Dear editor please delete the previous letter which I submitted one
hour ago and consider this new letter for response to the article
THE LETTER:
Very nice case and I read with much attention the article "
Alcoholic cardiomyopathy" by Antonio Mirijello, et al published in BMJ
Case Reports 2013 :doi:10.1136/bcr-2013-201449.
I think that the most important sign is the rapidity of myocardial
recovery during absti...
Dear editor please delete the previous letter which I submitted one
hour ago and consider this new letter for response to the article
THE LETTER:
Very nice case and I read with much attention the article "
Alcoholic cardiomyopathy" by Antonio Mirijello, et al published in BMJ
Case Reports 2013 :doi:10.1136/bcr-2013-201449.
I think that the most important sign is the rapidity of myocardial
recovery during abstinence of drinking with the rapidity of disappearing
of the signs: "cardiomegaly and pulmonary edema" in chest x-ray after
cessation of drinking.
Perfusion MRI can play a role in differential diagnosis of non ischemic
dilated cardiomegaly.
It will be great if the authors can explain in more details the meaning of
"typical signs of alcoholic cardiomyopathy" in one non dynamic chest x-ray
and what is the difference from other chest x-ray signs of other causes of
dilated hypertrophic cardiomyopathy?
Best regards
Suheil Artul
EMMS Hospital Nazareth Israel, Radiology Department
26-10-2013
We thank the reader for the interesting comment on our recently
published "Images in..." entitled Alcoholic Cardiomyopathy, describing a
case of severe cardiomegaly found at a chest X-ray in an alcoholic
patient. We agree on the utility of perfusion MRI in the differential
diagnosis of non-ischemic dilated cardiomegaly. Unfortunately, the patient
declined a perfusion MRI, thus we were not able to pe...
We thank the reader for the interesting comment on our recently
published "Images in..." entitled Alcoholic Cardiomyopathy, describing a
case of severe cardiomegaly found at a chest X-ray in an alcoholic
patient. We agree on the utility of perfusion MRI in the differential
diagnosis of non-ischemic dilated cardiomegaly. Unfortunately, the patient
declined a perfusion MRI, thus we were not able to perform it. The rapid
improvement of pulmonary oedema is surely a very important sign. We are
cautious, however, with its diagnostic utility because we cannot attribute
the improvement of ventricular volumes only to the cessation of drinking,
since both abstinence from alcohol use and heart failure pharmacological
treatment were started concurrently. We agree that cardiomegaly in a
patient complaining of exertional dyspnoea, peripheral oedema and reduced
effort tolerance is not specific per se and that obviously a "non dynamic"
exam, such as chest X-ray cannot provide information on the cause of
cardiomyopathy. However, in the reading and clinical interpretation of the
X-ray, we also considered the medical history of this patient, i.e. the
lack of risk factors for or history of cardiovascular disease as well as
the positive history for alcoholism during the last 20 years. As such, it
is reasonable that this chest X-ray connotes a specific image of alcoholic
cardiomyopahty. In summary, while radiology exams may not be diagnostic
per se, on the other hand their interpretation together with a complete
medical history may help the clinician to guide the diagnosis.
Reply to reader's observation:
The serotonin syndrome is a clinical diagnosis based on a broad spectrum
of certain clinical signs and symptoms after the intake of serotonergic
agents. Diagnosis of our case was based on the Hunter Criteria.1 Other
sets of diagnostic criteria have been studied for the definition of the
serotonin syndrome.2,3 However the Hunter Criteria were more accurate,
sensitive (84 per cent vs. 75 per...
