Thank you for the opportunity to reply to the correspondant. Although
we
agree with him/her on one point, which is that there is no large,
randomized
study that would allow us to recommend the use of probiotics on a
systematic
basis in patients receiving a broad spectrum antibiotherapy, we would like
to stress out that the majority of the cases reported here are from
patients
who developed a sepsis after being to probiotic...
Thank you for the opportunity to reply to the correspondant. Although
we
agree with him/her on one point, which is that there is no large,
randomized
study that would allow us to recommend the use of probiotics on a
systematic
basis in patients receiving a broad spectrum antibiotherapy, we would like
to stress out that the majority of the cases reported here are from
patients
who developed a sepsis after being to probiotics which were either bought
over the counter (so as to improve digestive function) or prescribed for a
shortgut syndrome, and not, as in our case, in a situation of a profound
disiquilibrium of the intestinal flora consecutive to a course of
broad-spectrum antibiotitics. In ref#7, however, Lherm et al. describe ICU
patients who were severely ill and/or immunocompromised in the first
place,
and who developed septic complications after being exposed to probiotics
prescribed (in some of the cases) in the intent to solve a diarrhea
related
to antibiotics, and this report should indeed urge us to be careful in the
indication of probiotics. We persist to think that, in our young patient
whose cancer was in remission, and who had indwelling urinary catheters,
probiotics might have prevented the occurrence of severe fungal
complications. Again, though, there is no hard evidence in the literature
that we are right, and we thank the correspondant for the reminder.
Best regards,
Alexandre Hertig and Marie Dubert
I read with interest the description of an orbital floor and nasal
bone fractures associated with orbital and subcutaneous emphysema(1).
The presentation of orbital floor fracture with orbital emphysema in
the absence of a history of trauma is indeed unusual as noted by the
author. Even more unusual is a nasal bone fracture caused by nose blowing,
with the current case apparently being the...
I read with interest the description of an orbital floor and nasal
bone fractures associated with orbital and subcutaneous emphysema(1).
The presentation of orbital floor fracture with orbital emphysema in
the absence of a history of trauma is indeed unusual as noted by the
author. Even more unusual is a nasal bone fracture caused by nose blowing,
with the current case apparently being the first ever reported case.
Whilst this rare constellation of injuries is attributed to simple
nose blowing, it is hoped that this diagnosis was made after more common
causes such as domestic abuse were excluded.
It has been suggested that unwitnessed head, neck or face injuries
should be considered significant "red flags" of suspected intimate partner
violence (IPV) in women presenting Emergency Departments(2). Also of note
is that victims of IPV are more likely to present with orbital blow-out or
zygomatic complex fractures than other facial fractures(3).
The Emergency Department is often the entry point into the health
care system for victims of IPV, as such, it is important for health care
professionals working within this environment to remain vigilant to the
possibility domestic assaults in order to better identify victims.
IPV is generally considered to be under-reported by victims and it
has been found that direct questioning through the use of screening tools
during Emergency Department (ED) presentation can lead to increased
reporting of such assaults(4,5).
Whilst it is exciting to diagnose rare and exotic pathologies, such
as that identified in the case report by Jawaid, one hopes that more
frequent and perhaps sinister causes were thoroughly excluded before
reaching such diagnoses.
References:
1. Jawaid MS. Orbital emphysema: nose blowing leading to a blown
orbit. BMJ Case Rep 2015;29:2015-212554.
2. Wu V, Huff H, Bhandari M. Pattern of physical injury associated
with intimate partner violence in women presenting to the emergency
department: a systematic review and meta-analysis. Trauma Violence Abuse
2010;11:71-82.
3. Arosarena OA, Fritsch TA, Hsueh Y, Aynehchi B, Haug R.
Maxillofacial injuries and violence against women. Arch Facial Plast Surg
2009;11:48-52.
4. Perciaccante VJ, Carey JW, Susarla SM, Dodson TB. Markers for
intimate partner violence in the emergency department setting. J Oral
Maxillofac Surg 2010;68:1219-1224.
5. Morrison LJ, Allan R, Grunfeld A. Improving the emergency
department detection rate of domestic violence using direct questioning. J
Emerg Med 2000;19:117-124.
