Thank you for your question and kind comments regarding the case
report. The mass seen is the same as in the Computerised Tomography (CT)
and the Magnetic Resonance (MR) images. It is an isolated, large (3x2.5
cm) mass lesion. The CT was taken almost 48 hours prior to the MR as the
patient had been incorrectly diagnosed and triaged to the stroke unit. As
a result this time-frame may account for c...
Thank you for your question and kind comments regarding the case
report. The mass seen is the same as in the Computerised Tomography (CT)
and the Magnetic Resonance (MR) images. It is an isolated, large (3x2.5
cm) mass lesion. The CT was taken almost 48 hours prior to the MR as the
patient had been incorrectly diagnosed and triaged to the stroke unit. As
a result this time-frame may account for changes in the visualisation of
vasogenic oedema. I'm sure that you'd also agree that vasogenic oedema is
better visualised with the MR imaging modality rather than CT.
We have re-reviewed the images on the dedicated imaging monitors and
the mass is superior to the sylvan fissure, contained in the high right
parietal lobe, this is demonstrated in the coronal image (Figure 4) of the
case report (1). In later images (not shown) 2 months later, it was seen
to extend into the fronto/parietal junction as the mass lesion enlarged.I
hope that this has answered your questions.
Thank you once again for your question and interest in the case.
Kind regards
Hew DT Torrance, MRCS; Kai Lee Tan, FRCR; & Ava Jackson, MRCP.
References:
1. Torrance HD, Tan KL, Jackson A. Metastatic lung cancer, an
interesting stroke mimic. BMJ Case Rep. 2014 Jan 21;2014.
This oversight indicates the shortcomings of present day medical
training. The emphasis is on technology and newer diagnostics at the cost
of patient centered clinical skills, which included detailed history
taking. We are in danger of churning out technicians rather than doctors.
Indeed, this is a very interesting case illustrating that a positive
intraoperative sign (finding bile in what is considered a distal segment
of an atretic duodenum) does not exclude every possible pathology.
However, I am still not convinced about the underlying pathology in this
case.
In my opinion, a perforated duodenal windsock web would allow a greater
amount of air to pass through (and more gas appearing in the ab...
Indeed, this is a very interesting case illustrating that a positive
intraoperative sign (finding bile in what is considered a distal segment
of an atretic duodenum) does not exclude every possible pathology.
However, I am still not convinced about the underlying pathology in this
case.
In my opinion, a perforated duodenal windsock web would allow a greater
amount of air to pass through (and more gas appearing in the abdomen)
particularly when bile passes freely through. A pathology that could fit
better to the findings is that of a bifid distal portion of the bile duct
with openings proximally and distally to the web. This explains why bile
flows both proximally and distally to the web. Air (in small amounts) can
enter the proximal orifice, bypass the web through the bile duct and empty
to the distal duodenum through the distal orifice. If the authors take
this possibility under consideration, I would like to know if their
findings were consistent with this hypothesis.
Annular pancreaas is a more complex anomaly that might (?), by its protean
pathology, cause similar difficulties, but I believe that it could have
been recognized and described.
Please allow a final question. Do I understand correctly that, at least
in the first operation, no pediatric surgeon was involved?
Thank you for the interesting case and fruitful discussion.
The fungal kingdom is characterized by significant biodiversity
within genera and species. Several hundred of fungi have been described as
cause of disease in humans. Abdulaziz and colleagues describe a case of
invasive fungal disease that supports their plea for more research into
polyene and azole combination therapy. In their case report the authors
make assumptions that do not take into account the fungal biodiversity...
The fungal kingdom is characterized by significant biodiversity
within genera and species. Several hundred of fungi have been described as
cause of disease in humans. Abdulaziz and colleagues describe a case of
invasive fungal disease that supports their plea for more research into
polyene and azole combination therapy. In their case report the authors
make assumptions that do not take into account the fungal biodiversity.
The case is presented as invasive pulmonary aspergillosis, but the
diagnosis is based on a tissue biopsy that shows septate hyphae which
might be consistent with aspergillosis. However, the morphology of fungi
in tissue is insufficient to provide a genus identification. There are
numerous fungi, including Fusarium, Paecilomyces, and Scedosporium, that
exhibit similar morphologic characteristics as Aspergillus in tissue.
Furthermore, the new taxonomy of Aspergillus has created a number of new
sibbling species, that might have very different antifungal susceptibility
profiles compared to the conventional species complexes. At best the
diagnosis in the presented case is proven invasive fungal disease. The
question is why additional tests such as PCR were not applied to obtain
identification of the fungus.
To support the plea for polyene plus azole combination therapy the authers
refer to an animal study that was performed with Cryptocuccus neoformans
in SCID-mice. Although in this model dose fractionation, PK/PD analysis
and drug interaction models were not used, it remains unclear if
observations with the yeast Cryptococcus can be extraprolated to the mold
Aspergillus. Also the case series of patients treated with polyene plus
azole combination therapy included a variety of pathogens and patient
groups.
