We read with interest your unusual case of migraine presenting with
complete body paralysis and aphasia. We recently witnessed a similar
presentation in our emergency department.
A 45-year-old lady with no past medical history was "blue-lighted" to
our facility by the ambulance service after her husband discovered her to
be very upset and confused upon awakening in the morning. On examination
by the ambulance...
We read with interest your unusual case of migraine presenting with
complete body paralysis and aphasia. We recently witnessed a similar
presentation in our emergency department.
A 45-year-old lady with no past medical history was "blue-lighted" to
our facility by the ambulance service after her husband discovered her to
be very upset and confused upon awakening in the morning. On examination
by the ambulance crew she was found to have occipital headache and neck
pain exacerbated by attempting to bring her chin to her chest. She had
acute limb weakness in all four limbs and was having difficulty finding
words. Vital signs were all normal.
Upon arrival to hospital, the patient had marked expressive aphasia
but full receptive cognition. She was weak in all four limbs, producing
only some effort against gravity in the arms, and movement but no effort
against gravity in the legs. Weakness was symmetrical bilaterally.
Neurological examination was otherwise unremarkable.
All observations and investigations, including head CT were
unremarkable, with the exception of blood (++) on urine dipstick.
The patient had not taken any medications, alcohol, or illicit drugs.
Symptoms improved progressively such that the patient's verbal
fluency was increasing in scope and limb weakness was noticeably improved
(although still very present) within an hour of her arrival at hospital.
By two hours' time she had made a full neurological recovery and after a
further brief period of observation was discharged home with instructions
to follow up with her general practitioner.
A differential diagnosis of atypical migraine or panic attack was
arrived at by exclusion.
None of the professionals involved in her care, including senior
emergency medicine and stroke physicians, had ever seen such a
presentation. We also agree that an MRI scan would ideally have been
conducted, but was not possible at the time.
Computed tomography-guided cutting needle biopsy of pulmonary lesions
is a relatively safe technique with a high diagnostic accuracy and
acceptable rate of complications. Complications of the procedure include
pneumothorax, haemoptysis, and pulmonary haemorrhage. Whereas hemorrhage
is an infrequent complication of transthoracic needle lung biopsy,
pneumothorax is common and often necessitates chest tube placement. Only a...
Computed tomography-guided cutting needle biopsy of pulmonary lesions
is a relatively safe technique with a high diagnostic accuracy and
acceptable rate of complications. Complications of the procedure include
pneumothorax, haemoptysis, and pulmonary haemorrhage. Whereas hemorrhage
is an infrequent complication of transthoracic needle lung biopsy,
pneumothorax is common and often necessitates chest tube placement. 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. In a study "complications after transthoracic needle In a study
Population-based risk for lung biopsy of a pulmonary nodule: an analysis
of discharge records.'
Wiener RS, Schwartz LM, Woloshin S, Welch HG.
Source
Boston University School of Medicine, Boston, Massachusetts 02118, USA.
rwiener@bu.edu
2. Clin Radiol. 2000 Dec;55(12):964-9.
CT-guided cutting needle biopsy of lung lesions--safety and efficacy of an
out-patient service.
Charig MJ, Phillips AJ.
3. 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.
4. 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.
5. 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.
6. 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.
I read with enjoyment your unusual case report of mucinous
adenocarcinoma arising from a villous adenoma in the terminal ileum and
invading the bladder.
This case represents the importance of team collaboration i.e.
urology and colorectal surgeons in complicated and rare cases.
It would be interesting to know what percentage of small bowel
tumours fistulae to the bladder? and how many similar case re...
I read with enjoyment your unusual case report of mucinous
adenocarcinoma arising from a villous adenoma in the terminal ileum and
invading the bladder.
This case represents the importance of team collaboration i.e.
urology and colorectal surgeons in complicated and rare cases.
It would be interesting to know what percentage of small bowel
tumours fistulae to the bladder? and how many similar case reports there
are in the literature.
I read your article thoroughly and in my opinion it was
magnificent.For a while I worked in an emergency department of a referral
university hospital where, I must admit ,I rarley thought about WE in the
context out side of alcoholism,diabetes and malnutrition.
When I read your report ,I learnt so many clinical hints.The patient's
presentation,the way you manged her and the comprehensive and practic...
