Journal of Medical Case Reports - Latest Comments

Biomedicine and culture-bound health: is it a double-deaf conversation?

Nasser Al-Azri — 2010-02-11T00:00:00Z

Dear sir,

I've read with great interest the article of Guenedi, et al,[1] on investigating biomedically a supposed "spirit possession" case. The idea is interesting but it seems we are missing the point in here. Biomedicine is a wholly different paradigm that has its' own epistemological foundations and assumptions on which it bases its' interpretation and management of events. A particular culture, on the other hand, has its' own. With such significant differences in the input (epistemology) and output (interpretation and management), the description of the process (event) is a mere de facto. Therefore, “linking possession to brain abnormality' empirically is like building a bridge on the earth to reach the moon. It takes us no further than our eyesight does within our own world.

The pathologic process, which is the focus in western biomedicine, should not be confused with the cause as the latter entails aspects of beliefs and theoretical foundations of the healing system. The positivist approach in the biomedical model acknowledges only observable and measurable phenomena and thus limits the ontological world of health and healing within such constraints. Etiology is not so central to biomedical practice as management usually targets, more or less, the pathologic process rather than its’ underlying cause.

On the other hand, etiology of illness is a central aspect of ethnomedical systems while the (pathologic) process is of much less concern. Moreover, it is very important when dealing with ethnomedical systems to comprehend the presence of multi-level etiology. Glick has defined at least two levels in such systems: the efficient cause and the instrumental cause[2]. He asserts that “[c]auses may turn out to be as invisible as viruses, but never as impersonal”. This is quite in contrast with the approach adopted in biomedicine where the cause is, at best, of less practical importance while the process dominates the practice.

Confining socio-cultural issues of health and illness within the boundaries of the medical paradigm will do no benefit to understand the hidden doctrines underlying cultural perception of health and illness. It might be interesting to indulge further in such cases to examine whether a treatment outcome considered successful on biomedical bases is so for the patient and his/ her family. Also, whether such a perceived success alters initial assumptions of the illness or not.

The current study is valuable in trying to investigate the case from a psychopathological perspective. Nevertheless, a comprehensive approach including social, religious, cultural and anthropological perspectives is indispensable[3]. Without this, such an investigation might just augment the imbalance in favour of biomedical view which may increase further the gap between biomedical practitioners and patients with socio-cultural perceptions of illness. Possession and brain abnormalities are words of two different ontological languages, and a true conversation between the two requires more than one speaking and the other hearing. It requires active listening.

References:
1. Guenedi AA, Al Hussaini A, Obeid YA, Hussain S, Al-Azri F, Al-Adawi S: Investigation of the cerebral blood flow of an Omani with supposed ‘spirit possession’ associated with an altered mental state: a case report. Journal of Medical Case Reports 2009, 3:9325. Available: http://jmedicalcasereports.com/content/3/1/9325. Accessed February 7th 2010.
2. Glick LB: Medicine as an Ethnographic Category: The Gimi of the New Guinea Highlands. Ethnology 1967, 6(1):31-56
3. Khalifa N, Hardie T: Possession and jinn. J R Soc Med 2005, 98:351-353

Author name

mehmet ali erkurt — 2010-02-05T00:00:00Z

Author title "Mehmet ALI Erkurt" should be corrected "Mehmet Ali Erkurt". No Additional comment. Thank you for kind interest.

Very minor changes in the conclusion

Suresh Krishnamoorthy — 2010-02-05T00:00:00Z

In paragraph B.4.1 sentence 2.

"There should be a high index of clinical suspicion in considering a thyrotoxic state when cachexia is associated with heart rhythm abnormalities, particularly heart blocks."

- which sounds better, I think.

Why wasn't carcinoid syndrome considered?

Rajesh Sankar — 2009-12-07T00:00:00Z

Why wasn't carcinoid syndrome considered, and 5HIAA, serotonin, tryptophan, and Chromogranin A levels looked for, in this patient?

Previous reports of ruptures absent of the use of steroids

david fuller — 2009-02-13T00:00:00Z

WHO Pharmaceuticals Newsletter No. 1, 2002 reported that Levofloxacin (Tavanic) had been associated with a number of adverse reactions, including 12 cases of tendinitis, which had been reported to the Belgian centre for pharmaco-vigilance since the drug's launch in August 2000. Of the 12 reports of levofloxacin-associated tendinitis, 6 cases involved tendon rupture. Of the six cases of tendon rupture associated with the use of levofloxacin, only in five of these cases the concomitant corticosteroid therapy may have been a contributing risk factor. Here we have a report of rupture in which the use of corticosteroids was NOT a factor.

Within a correspondence published in the Journal of Antimicrobial Chemotherapy ((2003) 51, 747-748)
Haddow et al report upon spontaneous Achilles tendon rupture in four patients treated with levofloxacin stating that:

“None of the four patients described had a history of tendinitis, or any systemic disease known to cause an enthesopathy (such as psoriasis, inflammatory bowel disease, ankylosing spondylitis or spondyloarthropathy). All were over 65, two had poor cardiac function, two had chronic lung disease and one was on corticosteroids. None had raised serum creatinine at the time of treatment. The patients described received levofloxacin 500 mg twice daily for between 1 and 10 days." Here again we have a report of a rupture in which the use of corticosteroids was not a factor.

In 2004 Kowatari et al [1] reported a case of spontaneous bilateral Achilles tendon rupture induced by levofloxacin in a 76-year-old man who was diagnosed with acute appendicitis and was commenced on oral levofloxacin 300 mg/day for 2 weeks. Both Achilles tendons ruptured completely at the mid-portion. There was no obvious underlying disease or pathophysiological factor causing fragility of his Achilles tendons. This would be our third reported case within two years in which the use of corticosteroids was not a factor in the rupture.