The discussion on the use of combination therapy in patients with invasive
aspergillosis is not new and continues to deserve our attention,
especially with the emergence of azole resistance in many coutries. With
the new taxonomy and the possibility of resistance the need to identify
the fungal pathogen is essential to understand therapeutic responses.
Conflict of Interest:
I have received research grants from Gilead Sciences, Pfizer, Astellas and Merck.
We are grateful for your comments in our images in medicine article in BMJCR entitled "'Neonatal duodeno-duodenostomy and missed duodenal stenosis with windsock deformity: a rare intraoperative error of technique and judgement by an unwary surgeon"1
We agree that finding bile in what is considered a distal segment of an atretic duodenum does not exclude all possible pathology. We are in agreement with your statement that duodena...
We are grateful for your comments in our images in medicine article in BMJCR entitled "'Neonatal duodeno-duodenostomy and missed duodenal stenosis with windsock deformity: a rare intraoperative error of technique and judgement by an unwary surgeon"1
We agree that finding bile in what is considered a distal segment of an atretic duodenum does not exclude all possible pathology. We are in agreement with your statement that duodenal atresia diagnosed prenatally and presenting at birth with distal bowel gas (on abdominal radiograph) via an anomalous bifurcated bile duct connection is more common than initially thought and occurs more frequently than duodenal stenosis2.
We agree with you that a perforated duodenal windsock web would allow a greater amount of air to pass through (and more gas appearing in the abdomen) particularly when bile passes freely through. We reviewed the abdominal radiograph with our radiology team and indeed there was greater amount of air in the right and transverse colon as seen in figure 1. The gas in the left transverse colon was still visible one week post-operatively as shown in figure 2.
We have considered the pathology of bifid distal bile duct with openings proximal and distal to the web and therefore have performed upper gastrointestinal series and followed it for 24 hours in an attempt to demonstrate this as there is risk for cholestasis, possibly due to duodeno-biliary reflux through the abnormal ampulla2. Upper gastrointestinal contrast studies delineated the windsock deformity and show the site of attachment of the diaphragm. Sometimes there is an indentation externally to mark the site of attachment of the diaphragm as shown with arrows in figure 3.
At operation, there was no duodenal atresia or annular pancreas. WE routinely use flexible neonatal endoscope during the operation to see any visible bile duct opening or the wind shock deformity with or without an opening and provide air distention and transillumination to see shouldering at the attachment of the diaphragm as reported earlier3-4. In this case we could not see any anomalous bile duct opening and a single normal ampulla opening was seen just above the attachment of the diaphragm medially and the eccentric opening in the duodenal wind shock deformity was abutting the medial wall of the duodenum obstructing it completely.
At the first operation, consultant paediatric surgeon was available in the theatre suite and in fact popped in and requested for any help required but the operating senior registrar with special interest in paediatric surgery was confident as has seen dark green bile as confirmation of being distal to the site of obstruction. He did repent his decision not to allow paediatric surgeon to join and learn during first operation when he joined us at second operation and apologized to the parents admitting his ignorance and arrogance.
Patel RV, Govani D, Patel R, Dekiwadia DB
Department of Surgery, PGICHR, KTCGH and PDUMC, Rajkot, India
References:
1. Patel RV, Govani D, Patel R, Dekiwadia DB. Neonatal duodeno-duodenostomy and missed duodenal stenosis with windsock deformity: a rare intraoperative error of technique and judgement by an unwary surgeon. BMJ Case Rep 2014. 15 Jan 2014 doi:10.1136/bcr-2013-202782
2. Komuro H1, Ono K, Hoshino N, Urita Y, Gotoh C, Fujishiro J, Shinkai T, Ikebukuro K. Bile duct duplication as a cause of distal bowel gas in neonatal duodenal obstruction. J Pediatr Surg. 2011; 46(12):2301-4.
3. Patel RV, Kumar H, More B. Preampullary duodenal web simulating gastric outlet obstruction. J Neonat Surg. 2013; 2: 13.
4. Patel RV, Philip I. Distal duodenal stenosis in Down's syndrome-a rare diagnostic and therapeutic challenge. J Pediatr Surg Specialities (in press)
Legends to illustrations
Figure 1. Abdominal radiograph showing greater gas in the right and transverse colon between arrows.
Figure 2. Post-operative chest radiograph demonstrating gas in the left transverse colon
Figure 3. Post-operative upper gastrointestinal contrast at 24 hours depicting indentation at the site of diaphragm attachment (arrows
After reading this article, we are prompted to ask whether the use of
functional magnetic resonance imaging (fMRI) or a fluoro-desoxy-glucose
positron emission tomography (FDG-PET) can help solve ambiguities
associated with clinical and computed tomography angioraphy (CTA) based
techniques for affirming brain-death.