Reply to reader's observation:
The serotonin syndrome is a clinical diagnosis based on a broad spectrum
of certain clinical signs and symptoms after the intake of serotonergic
agents. Diagnosis of our case was based on the Hunter Criteria.1 Other
sets of diagnostic criteria have been studied for the definition of the
serotonin syndrome.2,3 However the Hunter Criteria were more accurate,
sensitive (84 per cent vs. 75 per cent), specific (97 per cent vs. 96 per
cent) and simpler compared to the original Sternbach Criteria.1,4
Diagnostic Hunter Criteria include spontaneous clonus; inducible clonus
and agitation or diaphoresis; ocular clonus and agitation or diaphoresis;
tremor and hyperreflexia; hypertonia and temperature above 38*C and ocular
or inducible clonus.1,4,5 Not all clinical findings might be present in a
single patient. Presentation depends on mild, moderate or severe
toxicity.4-6 Our patient was on a dual serotonergic drug regimen of a
normal dose of venlafaxine and an overdose of sumatriptan, when he
developed spontaneous clonus resulting in head shaking with only mild
symptoms of serotonin toxicity (confer video in the full text).7 Signs of
neuromuscular hyperreactivity such as clonus (spontaneous or inducible)
with serial involuntary, rhythmic, muscular contractions and relaxations
are the most important diagnostic findings also to distinguish from the
neuroleptic malignant syndrome, anticholinergic and sympathomimetic
toxicity, or CNS infections.4,6 Bilateral occurrence of clonus is not
mandatory for the diagnosis of serotonin toxicity, however bilateral
Babinski signs may occur.4 Clonus is typically more pronounced in the
lower extremities in contrast to our patient's twitching of the head.4-6
However, previous observations described a "peculiar head-turning behavior
characterized by repetitive rotation of the head" in patients with
serotonin syndrome.5 Moreover animal studies found a link between head
movements and the serotonin system, where the head-twitch response is
induced by activation of serotonergic 5-ht receptors in rodents.8-10
Other mild cases of serotonin toxicity were found to be "afebrile but
tachycardic and with twitching or tremor".6,11 Fever higher than 38*C was
not as strongly associated with the diagnosis of the serotonin syndrome.1,
5 Otherwise temperature increase over 38.5*C usually caused by muscular
hyperactivity indicated severe life-threatening cases of serotonin
toxicity.1,4,5 In our patient with mild symptoms and low muscular
hyperactivity the temperature was not elevated.
Symptoms in our patient started shortly after increase of sumatriptan
dosage and typically resolved within 24 hours after the discontinuation of
serotonergic drugs and the initiation of symptomatic therapy with
benzodiazepines.
Synoptical with the timing of onset and resolution of symptoms, the
pattern of illness, and the results of investigations to rule out
alternative causes we established the diagnosis of a serotonin syndrome
aka serotonin toxicity. We did not rechallenge the patient with the drug
as a last option to attribute causality to the suspected adverse drug
reaction.12
References
1. Dunkley EJ, Isbister GK, Sibbritt D, et al. The Hunter Serotonin
Toxicity Criteria: simple and accurate diagnostic decision rules for
serotonin toxicity. QJM 2003; 96:635.
2. Sternbach H. The serotonin syndrome. Am J Psychiatry 1991; 148:
705-13.
3. Hegerl U, Bottlender R, Gallinat J, Kuss HJ, Ackenheil M, M?ller
HJ. The serotonin syndrome scale: first results on validity. Eur Arch
Psychiatry Clin Neurosci 1998; 248: 96-103.
4. http://www.uptodate.com/contents/serotonin-syndrome (accessed
October 21, 2013).
5. Boyer EW, Shannon M. The serotonin syndrome. N Engl J Med
2005;352:1112-20.
6. Iqbal MM, Basil MJ, Kaplan J, Iqbal MT. Overview of serotonin
syndrome. Ann Clin Psychiatry 2012; 24: 310-8.
7. Weiler S, Offinger A, Exadaktylos AK. Shaking head means "no". BMJ
Case Rep 2013 Sep 10;2013.
8. Darmani NA, Zhao W. Production of serotonin syndrome by 8-OH DPAT
in Cryptotis parva. Physiol Behav 1998; 65:327-31.
9. Reissig CJ, Eckler JR, Rabin RA, Rice KC, Winter JC. The stimulus
effects of 8-OH-DPAT: evidence for a 5-HT2A receptor-mediated component.
Pharmacol Biochem Behav 2008; 88:312-7.
10. Fantegrossi WE, Simoneau J, Cohen MS, Zimmerman SM, Henson CM,
Rice KC, Woods JH. Interaction of 5-HT2A and 5-HT2C receptors in R(-)-2,5-
dimethoxy-4-iodoamphetamine-elicited head twitch behavior in mice. J
Pharmacol Exp Ther 2010; 335:728-34.