I read your article thoroughly and in my opinion it was
magnificent.For a while I worked in an emergency department of a referral
university hospital where, I must admit ,I rarley thought about WE in the
context out side of alcoholism,diabetes and malnutrition.
When I read your report ,I learnt so many clinical hints.The patient's
presentation,the way you manged her and the comprehensive and practical
discussion, all helped me in ehnacing my clinical awareness of this
entity.Hence,I decided to write to you and thank for taking time and
reporting the case.
Dear Dr Sedat Isikay
I read your case report with enjoyment.It was great and increased my
knowledge on this topic.I am writing to you to ask what made you looked
for CD when her iron deficiency anemia could be attributed to pulmonary
haemosiderosis and she had no gastro intestinal complaint?
The author Mallinson T must be commended for the detailed and
informative description of existing reality in Nepal. Hailing from the
neighboring nation, India, I have personally traveled across the sub-
continent, and have witnessed an entire spectrum of health-care facilities
- ranging from the most modern, to the utterly rudimentary.
Health-care receives a low priority, not just from the financial
aspect, but a...
The author Mallinson T must be commended for the detailed and
informative description of existing reality in Nepal. Hailing from the
neighboring nation, India, I have personally traveled across the sub-
continent, and have witnessed an entire spectrum of health-care facilities
- ranging from the most modern, to the utterly rudimentary.
Health-care receives a low priority, not just from the financial
aspect, but also with the investment of public thought.
It is not uncommon for hospitals to be set-up on short-notice prior
to major political elections; needless to say, these 'hospitals' are mere
empty little buildings with an appalling lack of infrastructure.
I certainly feel for the 'primary health care' doctor in this region
of the world who gets 'posted' to such rudimentary hospitals. I see such
doctors in a way one could see 'a young soldier sent into a major war with
lots of training, but with absolutely no rations or weaponry'.
The current state of the war on disease is a farce. And I can safely
conclude, for now, prevention is certainly better than cure, given that
cure may be unthinkable- some-times, some-places.
The correct learning points from this case study would be to dissuade
physicians from the circumcision of minors. When describing it as
'relatively safe', you fail to recognise that all circumcision causes harm
- pain, both short and long term, and the removal of tissue and penile
structures that can never be replaced. This makes it an unethical surgery
when you consider that a) There is a wealth of evidence to suggest tha...
The correct learning points from this case study would be to dissuade
physicians from the circumcision of minors. When describing it as
'relatively safe', you fail to recognise that all circumcision causes harm
- pain, both short and long term, and the removal of tissue and penile
structures that can never be replaced. This makes it an unethical surgery
when you consider that a) There is a wealth of evidence to suggest that
there is no medical benefit whatsoever, and b) That the patient is too
young to give consent, thus this is a forced and unnecessary procedure and
should be regarded similarly to FGC which maims and amputates analogous
genital structures.
Even given the frequent but absurd claims that circumcision itself is
not harmful, this is a reminder that this practice has the potential for
devastating consequences.
The authors allude to the circumcision as a religious and traditional
ritual in some cultures and as such this case would appear to arise out of
traditional practices rather than therapeutic need. For a child to suffer
this when the operation was t...
Even given the frequent but absurd claims that circumcision itself is
not harmful, this is a reminder that this practice has the potential for
devastating consequences.
The authors allude to the circumcision as a religious and traditional
ritual in some cultures and as such this case would appear to arise out of
traditional practices rather than therapeutic need. For a child to suffer
this when the operation was therapeutically necessary would have been
tragic, but in the absence of therapeutic necessity it is unacceptable.
This case is a reminder that circumcison has the potential to damage
the health and wellbeing of a child and that it should only be considered
when there is disease which makes it unavoidable.
Conflict of Interest:
Trustee of educational and human rights charities related to genital surgery in children.
We thoroughly enjoyed reading this informative article of
mucormycosis infection, umusually in an immunocompetent patient.
We noted that following the patient's surgical management of presumed
rhinocerebral mucormycosis infection, and an initial 3 day course of
amphotericin B, the patient was commenced on oral fluconazole. However,
according to Sun et al, 2002, most mucorales isolates are res...