It would appear that the authors of this article would be mistaken to assume that theirs is the first report of such ruptures being associated with levaquin absent of any of the known risk factors such as the use of corticosteroids. The above reports took place between five and seven years before the authors published their paper.

Within these three publications alone we find three reported cases of spontaneous rupture of the
Achilles tendon, attributed to Levaquin (between 2002 and 2004) in which spontaneous tendon rupture had occurred in patients who had no previous exposure to corticosteroids. In one case in particular it was noted that “Both Achilles tendons ruptured completely at the mid-portion...” A more diligent search by the authors may have revealed additional cases of this nature.

Respectfully submitted for your review,

Mr. David T. Fuller

1. J Orthop Sci. 2004;9(2):186-90.
Levofloxacin-induced bilateral Achilles tendon rupture: a case report and review of the literature.
Kowatari K, Nakashima K, Ono A, Yoshihara M, Amano M, Toh S.
Department of Orthopaedic Surgery, Aomori Rosai Hospital, 1 Minamigaoka, Shirogane-machi, Hachinohe 031-8551, Japan.
PMID: 15045551 [PubMed - indexed for MEDLINE]

The authors reply to Dr Horvarth

Effrossyni Gkrania-Klotsas — 2009-01-05T00:00:00Z

We thank Dr Horvarth for his comments. HSE remains a difficult diagnosis. We feel that this patient's clinical history, clinical presentation and outcome strongly suggest it as well. Our original screen for other viruses included, by local protocols, a PCR for VZV and a PCR for enterovirus, both from CSF specimens, which were both negative. The lack of any relevant exposure history, paired with a negative HIV test from the peripheral blood by ELISA, made us not pursue further an acute HIV diagnosis, for instance by doing a peripheral viral load. Similarly, the patient had serological evidence of past but not recent EBV infection at the time, so EBV was not considered as a diagnosis. No evidence of immunodeficiency was present at the time or during follow-up. Although an EEG was ordered, it was cancelled in view of the patients favorable clinical response. Overall, the clinical impression remains the most important tool for diagnosis. The overall sensitivity and specificity ranges of PCR in HSE in children and adults are excellent, ranging from 95–100% to 94–99%, respectively.1. Lakeman FD, et al. PCR in the diagnosis of HSE. J Infect Dis. 1995;171:857–863 2. Aurelius E, et al. Rapid diagnosis of herpes simplex encephalitis.... Lancet. 1991;337:189–192.

Uncertainity of the diagnosis

Szatmar Horvath — 2009-01-05T00:00:00Z

The diagnosis of viral CNS infections are undoubtedly one of the clinical challenges. However, there are well defined steps and clinical protocols that everyone who is involved in clinical practice should keep in mind (1). Based on a single PCR result and an MRI scan Gkrania-Klotsas & Lever claim that the presented case is a HSE, but have neither screened for other, clinically relevant neurotropic viruses (e.g. EBV, HIV), nor performed EEG for HSE specific brain activity. Now, however, it is clear the relatively high frequency of false positive and the large number of false-negative results stress the need for improvement in the quality of HSV nucleic acid amplification tests and for external quality control programmes(2, 3). Hence, we propose that PCR should never stand alone (without a concomitant ELISA) in the diagnosis of herpesviral encephalitis, as described in our recent EBV case (4). Altogether, I am not convinced the case being a real HSE case and this paper sets the course and standards for encephalitis diagnosis. 1. Steiner I, Budka H, Chaudhuri A, Koskiniemi M, Sainio K, Salonen O, Kennedy PG.Eur J Neurol. 2005 May;12(5):331-43. 2.Schloss L, van Loon AM, Cinque P, Cleator G, Echevarria JM, Falk KI, Klapper P, Schirm J, Vestergaard BF, Niesters H, Popow-Kraupp T, Quint W, Linde A. J Clin Virol. 2003 Oct;28(2):175-85. 3. Schultze D, Weder B, Cassinotti P, Vitek L, Krausse K, Fierz W. Swiss Med Wkly. 2004 Nov 27; 134(47-48):700-4. 4. Chadaide Z, Voros E, Horvath S. J Med Virol. 2008 Nov;80(11):1930-2.

correction on GFAP

Clinton mcelroy — 2008-12-18T00:00:00Z

GFAP, or glial fibrillary acidic protien is a type III intermediate filament (just like desmin in muscle). Neuronal cells do not express GFAP, which is positive in glial cells such as astrocytes.

reactive arthritis and it effects on breast implants

kamal SALEH — 2008-11-03T00:00:00Z

In my experience in breast implants in al emadi hospital-qatar for more than 2 years only one case of silicon breast implant get abnormal capsuler metaplasia, but the patients also coplaining from reactive arthrites (diagnosed by lab) so at that time we considered that the reaction in site of breast implant due to her actual diseases (reactive arthritis)

updated on pubished cases

Axel Petzold — 2008-09-29T00:00:00Z

coinciding with our publication Dr Arthur Siegel and colleagues published in The American Journal of Medicine 2007;120:461.e11-461.17 a study on 'hyponatremia in marathon runners due to inappropriate arginine vasopressin secretion'. In their paper the authors refer to one of the cases reported by us [reference 1].

In order to update the data in our Table 1; the serum Na of this 32 year old runner was 123 mM, CT brain showed diffuse cerebral and pulmonary oedema.

One further case not know to us at time of publication was a 24 year old female participating at a Marine Corps marathon. She had a serum Na of 113 mM, again with diffuse cerebral and pulmonary oedema.

Axel Petzold