Lugg et al. present a case of acute hepatitis in a 16-year old girl
and, using the CIOMS/RUCAM scale, conclude the probable cause as a 3-month
exposure to a Chinese green tea ordered via the internet. Other case
reports have associated an idiosyncratic hepatoxicity with green tea
though other factors, including adulterants, can contribute to its
causality (Blumberg et al.). Regrettably, like many of these reports, this
on...
Lugg et al. present a case of acute hepatitis in a 16-year old girl
and, using the CIOMS/RUCAM scale, conclude the probable cause as a 3-month
exposure to a Chinese green tea ordered via the internet. Other case
reports have associated an idiosyncratic hepatoxicity with green tea
though other factors, including adulterants, can contribute to its
causality (Blumberg et al.). Regrettably, like many of these reports, this
one also fails to test the product and inappropriately presumes the
product label is correct. Green tea adulterated with plant extracts and/or
drugs is not green tea but an illegal product! A relatively simple
analytical test would have revealed adulteration of this product and
helped to remove it from the marketplace and prevent others from suffering
a fate like this patient. Unsurprisingly, the story of this report carried
widely by the media appear to have used only its title and summary to warn
readers about the harm of drinking green tea, despite a strong likelihood
that this product was not simply green tea. Thus, many people may now
choose to forego what Lugg et al. note is "a very safe and healthy drink".
Jeffrey B. Blumberg
Tufts University
Reference
Blumberg, JB, Bolling BW, Xiao H, Chen C-YO. Review and perspective
on the composition and safety of green tea extracts. Eur J Nutr Food
Safety 2015;5:1-31
A clear exposition of the case using a simple drawing to explain the
image. In depth and summarised investigation on the subject.
Practical tips for a general surgeon's practice usefull to avoid serious
injuries.
"Only following specific questioning did she reveal that she had, in
the preceding 3 months, regularly consumed internet ordered Chinese green
tea, which contained Camellia sinensis."
My issue with this sentence is the word "contained". Chinese green
tea, or any other true tea, must come from Camellia sinensis.
"Only following specific questioning did she reveal that she had, in
the preceding 3 months, regularly consumed internet ordered Chinese green
tea, which contained Camellia sinensis."
My issue with this sentence is the word "contained". Chinese green
tea, or any other true tea, must come from Camellia sinensis.
The word "contained" gives the impression that this was added to the
green tea.
Any "tea" from any other plant is considered an herbal tea.
I feel the article is well justified because the dangers of
adulteration are very serious. I also agree with the dangers of
supplements and liver toxicity from high levels of EGCG ingestion.
My concern is that green tea, oolong tea and black tea are all very
healthy drinks and many bloggers will create misinformed conclusions from
the summary which may derogate from the benefits of tea.
This misleading statement in the summary of this article has already
been misinterpreted and published on "Grub Street"
(http://www.grubstreet.com/2015/09/green-tea-hepatitis.html). A reader
pointed out their mistake in the comments section and they have since
retracted and corrected their error.
The real issue here is not the tea. It is the contaminants either
sprayed on, or added to, the tea.
I think the sentence should be revised to prevent any further
confusion.
Should this comment be posted on this or any other website, I ask
that my email not be displayed.
Thank you for your time,
Shawn Weldon
Conflict of Interest:
I run a green tea information website promoting the benefits of green tea consumption. I focus primarily on Japanese green tea.
I don't believe there are any competing interests.
The prostatic utricle is a cul-de-sac of the prostatic urethra and
extends backward and slightly upward for a very short distance within the
middle lobe of the prostate. It is composed of fibrous tissue, muscular
fibers, and mucous membrane. The prostatic utricle is 10-12 mm long,
sometimes it is 20-25 mm, rarely it is 6-8 cm long.1 It is located in the
seminal colliculus (i.e. veru montanum): this is a prominence of the...