We thoroughly enjoyed reading this informative article of
mucormycosis infection, umusually in an immunocompetent patient.
We noted that following the patient's surgical management of presumed
rhinocerebral mucormycosis infection, and an initial 3 day course of
amphotericin B, the patient was commenced on oral fluconazole. However,
according to Sun et al, 2002, most mucorales isolates are resistant to
fluconazole, and we thus wonder whether this course of medical management
was a contributing factor in the eventual demise of the patient
Reference
Sun, QN; Fothergill, AW; McCarthy, DI; Rinaldi, MG; Graybill JR. In
Vitro Activities of Posaconazole, Itraconazole, Voriconazole, Amphotericin
B, and Fluconazole against 37 Clinical Isolates of Zygomycetes.
Antimicrob. Agents Chemother. 2002, 46(5):1581-82.
I'm a first/corresponding author of this article.
Because email server has been changed, old e-mail: mdksu@ilsanpaik.ac.kr
will not be use.
New email address is "prof.mdksu@gmail.com"
Please correct past email address as a new one.
We read with interest your unusual case of migraine presenting with complete body paralysis and aphasia. We recently witnessed a similar presentation in our emergency department.
A 45-year-old lady with no past medical history was "blue-lighted" to our facility by the ambulance service after her husband discovered her to be very upset and confused upon awakening in the morning. On examination by the ambulance...
Computed tomography-guided cutting needle biopsy of pulmonary lesions is a relatively safe technique with a high diagnostic accuracy and acceptable rate of complications. Complications of the procedure include pneumothorax, haemoptysis, and pulmonary haemorrhage. Whereas hemorrhage is an infrequent complication of transthoracic needle lung biopsy, pneumothorax is common and often necessitates chest tube placement. Only a...
I read with enjoyment your unusual case report of mucinous adenocarcinoma arising from a villous adenoma in the terminal ileum and invading the bladder.
This case represents the importance of team collaboration i.e. urology and colorectal surgeons in complicated and rare cases.
It would be interesting to know what percentage of small bowel tumours fistulae to the bladder? and how many similar case re...
Dear authors
I read your article thoroughly and in my opinion it was magnificent.For a while I worked in an emergency department of a referral university hospital where, I must admit ,I rarley thought about WE in the context out side of alcoholism,diabetes and malnutrition. When I read your report ,I learnt so many clinical hints.The patient's presentation,the way you manged her and the comprehensive and practic...
Dear Dr Sedat Isikay I read your case report with enjoyment.It was great and increased my knowledge on this topic.I am writing to you to ask what made you looked for CD when her iron deficiency anemia could be attributed to pulmonary haemosiderosis and she had no gastro intestinal complaint?
Conflict of Interest:
None declared
The author Mallinson T must be commended for the detailed and informative description of existing reality in Nepal. Hailing from the neighboring nation, India, I have personally traveled across the sub- continent, and have witnessed an entire spectrum of health-care facilities - ranging from the most modern, to the utterly rudimentary.
Health-care receives a low priority, not just from the financial aspect, but a...
The correct learning points from this case study would be to dissuade physicians from the circumcision of minors. When describing it as 'relatively safe', you fail to recognise that all circumcision causes harm - pain, both short and long term, and the removal of tissue and penile structures that can never be replaced. This makes it an unethical surgery when you consider that a) There is a wealth of evidence to suggest tha...
Even given the frequent but absurd claims that circumcision itself is not harmful, this is a reminder that this practice has the potential for devastating consequences.
The authors allude to the circumcision as a religious and traditional ritual in some cultures and as such this case would appear to arise out of traditional practices rather than therapeutic need. For a child to suffer this when the operation was t...
Dear Sir
We thoroughly enjoyed reading this informative article of mucormycosis infection, umusually in an immunocompetent patient.
We noted that following the patient's surgical management of presumed rhinocerebral mucormycosis infection, and an initial 3 day course of amphotericin B, the patient was commenced on oral fluconazole. However, according to Sun et al, 2002, most mucorales isolates are res...
I'm a first/corresponding author of this article. Because email server has been changed, old e-mail: mdksu@ilsanpaik.ac.kr will not be use. New email address is "prof.mdksu@gmail.com" Please correct past email address as a new one.
Conflict of Interest:
None
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