Weekitt Kittisupamongkol

Near-fatal bleeding, senna, and the opposite of lettuce.

In February, 2006, a 45-year-old woman went to her local hospital with diff use abdominal pain. When the hospital realised that she might have a serious illness, she was brought by ambulance to our hospital, for insurance reasons. By the time she arrived, the pain had been present for 15 h. Her aortic valve had been replaced in 1999, but she had had no abdominal problems until mid-2005, when she developed a tendency to constipation. She had therefore taken 1–2 tablets of a senna-based laxative, once or twice a week. She had seen no need to tell her doctors about the laxative. For 3 weeks preceding her admission she had taken several tablets of laxative a day, and passed loose, watery stools up to three times a day. The day before the pain started, she had taken many tablets, after passing no stool for 2 days. She had then passed three watery stools, followed by three bloody stools— some blood was fresh and red, and some old and black. She had no other medical history of note; notably, she had no psychiatric disorder. She was on no drugs other than warfarin, which she had taken ever since her operation. She took her warfarin regularly, and her international normalised ratio (INR) had been in the therapeutic range for years. Her diet, including her consumption of green vegetables, varied little. She took no herbal medications. 25 days before admission, her INR had been 2·3. She was hypotensive and tachycardic. Her abdomen was distended, with widespread tenderness and guarding. Rectal examination revealed fresh blood. Blood tests showed a haemoglobin concentration of only 84 g/L; the platelet count was normal, at 164×109/L, but the INR was 11·9; the activated partial thromboplastin time was 92·4 s (control time 29·3 s). The concentrations of bilirubin and aspartate aminotransferase were slightly high, at 33·5 μmol/L and 48 U/L, respectively, but the results of liver function tests were otherwise normal. CT of the abdomen showed extensive haematoma in the pelvic, paracolic, and subhepatic regions. We admitted the patient for several days, during which we gave her vitamin K, fresh frozen plasma, and packed red cells. She subsequently resumed taking warfarin, and stopped taking laxatives in excess; her INR rapidly returned to the target range, where it has remained ever since. When last seen, in November, 2007, she was well. Vitamin K is an essential cofactor for γ-carboxylation, the post-translational modifi cation of coagulation factors II, VII, IX, and X (fi gure). Although vitamin K is also a cofactor for the γ-carboxylation of protein C and protein S, lack of vitamin K reduces coagulation. Green leafy vegetables have especially high con centrations of vitamin K, but the vitamin K in vegetable oils and soya may be more bioavailable. Many patients on warfarin are aware—as, indeed, was our patient—that their dietary consumption of vitamin K should remain fairly constant. However, not all are aware that diarrhoea can reduce absorption of vitamin K, and increase the risk of bleeding. Although some physicians recommend halving the dose of warfarin when the patient has diarrhoea, many doctors seem unaware of the increased risk of bleeding—and many textbooks, formularies, and patient-information leafl ets fail to mention the increased risk, or do so only in passing. Cases like ours will continue to occur, until doctors and patients are better informed.

Antibodies in tubulointerstitial nephritis and uveitis syndrome.

Editor, T homassen and colleagues describe an 11-year-old boy with tubulointerstitial nephritis and uveitis (TINU) syndrome (Thomassen et al. 2009). The authors do not mention whether there were autoantibodies against antigen in both tubulars and uveal cells. Such findings were found in a 15-year-old boy diagnosed with TINU syndrome. (Abed et al. 2008) It is interesting if their case shows similar result. This would support the immune-mediated process as the pathogenesis of TINU syndrome.

Takotsubo cardiomyopathy in subarachnoid hemorrhage.

The authors cannot conclude that they report the first case of Takotsubo cardiomyopathy associated with subarachnoid hemorrhage in a Caucasian patient.

Celiac Disease First Diagnosed in the Elderly

To the Editor: I read with interest the article by Pilotto et al . (1) . e authors are not aware of celiac disease. None of the investigations in the study can e ectively search for such a disorder. e most common symptom of celiac disease on ! rst presentation is diarrhea (2) . Moreover, up to 34 % of patients with newly diagnosed celiac disease are over 60 years old (3) . Celiac disease should be considered before the authors conclude that drug use is the cause of diarrhea in elderly outpatients.

Angiotensin-Converting Enzyme Levels in Chronic Sarcoidosis

To the Editor: I read with interest the article by Ebert et al. (1). The authors state that angiotensin-converting enzyme levels are elevated in 60% of sarcoidosis patients; I partly agree. This is incorrect in chronic sarcoidosis. Although the granulomatous response in acute sarcoidosis resolves within 2–5 years in more than three-fifths of patients (2), the rest will progress to a chronic stage in which angiotensin-converting enzyme levels are elevated in only 20% (3).

