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 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.
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 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.
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 read with interest your case report (1), however I have to make the
critical comment, that patient position in your case indeed was one
essential factor of air embolism.
You attempted to biopsy a lung nodule of the left lower lobe in dorso-
lateral position with patient placed in prone oblique position on the
right side. You should have placed patient in ipsilateral-dependent
position, in other words on the side of the n...
I read with interest your case report (1), however I have to make the
critical comment, that patient position in your case indeed was one
essential factor of air embolism.
You attempted to biopsy a lung nodule of the left lower lobe in dorso-
lateral position with patient placed in prone oblique position on the
right side. You should have placed patient in ipsilateral-dependent
position, in other words on the side of the nodule, which is the left
side!
Only in this position the motion of the appropriate hemithorax is reduced
and only in this position the biopsy can be performed below the level of
the left atrium.
Or, as we have stated in our paper (2), "lateral lesions can be biopsied
in supine position or from the back in ipsilateral dependent position"
Best regards,
Gernot Rott
1. Khalid F, Rehman S, AbdulRahman R, Gupta S: Fatal air embolism
following local anaesthetisation: does needle size matter? BMJ Case
Reports, February 2018, 2018:bcr-2017-222254
2. Rott G, Boecker F: Influenceable and avoidable risk factors for
systemic air embolism due to percutaneous ct-guided lung biopsy: patient
positioning and coaxial biopsy technique-case report, systematic
literature review, and a technical note. Radiol Res Pract 2014;2014:1-8.
It has been known for years that kerion celsi can be misdiagnosed as
bacterial infection and that incision and drainage is not only unnecessary
but inappropriate treatment. (See these: Journal of Pediatric Surgery
Volume 42, Issue 8, August 2007, Pages e33-e36; Feetham JE, Sargant N
Kerion celsi: a misdiagnosed scalp infection Archives of Disease in
Childhood 2016;101:503; and finally British Association of Dermatologists'...
It has been known for years that kerion celsi can be misdiagnosed as
bacterial infection and that incision and drainage is not only unnecessary
but inappropriate treatment. (See these: Journal of Pediatric Surgery
Volume 42, Issue 8, August 2007, Pages e33-e36; Feetham JE, Sargant N
Kerion celsi: a misdiagnosed scalp infection Archives of Disease in
Childhood 2016;101:503; and finally British Association of Dermatologists'
guidelines for the management of tinea capitis 2014)
Unfortunately this case report leaves the impression that I&D of
"scalp abscesses" was necessary and appropriate treatment. It is so widely
recognized that surgical treatment of these cases is not necessary, it is
not always mentioned in guidelines.
It would be wise to include an editors comments along these lines or
perhaps suggested further reading?
We read with interest the work by Haywood et al.[1] dealing with the
treatment of a 67 years old Caucasian woman with a 4-day history of sore
throat, dysphagia, fever and nasal blockage. During the examination it was
revealed a swollen neck and pharyngeal pseudomembranes, positive on
culture for Corynebacterium ulcerans after a throat swab, with toxin
expression confirmed on PCR and Elek testing. T...
We read with interest the work by Haywood et al.[1] dealing with the
treatment of a 67 years old Caucasian woman with a 4-day history of sore
throat, dysphagia, fever and nasal blockage. During the examination it was
revealed a swollen neck and pharyngeal pseudomembranes, positive on
culture for Corynebacterium ulcerans after a throat swab, with toxin
expression confirmed on PCR and Elek testing. The patient was diagnosed of
classical respiratory diphtheria, and the diagnosis was later confirmed on
the patient's domesticated dog, which was thought to be the source of
infection. The dog had recently been attacked by a wild badger and was
being treated for an ear infection. The patient made a good recovery with
intravenous antimicrobial and supportive therapy; however, she
subsequently developed a diphtheritic polyneuropathy in the form of a
severe bulbar palsy with frank aspiration necessitating percutaneous
endoscopic gastrostomy feeding. A mild sensorimotor peripheral neuropathy
was also diagnosed. The patient eventually made an almost complete
recovery.
Zoonotic infections are defined, in general, as infections
transmitted from animal to man (and, less frequently, vice versa), either
directly (through direct contact or contact with animal products) or
indirectly (through an intermediate vector, such as an arthropod)[2].
Zoonotic disease may affect ENT districts. Unfortunately, literature is
often limited to single case reports from different countries and does not
allow adequate appreciation of the problem.
Otorhinolaryngologists often lack in-depth knowledge of zoonotic
diseases, which complicates etiological identification and treatment and
control strategies.