11. Radomski JW, Dursun SM, Reveley MA, Kutcher SP. An exploratory
approach to the serotonin syndrome: an update of clinical phenomenology
and revised diagnostic criteria. Med Hypotheses. 2000; 55:218-24.
12. Edwards IR, Aronson JK. Adverse drug reactions: definitions,
diagnosis, and management. Lancet 2000; 356:1255-9.
In this interesting article, I'd like to submit the hypothesis that
deformations of the spine during the few msec of trauma can be temporary
(e.g. temporary disc bulging) and not picked up by CT/MRI scans after
injury.
We conducted a laboratory study which lent support to this idea.
In this interesting article, I'd like to submit the hypothesis that
deformations of the spine during the few msec of trauma can be temporary
(e.g. temporary disc bulging) and not picked up by CT/MRI scans after
injury.
We conducted a laboratory study which lent support to this idea.
http://www.ncbi.nlm.nih.gov/pubmed/8009357
CONCLUSIONS:
Two potential spinal cord injury-causing mechanisms in axial bursting
injuries of the cervical spine are occlusion and shortening of the canal.
Post-injury radiographic measurements significantly underestimate the
actual transient injury that occurs during impact.
If the abstract is representative of the report's contents then it
would seem rather unlikely that it makes any sense to label this case as
SS (aka ST). It would not appear that any of the symptoms to fulfil the
hunter criteria are present. There is no mention of the key symptoms of
bilateral clonus and hyperpyrexia.
We read with great interest the case report entitled "Gluteal
compartment syndrome with severe rhabdomyolysis" by Naryan et al. (1) This
is an outstanding case report and is a useful reminder to all trauma
surgeons of the urgent necessity for aggressive re-hydration and alkaline
diuresis in patients presenting with severe muscle crush injuries.
We read with great interest the case report entitled "Gluteal
compartment syndrome with severe rhabdomyolysis" by Naryan et al. (1) This
is an outstanding case report and is a useful reminder to all trauma
surgeons of the urgent necessity for aggressive re-hydration and alkaline
diuresis in patients presenting with severe muscle crush injuries.
We have little doubt that the team at The Royal London Hospital saved
this mans life through their immediate resuscitation. However, the role of
fasciotomy in the treatment of crush injuries is less certain.
A recent article by Reis and Better claims rather emphatically that:
'In view of the evidence that has accumulated it can now be
categorically stated that fasciotomy is contraindicated in patients with
closed acute muscle crush compartment syndrome'. (2)
The authors have clearly achieved an excellent outcome for this
patient and we would be very interested to know how they might wish to
refine the advice offered by Reis and Better.
Your sincerely,
Mark D Latimer MA MEng FRCS
Nnamdi J Obi BSc MBBS MRCS
References
1. Narayan N, Griffiths M, Patel HDL. Gluteal compartment syndrome
with severe rhabdomyolysis. BMJ Case Rep 2013; doi:10.1136/bcr-2013-010370
2. Reis ND, Better OS. Mechanical muscle-crush injury and acute
muscle-crush compartment syndrome. J Bone Joint Surg (Br) 2005;87-B:450-3
In ankylosing spine there are unique biomechanical conditions which
any spine surgeon has to know. Rules should be obeyed, otherwise the
implanted screw-rod-system will not lead to successful treatment. Often
revision surgery is necessary.
The authors very well describe the systemtic pharmacological therapy
that diminuished inflammation and helped the patient to recover.
In ankylosing spine there are unique biomechanical conditions which
any spine surgeon has to know. Rules should be obeyed, otherwise the
implanted screw-rod-system will not lead to successful treatment. Often
revision surgery is necessary.
The authors very well describe the systemtic pharmacological therapy
that diminuished inflammation and helped the patient to recover.
But in a spine surgeon's view the surgical procedure was inadequate:
An Andersson lesion is a sign of severe instability. This was recognized
by the surgeon because he tried to fix both ends of the vertebral column,
that has the appearance of a "bamboo spine" (shown image b). But he has
chosen a too short, bisegmental instrumentation.
There is a lot of evidence, that this type of instability can't be
restored by this surgical strategy (see literature below).
