for their comments, but did not receive a
response. This case was reviewed by two external peer reviewers prior to
publication. It uses cautious language throughout and correctly offers no
definitive conclusions. BMJ Case Reports is not responsible for claims
made in other media.
Conflict of Interest:
I am the Publishing Executive for BMJ Case Report...
BMJ approached the authors for their comments, but did not receive a
response. This case was reviewed by two external peer reviewers prior to
publication. It uses cautious language throughout and correctly offers no
definitive conclusions. BMJ Case Reports is not responsible for claims
made in other media.
Conflict of Interest:
I am the Publishing Executive for BMJ Case Reports
Acute Lymphoblastic Leukaemia can affect the eye in various ways . It
may present with an ischaemic optic nerve involvement (1) or optic
nerve swelling due to direct involvement . But sometimes it may also
present as an optic nerve involvement as an effect of a drug like
Linezolid which has been used for treatment of infections which coexist
(2) or it may present as an infiltration of the nerve in combination
with...
Acute Lymphoblastic Leukaemia can affect the eye in various ways . It
may present with an ischaemic optic nerve involvement (1) or optic
nerve swelling due to direct involvement . But sometimes it may also
present as an optic nerve involvement as an effect of a drug like
Linezolid which has been used for treatment of infections which coexist
(2) or it may present as an infiltration of the nerve in combination
with herpes virus (3)
Though papillodema is the most frequent sign of optic nerve
involvement it can be absent in direct infiltration of the nerve by
leukemic cells, or present just due to increased intracranial pressure ,
or swelling because of retrolaminar leukemic invasion.
The involvement in invasion of the optic nerve usually occurs
during the evolution of acute lymphoblastic leukemia, but that , when as
is elucidated in the present case and also by Mess et al earlier in 2003,
is the first sign of acute lymphoblastic leukemia or of extramedullary
relapse after remission , it usually means a poor prognosis for the
patient, especially if it happens when the patient is still receiving
treatment, rather than after it. And so earlier it is picked up, the
better .Hence the value of a routine check even in absence of symptoms .
Optic nerve swelling may mean many things and one needs to
differentiate the causes of the optic nerve swelling clinically and with
non invasive tests like Ocular coherence tomography ( OCT ) so as to
institute proper therapy . Optic nerve involvement, as one needs to
emphasise again , is not always a result of leukaemia infiltration as a
surprise in remission . Sometimes Peripapillary retinal leukemic
infiltration may be associated with papilledema in a patient without
cranial or optic nerve involvement.(4) . Optic nerve swelling may be seen
due to optic neuritis (5) which can be seen sometimes in cases of
leukaemia without leukaemic infiltration .Sometimes the peri neuritis may
be transient (6) Papillodema due to central nervous system involvement may
be seen .Medications used for treatment may sometimes cause secondary
optic nerve affectation and may include but be not limited to toxicity of
chemotherapy, antibiotics or radiotherapy, ischemia after anaemia or
hyperviscosity, and opportunistic infections in immunocompromised
patients. In such cases to figure out whether the optic nerve involvement
is indeed direct infiltration one may look for other layers of eye being
involved . (7) So if there are other layers involved there is a clue and
an eye surgeon will pick it up because conjunctival , scleral and
trabecular involvement is characteristic
But in a case where optic nerve alone is involved one can use OCT to
figure out what's hapenning at the optic nerve level. The swelling begins
not at superior or inferior edge of the optic nerve as in papillodema due
to raised intra cranial pressure and "doesn't follow ISNT rule " ( that's
a rule in glaucoma where loss occurs in that order but sometimes
swellings occur in similar way ) and also one doesn't see a typical
swelling of optic neuritis then it's obvious that a lot of clues are
waiting to be picked up
The present case report helped us manage a case locally and so we are
thankful to the authors and the journal for the same
The optic nerve is relatively unaffected by systemic chemotherapy and
serves as a sanctuary of ALL.(8) So it is probably essential that an eye
surgeon opinion is sought regularly since there's a lot they can tell ,
lots more than meets the non ophthalmologist's eye .
Reference :-
1) Chaudhuri T, Roy S, Roy P. Ischaemic optic neuropathy induced
sudden blindness as an initial presentation of acute lymphoblastic
leukemia. Indian J Med Paediatr Oncol 2013;34:335-6
2) Joshi L, Taylor SRJ, Large O, Yacoub S, Lightman S (2009). A case
of optic neuropathy after short-term linezolid use in a patient with acute
lymphocytic leukemia. Clin Infect Dis 48:73-74. ISSN 1537-6591.
3) Bhatt UK, Gregory ME, Madi MS, Fraser M, Woodruff HA (2008).
Sequential leukemic infiltration and human herpervirus optic neuropathy in
acute lymphoblastic leukemia. Journal of AAPOS 12:200-202. ISSN 1528-3933.