In our study we already considered, examining a total of 164
articles, that larynx was the most commonly involved ENT organ. Otherwise,
bacteria were the most representative microorganisms involved[2]. As read
on another study examined by us, a Corynebacterium ulcerans infection can
be responsible for a more aggressive involvement of the ENT district,
being capable of involving the total upper airway[3], with the subsequent
need to ensure a proper nutrition via a percutaneous endoscopic
gastrostomy feeding, as Haywood at al. did facing their case[1].
Another interesting thing to point out is that the ENT manifestations
in most of the zoonoses are often produced in immunosuppressed patients,
being responsible of disseminated forms which can lead to death rapidly if
misdiagnosed[1]. Albeit this, We want to point out, thanks to the work of
Vlachogianni et al., a case in which a zoonotic infection caused by
Mycobacterium avium was diagnosed in an immunocompetent 78 years-old
woman. She presented with a 6-month reddish, oedematous and painless
lesion with fine scaling in the right ear. Histology showed numerous
granulomas, composed of epithelioid histio-cytes without central necrosis.
Cultures grew Mycobacterium avium. An unusual accidental ear injury was
the portal of microbial entry. The patient's lesion fully regressed after
a 9-month course of antibiotics[4].
This two cases brought to Our attention the fact that the kind of
diseases are still of difficult diagnosis for most of the ENT specialists,
and need to be more pointed out by the Scientific Community, paying
particular attention during the anamnesis.
1. Haywood MJ, Vijendren A, Acharya V, Mulla R, Panesar MJ.
Multidisciplinary approach to the management of a case of classical
respiratory diphtheria requiring percutaneous endoscopic gastrostomy
feeding. BMJ Case Rep. 2017 Mar 6;2017. pii: bcr2016218408. doi:
10.1136/bcr-2016-218408.
2. Galletti B, Mannella VK, Santoro R, Rodriguez-Morales AJ, Freni F,
Galletti C, Galletti F, Cascio A. Ear, nose and throat (ENT) involvement
in zoonotic diseases: a systematic review. J Infect Dev Ctries. 2014 Jan
15;8(1):17-23. doi: 10.3855/jidc.4206.
3. Aaron L, Heurtebise F, Bachelier MN, Guimard Y. Pseudomembranous
diphtheria caused by Corynebacterium ulcerans. Rev Med Interne. 2006
Apr;27(4):333-5. Epub 2006 Jan 6.
4. Vlachogianni P, Volosyraki M, Stefanidou M, Krueger-Krasagakis S,
Evangelou G, Haniotis V, Kofteridis D, Maraki S, Krasagakis K.
Mycobacterium avium Auricular Infection in an Apparent Immunocompetent
Patient: A Case Report. Folia Med (Plovdiv). 2016 Apr-Jun;58(2):131-5.
doi: 10.1515/folmed-2016-0012.
Cases with combined facial nerve and trigeminal nerve involvement do
present with complex issues as elucidated by Allevi et al (1) . This
article helped us immensely in managing our case and we are grateful to
the authors and the journal.
A male patient suffering from fifth nerve and seventh nerve palsy
presented to us with similar issues with severely vascularised
hypertrophic insensitive bulging cornea with...
Cases with combined facial nerve and trigeminal nerve involvement do
present with complex issues as elucidated by Allevi et al (1) . This
article helped us immensely in managing our case and we are grateful to
the authors and the journal.
A male patient suffering from fifth nerve and seventh nerve palsy
presented to us with similar issues with severely vascularised
hypertrophic insensitive bulging cornea with zero corneal sensations on
anaesthesiometer .
Leyngold et al (2) (3) suggested endoscopic approach with scalp
incision and Bains et al (4) suggested a microincision approach.We
combined these approaches and did a corneal trasplant as well, as we had
no option since the cornea would otherwise perforate
The facial palsy was treated with gold weight implant and corneal
insensitivity with reinnervation and opacity with keratoplasty. Corneal
reinnervation was done with a different combined approach and we did a
small microincision surgery with endoscopical help , but did not take the
scalp incision and instead anastomoses was done on one side with the
contralateral supraorbital and supratrochlear nerve and the other end of
the sural nerve graft was tunnelled from contralateral side to the
ipsilateral side ,along the line connecting the eyebrows on either side
,and then across the ipsilateral eyelid , between the gold weight implant
and the medial horn of leavator palpebrea superioris and then tunnelled
subconjunctival as well as subtenons and after being dissected into
fascicles , the fascicles were inserted into four scleral tunnels and
sutured intrascleral. We got good short term result at two months and
corneal sensations have returned and we await long term results before
publishing the case . But in the interim we realised that we did see some
findings which could help others in the interim , like we were helped by
this article .
The corneal vascularisation reduced markedly as the corneal nerves
started growing and sensations returned ad the patient started feeling the
eyedrops and actual complained of pain !The palisades of Vogt thickened
and pigmentation was seen migrating into the cornea and corneal
vascularisation was seen reduced significantly in areas where the
pigmentation advanced into the cornea . There was no ptosis which we had
expected since we thought the levator would be damaged during the
procedure.