The prostatic utricle is a cul-de-sac of the prostatic urethra and
extends backward and slightly upward for a very short distance within the
middle lobe of the prostate. It is composed of fibrous tissue, muscular
fibers, and mucous membrane. The prostatic utricle is 10-12 mm long,
sometimes it is 20-25 mm, rarely it is 6-8 cm long.1 It is located in the
seminal colliculus (i.e. veru montanum): this is a prominence of the
dorsal surface of the prostatic urethra in which the two ejaculatory ducts
open and among them exists the prostatic utricle, besides sometimes the
ejaculatory ducts open into the prostatic utricle and not into the
prostatic urethra.1,2
The prostatic utricle and the female vagina develop from the sinovaginal
bulb that grows from the dorsal wall of the urogenital sinus to the level
of the Mullerian tubercle, without the contribution of the Mullerian
ducts.1,2 The fused Mullerian ducts form the uterus up to the external
cervical os, and the inducing mesonephric ducts regress cranially,
although they enlarge caudally from the level of the cervical os, form the
sinuvaginal bulbs, incorporate the Mullerian tubercle's cells, and give
rise to the vaginal plate. The embryological development of the human
vagina does not proceed from the Mullerian ducts (as classically thought)
but from the Wolffian ducts and Mullerian tubercle.3
In females, only the body of the uterus and the uterine tubes are formed
by the Mullerian ducts.1,2 This has been known for many decades, but
according to current opinion in urology textbooks the female vagina is
still a mixed structure, formed by the urogenital sinus and from the
Mullerian ducts, even if we know that the vagina always has the same
structure for all of its length, furthermore the glycogen is present in
the epithelium of the urogenital sinus, in the vagina, and cervix, while
it is missing in the Mullerian ducts.1
The prostate utricle is of urogenital sinus origin and forms as a separate
structure as the entire caudal ends of the mullerian ducts undergo
complete regression.4
In conclusion, the prostate utricle is the homologue of the female vagina:
male vagina is a more accurate term than prostatic utricle.
References
1. Testut L, Latarjet A. Traite d'Anatomie Humaine, neuvieme edition.
Paris: G. Doin & C.ie; 1972.
2. Puppo V. Anatomy and Physiology of the Clitoris, Vestibular Bulbs, and
Labia Minora With a Review of the Female Orgasm and the Prevention of
Female Sexual Dysfunction. Clin Anat 2013; 26: 134-52.
3. Acien P, Acien MI. The history of female genital tract malformation
classifications and proposal of an updated system. Hum Reprod Update
2011;17:693-705.
4. Shapiro E, et al. The prostatic utricle is not a Mullerian duct
remnant: Immunohistochemical evidence for a distinct urogenital sinus
origin. J Urol. 2004;172:1753-56.
Dear Dr Artul,
Thank you for your question and kind comments regarding the case report. The mass seen is the same as in the Computerised Tomography (CT) and the Magnetic Resonance (MR) images. It is an isolated, large (3x2.5 cm) mass lesion. The CT was taken almost 48 hours prior to the MR as the patient had been incorrectly diagnosed and triaged to the stroke unit. As a result this time-frame may account for c...
This oversight indicates the shortcomings of present day medical training. The emphasis is on technology and newer diagnostics at the cost of patient centered clinical skills, which included detailed history taking. We are in danger of churning out technicians rather than doctors.
This case report is a wake up call.
Conflict of Interest:
None declared
Indeed, this is a very interesting case illustrating that a positive intraoperative sign (finding bile in what is considered a distal segment of an atretic duodenum) does not exclude every possible pathology. However, I am still not convinced about the underlying pathology in this case. In my opinion, a perforated duodenal windsock web would allow a greater amount of air to pass through (and more gas appearing in the ab...
The fungal kingdom is characterized by significant biodiversity within genera and species. Several hundred of fungi have been described as cause of disease in humans. Abdulaziz and colleagues describe a case of invasive fungal disease that supports their plea for more research into polyene and azole combination therapy. In their case report the authors make assumptions that do not take into account the fungal biodiversity...
After reading this article, we are prompted to ask whether the use of functional magnetic resonance imaging (fMRI) or a fluoro-desoxy-glucose positron emission tomography (FDG-PET) can help solve ambiguities associated with clinical and computed tomography angioraphy (CTA) based techniques for affirming brain-death.
Conflict of Interest:
None declared
Lugg et al. present a case of acute hepatitis in a 16-year old girl and, using the CIOMS/RUCAM scale, conclude the probable cause as a 3-month exposure to a Chinese green tea ordered via the internet. Other case reports have associated an idiosyncratic hepatoxicity with green tea though other factors, including adulterants, can contribute to its causality (Blumberg et al.). Regrettably, like many of these reports, this on...
A clear exposition of the case using a simple drawing to explain the image. In depth and summarised investigation on the subject. Practical tips for a general surgeon's practice usefull to avoid serious injuries.
Conflict of Interest:
None declared
In the summary of this article is the following:
"Only following specific questioning did she reveal that she had, in the preceding 3 months, regularly consumed internet ordered Chinese green tea, which contained Camellia sinensis."
My issue with this sentence is the word "contained". Chinese green tea, or any other true tea, must come from Camellia sinensis.
The word "contained" gives the imp...
The prostatic utricle is a cul-de-sac of the prostatic urethra and extends backward and slightly upward for a very short distance within the middle lobe of the prostate. It is composed of fibrous tissue, muscular fibers, and mucous membrane. The prostatic utricle is 10-12 mm long, sometimes it is 20-25 mm, rarely it is 6-8 cm long.1 It is located in the seminal colliculus (i.e. veru montanum): this is a prominence of the...
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