4) ?eki? O, Biberoglu E, Esen F. Peripapillary retinal leukemic
infiltration associated with papilledema in a T-ALL patient without
cranial or optic nerve involvement. Tumori. 2016 Nov 11;102(Suppl. 2).
doi: 10.5301/tj.5000490
5) Yo Han Ra, Sun Young Park, Soo Ah Im, Jee Young Kim, Nak Gyun
Chung, Bin Cho. Enhancement of Optic Nerve in Leukemic Patients: Leukemic
Infiltration of Optic Nerve versus Optic Neuritis.iMRI 2016;20:167-174.
http://dx.doi.org/10.13104/imri.2016.20.3.167
6) Townsend JH, Dubovy SR, Pasol J, Lam BL. Transient optic
perineuritis as the initial presentation of central nervous system
involvement by pre-B cell lymphocytic leukemia. J Neuroophthalmol
2013;33:162-164
7) Rosenthal AR. Ocular manifestations of leukemia. A review.
Ophthalmology 1983;90:899-905
8) Ninane J, Taylor D, Day S. The eye as a sanctuary in acute
lymphoblastic leukemia. Lancet. 1980;1:452-3.
Rheumatic heart disease leading to mitral stenosis is seen more often in the developing countries than in the developed world. The patients are quite asymptomatic at rest until the 2nd or 3rd decade, when they may present with various signs and symptoms like dyspnoea on exertion, palpitations, easy fatigebility, dizziness, coughing up blood, chest pain or discomfort, and swelling in legs and upto 15% of patients may pr...
I have several points about this interesting case report.
1/ The first point that surprised me is this: apparently, this patient has had neither at the end of the procedure nor after an intercostal infiltration with long-acting local anaesthetic drug
2/ Then this could have helped in both diagnosis and treatment. The disappearing or alleviation of pain would have clearly identified the intercostal nerv...
I read with interest Dunne et al's paper kite surfing: epidemiology of trauma. They state that 'a comprehensive review of EMBASE, PubMed and Google Scholar was conducted' and that 'the search strategy included medical subject headings (MeSH) kitesurf/kitesurfing/kitesurfing hip/kitesurfing pelvis/kitesurfing fracture/kitesurfing injury'. At the time of writing, (3 April 2018) none of these terms may be found in the MeSH...
I greatly appreciate the well-advised comments from the reader on my case report, ''Fatal air embolism following local anaesthetisation: does needle size matter?''. (1) They discuss the significance of proper positioning prior to performing the biopsy. While having the appropriate hemithorax in ipsilateral-dependent position certainly minimizes the motion and reduces the risk of air embolism as the core biopsy needle tra...
We read with interest this case series having seen several nerf gun eye injuries in our own department. A search of the electronic patient records revealed 17 such cases since 2014. Of these 12 were male and 5 female with 9 under the age of 18. Analysis of the primary injury revealed 5 hyphemas, 5 cases of traumatic iritis, 2 corneal abrasions, 1 case of commotio retinae and 1 case of angle recession with the risk of glau...
I deeply appreciated the excellent description and discussion of the case in this paper. I would suggest one more piece of information to be given to the readers; not only genetic factors play a relevant role in the male breast cancers' web of causation but some, mainly occupational, exposures do too. I would therefore find it useful to know which work the patient practised, and if this occupation involved exposure to high le...
Varying sizes and quality of clots are seen in severe rheaumatic mitral valve stenosis, especially in Asian subcontinent. LA clots are also found in patients with non-valvular atrial fibrillation, but to a lesser extent as compared to rheumatic valvular disesase and are seen more in the advanced world. The clots can be fresh ones or multilayered organised clots or a mixture of the two. In severe mitral stenosis, because...
Zaidi et al conclude that "Dietary supplements, such as curcumin, may be beneficial for some myeloma patients". This is on the basis of their single case report; in other words it is an anecdote. In contrast, the medicinal chemistry of curcumin has been studied in depth for many years. Nelson et al conclude that, despite over 120 clinical trials, no beneficial effect has been observed (1).
I am wondering about h...
BMJ approached the authors for their comments, but did not receive a response. This case was reviewed by two external peer reviewers prior to publication. It uses cautious language throughout and correctly offers no definitive conclusions. BMJ Case Reports is not responsible for claims made in other media.
Conflict of Interest:
I am the Publishing Executive for BMJ Case Report...
Acute Lymphoblastic Leukaemia can affect the eye in various ways . It may present with an ischaemic optic nerve involvement (1) or optic nerve swelling due to direct involvement . But sometimes it may also present as an optic nerve involvement as an effect of a drug like Linezolid which has been used for treatment of infections which coexist (2) or it may present as an infiltration of the nerve in combination with...
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