Miller-Fisher Variant of Guillain-Barré Syndrome

The authors declare that the material here submitted is original and is not currently under consideration nor has been accepted for publication elsewhere. All authors have read the manuscript and approved its submission. The authors have reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal. org/site/misc/reprints.xhtml). Correspondence to: Simon Kwok Fai Leung, BM, MPhil, Respiratory Laboratory, Grantham Hospital, 125 Wong Chuk Hang Rd, Aberdeen, Hong Kong, People’s Republic of China; e-mail: skfleung@netvigator.com DOI: 10.1378/chest.09-0553 References

Prevalence of systemic lupus erythematosus-associated optic neuritis.

Editor, I read with interest the article on systemic lupus erythematosus-associated optic neuritis by Lin et al. (2009). The authors diagnosed eight patients with systemic lupus erythematosus according to the 1982 revised criteria (Tan et al. 1982). Some points need to be clarified, however. These criteria were updated in 1997 (Hochberg 1997), when the positive lupus erythematosus cell preparation was deleted and replaced with a positive finding of antiphospholipid antibodies. If patients are enrolled according to the updated criteria, the number of patients diagnosed with systemic lupus erythematosus may change and subsequently alter the prevalence of systemic lupus erythematosus-associated optic neuritis.

Francis Weld Peabody's classic quotation.

To the Editor: Lembo and colleagues (1) reported an interesting randomized, controlled trial of acupuncture for irritable bowel syndrome (IBS) and concluded that acupuncture is not superior to sham acupuncture in the treatment of IBS, even in a limited or an augmented patient – practitioner interaction. In this trial, both limited and augmented patient – practitioner interactions were designed, which I think is unnece ssary. As stated before, IBS is associated with generalized anxiety disorder (2,3) and psychological implication or treatment is helpful. Both acupuncture and sham acupuncture have a nonspecifi c therapeutic eff ect, which is also known as a psychological eff ect. Th is is the reason why acupuncture and sham acupuncture take eff ect for IBS. Th e patient – practitioner interaction in this article acted as a certain kind of psychological therapy, and the author did not compare the infl uence of limited patient – practitioner interaction with that of augmented patient – practitioner interaction in a genuine or sham acupuncture group. Th erefore, I think the patient – practitioner interaction design is unnecessary. In addition, IBS is an internal functional disorder. In traditional Chinese medicine, IBS is considered to be a large-intestine disorder, and hence acupoints on related meridians are usually selected. As any kind of treatment produces psychological comfort to a certain degree, I think the selection of acupoints on the IBS-non-related meridian is more appropriate for the control group.

Thrombophilia in Liver Disease

The American Journal of GASTROENTEROLOGY VOLUME 104 | JUNE 2009 www.amjgastro.com genous metastases are the major modes of spreading esophageal cancer. 0 e rates of lymph node and visceral metastases during the 3 rst diagnosis have been reported as 74.5 and 50 % , respectively (3) . In this patient it is unclear through which pathway the solitary metastasis from the esophageal carcinoma reached the urinary bladder. 0 ere is no literature on the possible mechanism of metastasis. On the basis of the anatomic relationship between the esophagus and bladder, local invasion can be ruled out as a cause. A lymphatic route does not seem likely. 0 erefore, we can only speculate on variation in the hematogenous pathway or point out the presence of malignant cells in ascites as a possible cause. Other atypical localizations of esophageal metastasis have been described. Earlier case reports describe the parotid gland, jaw, and even the brain as locations of metastatic spread through the vertebral routes, as proved by Batson (1,4 – 6) . However, a solitary macroscopic distant metastasis of an esophageal carcinoma in such a short time and without other tumor spread has not been described before. In conclusion, our case is the 3 rst case of bladder metastasis from an esophageal adenocarcinoma.

Enterovesical fistula and roundworms

Gupta et al.1 describe a man with urinary obstruction due to the presence of Ascaris lumbricoides. No further investigation was conducted to determine why such roundworms were present in the urinary system. The life cycle of A. lumbricoides in humans is spent only in respiratory and gastrointestinal tracts.2 Enterovesical fistula is possible, and the common causes for such fistulas, e.g. colon cancer and sigmoid diverticulitis, may present in the patient.3 Failure to perform further investigations on this aspect would delay the diagnosis and management of a treatable disorder.