The case report unfortunately reflects a common problem where the
referring clinician omits to include relevant clinical information. "The
chest radiogram was reported by a radiologist, who neither saw the patient
personally nor enquired into the patient's history." might well be amended
to read "the referring clinician omitted to mention the presence of
multiple large cutaneous neurofibromata"
The case report unfortunately reflects a common problem where the
referring clinician omits to include relevant clinical information. "The
chest radiogram was reported by a radiologist, who neither saw the patient
personally nor enquired into the patient's history." might well be amended
to read "the referring clinician omitted to mention the presence of
multiple large cutaneous neurofibromata"
Rubbish in-rubbish out!
David O'Keeffe FRCR FRCPI FFRRCPI
Consultant Radiologist
Galway University Hospital
Galway
Ireland
Dear author
Nice case
This case emphasizes the importance in differentiation between vasogenic
edema of white matter due to SOL and edema due to stroke. The vasogenic
edema due to SOL in general doesn't respect the anatomy and in the other
hand edema due to stroke in general yes it respect the anatomy of the
vessels territory and anatomical lobes.
However I have one question:
Is the mass seen in the CT is the same mass...
Dear author
Nice case
This case emphasizes the importance in differentiation between vasogenic
edema of white matter due to SOL and edema due to stroke. The vasogenic
edema due to SOL in general doesn't respect the anatomy and in the other
hand edema due to stroke in general yes it respect the anatomy of the
vessels territory and anatomical lobes.
However I have one question:
Is the mass seen in the CT is the same mass shown in the MRI?
Because the CT shows a mass in pre sylvian fissure And the MRI shows a
mass in the post sylvian fissure (parietal lobe)
Is this the same patient with two different lesions? And in such a case it
is difficult to understand the imaging findings because if so, the
vasogenic edema (the parietal one) that we see in the MRI is not seen in
the CT? Why? How much time occurred between the two modalities (MRI+CT)?
Best regards
Suheil Artul
Many thanks for raising another important point here. The primary
responsibility of making diagnosis of a patient lies with the clinician.
The radiology is a modality that helps in reaching diagnosis. The
clinician is expected to give a detailed note to the radiologist
mentioning the case history, clinical findings and his probable diagnosis.
This input is of utmost importance to a radiologist for concluding the
radiolog...
Many thanks for raising another important point here. The primary
responsibility of making diagnosis of a patient lies with the clinician.
The radiology is a modality that helps in reaching diagnosis. The
clinician is expected to give a detailed note to the radiologist
mentioning the case history, clinical findings and his probable diagnosis.
This input is of utmost importance to a radiologist for concluding the
radiological findings and giving a probable diagnosis. If this input is
not provided, it is wiser for the radiologist to mention only the
radiological findings in his report and leave the diagnosis to the
clinician. Another way is to interview the patient. Omission on both ends
may put the patient in trouble. For many inexperienced general
practitioners, the reported radiological diagnosis is a final word and
hence care needs to be taken while reporting X-rays.
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
Thank you for the opportunity to reply to the correspondant. Although we agree with him/her on one point, which is that there is no large, randomized study that would allow us to recommend the use of probiotics on a systematic basis in patients receiving a broad spectrum antibiotherapy, we would like to stress out that the majority of the cases reported here are from patients who developed a sepsis after being to probiotic...
Dear Editor,
I read with interest the description of an orbital floor and nasal bone fractures associated with orbital and subcutaneous emphysema(1).
The presentation of orbital floor fracture with orbital emphysema in the absence of a history of trauma is indeed unusual as noted by the author. Even more unusual is a nasal bone fracture caused by nose blowing, with the current case apparently being the...
The case report unfortunately reflects a common problem where the referring clinician omits to include relevant clinical information. "The chest radiogram was reported by a radiologist, who neither saw the patient personally nor enquired into the patient's history." might well be amended to read "the referring clinician omitted to mention the presence of multiple large cutaneous neurofibromata"
Rubbish in-rubbish...
Dear author Nice case This case emphasizes the importance in differentiation between vasogenic edema of white matter due to SOL and edema due to stroke. The vasogenic edema due to SOL in general doesn't respect the anatomy and in the other hand edema due to stroke in general yes it respect the anatomy of the vessels territory and anatomical lobes. However I have one question: Is the mass seen in the CT is the same mass...
Many thanks for raising another important point here. The primary responsibility of making diagnosis of a patient lies with the clinician. The radiology is a modality that helps in reaching diagnosis. The clinician is expected to give a detailed note to the radiologist mentioning the case history, clinical findings and his probable diagnosis. This input is of utmost importance to a radiologist for concluding the radiolog...
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...
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