The surgical principles in Andersson lesion seem to be the same as in
fractures in ankylosing spine.
The persisting postoperative pain can also be explained as a
persisting instability.
The therapy of Andersson lesion has to include both: First of all
adequate stabilization and second adequate pharmacological inhibiton of
inflammation.
Literature:
- Caron T, Bransford R, Nguyen Q et al (2010) Spine fractures in patients
with ankylosing spinal disorders. Spine (Phila Pa 1976) 35:E458-464
- Hitchon PW, From AM, Brenton MD et al (2002) Fractures of the
thoracolumbar spine complicating ankylosing spondylitis. J Neurosurg
97:218-222
It very important to be knowledgable regarding UNUSUAL causes of any clinical presentation. Epistaxis being a very common symptom presenting in varying degrees and forms maybe not taken seriously at times. This could lead to missing a vital diagnosis. I like this article as it has made me aware of another possible cause of epsitaxis which will make us more vigilant when managing these cases.
It very important to be knowledgable regarding UNUSUAL causes of any clinical presentation. Epistaxis being a very common symptom presenting in varying degrees and forms maybe not taken seriously at times. This could lead to missing a vital diagnosis. I like this article as it has made me aware of another possible cause of epsitaxis which will make us more vigilant when managing these cases.
Dear editor please delete the previous letter which I submitted one hour ago and consider this new letter for response to the article THE LETTER:
Very nice case and I read with much attention the article " Alcoholic cardiomyopathy" by Antonio Mirijello, et al published in BMJ Case Reports 2013 :doi:10.1136/bcr-2013-201449. I think that the most important sign is the rapidity of myocardial recovery during absti...
Dear Editor,
We thank the reader for the interesting comment on our recently published "Images in..." entitled Alcoholic Cardiomyopathy, describing a case of severe cardiomegaly found at a chest X-ray in an alcoholic patient. We agree on the utility of perfusion MRI in the differential diagnosis of non-ischemic dilated cardiomegaly. Unfortunately, the patient declined a perfusion MRI, thus we were not able to pe...
Reply to reader's observation: The serotonin syndrome is a clinical diagnosis based on a broad spectrum of certain clinical signs and symptoms after the intake of serotonergic agents. Diagnosis of our case was based on the Hunter Criteria.1 Other sets of diagnostic criteria have been studied for the definition of the serotonin syndrome.2,3 However the Hunter Criteria were more accurate, sensitive (84 per cent vs. 75 per...
In this interesting article, I'd like to submit the hypothesis that deformations of the spine during the few msec of trauma can be temporary (e.g. temporary disc bulging) and not picked up by CT/MRI scans after injury.
We conducted a laboratory study which lent support to this idea.
http://www.ncbi.nlm.nih.gov/pubmed/8009357
CONCLUSIONS:
Two potential spinal cord injury-causing mecha...
If the abstract is representative of the report's contents then it would seem rather unlikely that it makes any sense to label this case as SS (aka ST). It would not appear that any of the symptoms to fulfil the hunter criteria are present. There is no mention of the key symptoms of bilateral clonus and hyperpyrexia.
Conflict of Interest:
None declared
This work will open many unknown horizons. My sincerest congratulations to authors well as to the Journal.
Conflict of Interest:
None declared
Dear Basavanna Gowdappa,
Excellent effort and good case.
It would be really interesting to see what happens to intrinsic factor antibodies after eradicating H Pylori.
-Dr.Suresh Shastri
Conflict of Interest:
None declared
Dear Editor,
We read with great interest the case report entitled "Gluteal compartment syndrome with severe rhabdomyolysis" by Naryan et al. (1) This is an outstanding case report and is a useful reminder to all trauma surgeons of the urgent necessity for aggressive re-hydration and alkaline diuresis in patients presenting with severe muscle crush injuries.
We have little doubt that the team at The Roy...
In ankylosing spine there are unique biomechanical conditions which any spine surgeon has to know. Rules should be obeyed, otherwise the implanted screw-rod-system will not lead to successful treatment. Often revision surgery is necessary.
The authors very well describe the systemtic pharmacological therapy that diminuished inflammation and helped the patient to recover.
But in a spine surgeon's view t...
Conflict of Interest:
...Pages