This is a well written case report of a common presentation in emergency departments (altered mental state associated with alcohol intoxication and a possible head injury). It highlights the importance of a good history and maintaining a high index of suspicion for relatively uncommon diagnoses in patients with this common emergency department presentation. Can the authors please clarify if they considered any other diagnoses (that is, their differential diagnosis) before they became aware of the arterial blood gas result and the CT brain result?

Dr Abel Wakai
Reviewer

Pop goes the O₂: a case of popper-induced methaemoglobinamia

A useful approach to all patients with non-healing wounds can be summarised by the following concept: “Wounds do not heal for no reason.” The development of an ulcer is a priori evidence of some pathological process (e.g. unrelieved pressure). For a wound or an ulcer to persist, there must be a disruption in the elegant cascade of natural events which normally effect healing. Despite its complexity, healing is the NORM. The in-ability to heal is evidence of a disease state.  For a patient to have a non-healing wound or ulcer, there must be factors responsible for the failure of one of the most reliable of physiological processes, that of tissue repair.  Although textbooks and clinical research may force us to think of these ulcers as belonging to clearly defined categories (e.g. venous stasis, diabetic, pressure) the approach to treating them must be based on correcting the agent(s) which produce non-healing, many of which overlap and thus defy categorisation. (In other words, patients with venous ulcers need arterial screening and many patients with pressure ulcers need control of their diabetes.)
 
Clinical practice guidelines from major organisations invariably begin with arterial screening of all non-healing lower extremity ulcers, no matter what the presumed etiology might be (Chronic Wound Care Guidelines). They all include moist wound care, debridement of necrotic material, control of bioburden, control of edema, and off-loading of pressure. When appropriate measures such as these fail to result in healing within 6 weeks, all chronic ulcers should undergo biopsy for histological diagnosis. When a consistent protocol is followed, patients are more likely to get appropriately directed therapy. This case is an excellent example of following such a protocol. A rare condition was discovered and successfully treated “simply” by following a logical plan of assessment and treatment.

Caroline E. Fife, MD
Professor of Medicine, Division of Cardiology
University of Texas Health Science Center, Houston
Director of Clinical Research, Memorial Hermann Center for Wound Healing

The importance of challenging your diagnosis even in straightforward cases

Here the authors report a case of cryptococcal meningoencehalitis associated with the H1N1 pandemic.

Seema Biswas
Editor-in-Chief

Cryptococccal meningoencephalitis after H1N1 influenza

Neonates have the highest incidence of bacterial meningitis. Here the authors report the case of a neonate with Citrobacter koseri – a rare cause of meningitis and cerebral abscess.

Seema Biswas
Editor-in-Chief

Sepsis, meningitis and cerebral abscesses caused by Citrobacter koseri

This case from Brazil describes interstitial keratitis, deafness and dental defects characterising Hutchinson’s triad resulting from congenital syphilis in a seven year old girl.

Seema Biswas
Editor-in-Chief

Clinical aspects of congenital syphilis with Hutchinson’s triad

Scott Routley – a man who has appeared to be in a persistent vegetative state for 10 years – has answered questions using a functional MRI scan. Canadian researchers asked him to think of playing tennis to answer ‘yes’ and to think of walking around his house to answer ‘no’. These thoughts stimulate different parts of the motor cortex which can then be detected by fMRI. The researchers have been evaluating these techniques in various patients but this is the first time it has been used for complex communication in a person in apparent persistent vegetative state. It was the subject of  a recent BBC Panorama programme “The mind reader: unlocking my voice“.

The ongoing research in this area demonstrates different types of techniques [1,2] for communication and is also confirming that there are different sub-types (or misclassifications) of vegetative state [2]. Some patients do have awareness of their surroundings, can understand speech but are unable to make any form of communication themselves. Functional MRI as a communication tool can be used in these patients to better understand their perspective, their symptoms, and their wishes.

1. Bardin JC, Schiff ND, Voss HU. Pattern classification of volitional functional magnetic resonance imaging responses in patients with severe brain injury. Arch. Neurol. 2012 Feb;69(2):176–181.

2. Cruse D, Chennu S, Chatelle C, Bekinschtein TA, Fernández-Espejo D, Pickard JD, Laureys S, Owen AM. Bedside detection of awareness in the vegetative state: a cohort study. Lancet 2011 Dec;378(9809):2088–2094.

Here a 12 day neonate presents with a fever and generalised vesicular rash. Fortunately, he recovers with intravenous acyclovir…

Seema Biswas
Editor-in-Chief

A 12-day-old male newborn with extensive vesicles and fever

Here the authors describe a case of gas forming Klebsiella pneumonia causing fatal meningitis in a 40 year old woman.

Seema Biswas
Editor-in-Chief

Nosocomial meningitis caused by gas producing Klebsiella pneumoniae

Dipheroids are usually regarded as skin or mucous membrane commensals. In this case from Jamaica the authors describe the role of the bacteria in fatal infective endocarditis.

Diphtheroids as a cause of endocarditis in a haemodialysis patient

Seema Biswas
Editor-in-Chief

In this case from Iran the authors tease out a diagnosis of TB from systemic sarcoidosis in a 58 year old woman.

Seema Biswas
Editor-in-Chief

Systemic sarcoidosis with caseating granuloma