Corneal innervation is known to be necessary to maintain stemness of
stem cells and in the cornea nerves and neovessels are hypothesised to
inhibit each other (5) but we saw this clinically with areas of corneal
vascularisation disappearing as the corneal nerves grew and sensations
returned.
We thank all authors for the techiniques and would want to point out
that journals like British Journal of Case Report with its open access
policy and speedy publication of recent advances , need to be applauded
for such articles which help us in the developing countries help our poor
patients with the latest advances as soon as they occur.
References :-
1) Allevi F, Fogagnolo P, Rossetti L, Biglioli F. Eyelid reanimation,
neurotisation, and transplantation of the cornea in a patient with facial
palsy. BMJ Case Reports. 2014;2014:bcr2014205372. doi:10.1136/bcr-2014-
205372.
2) Leyngold I, Weller C, Leyngold M, Espana E, Black KD, Hall KL, Tabor
M.Endoscopic Corneal Neurotization: Cadaver Feasibility Study. Ophthal
Plast Reconstr Surg. 2017 May 2. doi: 10.1097/IOP.0000000000000913.
3) Leyngold I, Weller C, Leyngold M, Tabor M. Endoscopic Corneal
Neurotization:Technique and Initial Experience. Ophthal Plast Reconstr
Surg. 2017 Nov 27. doi: 10.1097/IOP.0000000000001023
4) Bains RD, Elbaz U, Zuker RM, Ali A, Borschel GH. Corneal neurotization
from the supratrochlear nerve with sural nerve grafts: a minimally
invasive approach. Plast Reconstr Surg. 2015 Feb;135(2):397e-400e.
doi:10.1097/PRS.0000000000000994.
5) Ferrari G, Hajrasouliha AR, Sadrai Z, Ueno H, Chauhan SK, Dana R.
Nerves and neovessels inhibit each other in the cornea. Invest Ophthalmol
Vis Sci. 2013 Jan 28;54(1):813-20. doi: 10.1167/iovs.11-8379.
Sir,
Its with interest that I read the small and crisp description and medical
images related to Artery of Percheron infarct.
The diagnosis of this condition indeed is sometimes difficult and
requires clinical suspicion accompanied by proper radiological imaging.
What i would also like to highlight is the fact that its not only the
imaging modality i.e MRI which is required,or the sequence DWI/ADC which
is also important, the imaging machinery should also be optimal i.e a
magnetic strength of at least 1.5 tesla or higher.
I emphasize this point because many MRI machines in the Indian
context are suboptimally designed to pick up these important but often
small lesions and prescribing physicians often donot have the proper
knowledge and thus fail to arrive at a proper diagnosis.
Thanks and regards,
Dr Deep Das
Consultant Interventional Neurology
Kolkata, West Bengal,
India
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 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 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 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...
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 read with interest your case report (1), however I have to make the critical comment, that patient position in your case indeed was one essential factor of air embolism. You attempted to biopsy a lung nodule of the left lower lobe in dorso- lateral position with patient placed in prone oblique position on the right side. You should have placed patient in ipsilateral-dependent position, in other words on the side of the n...
It has been known for years that kerion celsi can be misdiagnosed as bacterial infection and that incision and drainage is not only unnecessary but inappropriate treatment. (See these: Journal of Pediatric Surgery Volume 42, Issue 8, August 2007, Pages e33-e36; Feetham JE, Sargant N Kerion celsi: a misdiagnosed scalp infection Archives of Disease in Childhood 2016;101:503; and finally British Association of Dermatologists'...
Dear Editor,
We read with interest the work by Haywood et al.[1] dealing with the treatment of a 67 years old Caucasian woman with a 4-day history of sore throat, dysphagia, fever and nasal blockage. During the examination it was revealed a swollen neck and pharyngeal pseudomembranes, positive on culture for Corynebacterium ulcerans after a throat swab, with toxin expression confirmed on PCR and Elek testing. T...
Cases with combined facial nerve and trigeminal nerve involvement do present with complex issues as elucidated by Allevi et al (1) . This article helped us immensely in managing our case and we are grateful to the authors and the journal.
A male patient suffering from fifth nerve and seventh nerve palsy presented to us with similar issues with severely vascularised hypertrophic insensitive bulging cornea with...
Sir, Its with interest that I read the small and crisp description and medical images related to Artery of Percheron infarct.
The diagnosis of this condition indeed is sometimes difficult and requires clinical suspicion accompanied by proper radiological imaging.
What i would also like to highlight is the fact that its not only the imaging modality i.e MRI which is required,or the sequence DWI/ADC which...
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