613
CORRESPONDENCE
on a11patients who present to the emergency department to look for incidental findings’? I believe that before readers cite or consider the review by Mace as an authoritative and balanced assessment of the problems surrounding the use of cervical spine radiology in emergency medicine, they should carefully reread the primary sources reviewed. KENNETH J. RHEE, MD University of California, Davis Medical Center Sacramento, CA
STEPHEN HOERLER, JONAH UKIWE,
References 1. Mace SE: The unstable occult cervical spine fracture. Am J Emerg Med 1992;10:136-142 2. Thambyrajah K: Fractures of the cervical spine with minimal or no symptoms. Med J Malaysia 1972;26:244-249 3. Haines JD: Occult cervical spine fractures. Postgrad Med 1986;80:73-77. 4. Williams C, Bernstein T, Jelenko C: Essentiality of the lateral cervical spine radiograph. Ann Emerg Med 1961;10:196-204 5. Walter J, Doris P, Shaffer M: Clinical presentation of patients with acute cervical spine injury. Ann Emerg Med i984;13:512-515 6. Mace SE: Unstable occult cervical spine fracture. Ann Emerg Med 1991;20:1373-1375 E&or’s
Reactions commonly occur with raw celery ingestion and less commonly with cooked celery, indicating that the mediating chemical substances (furanucoumarin and psoralen) are heat labile. Pauli et al4 also reported a higher incidence of allergic reaction to the root then to the leaves. Food allergy is a rising cause of morbidity and mortality. Adequate history taking and physical examination leading to early recognition of signs and symptoms would help identify the offending agent and prevent further occurrences and potential consequences.
note: The author did not elect to reply to the above letter.
LARYNGEAL EDEMA FROM CELERY ALLERGIC REACTION To the Editor:-Allergy to celery (Apium gravedens) and other food produce has been described by various investigators. However, these are uncommon; moreover, they are most commonly seen in grocery workers and farm produce handlers. To our knowledge, no previous cases of celery allergy have been reported to cause significant laryngeal edema. We describe a case of a 54-year-old woman brought into the emergency department of our hospital because of increasing difficulty with breathing. On the day of presentation, the patient had eaten only raw celery. About 3 hours later she began to experience shortness of breath. Physical examination revealed a middle-age woman in severe respiratory distress. Blood pressure and pulse were normal. Respiratory rate was 36 and labored. Physical findings included facial edema and stridor. The rest of the physical and laboratory examinations were unremarkable. The patient’s condition continued to deteriorate despite initial aggressive management. She was later intubated and placed on mechanical ventilation. On the third day of admission she was discharged home. The mediators of allergic reaction to celery are naturally occurring chemical substances, principally furanscoumarin and psoralen.’ Other reactions are thought to be due to the fungus Sclerorina sclerorium. This case illustrates the rising importance of food as a potential source of allergic reactions that could lead to significant morbidity and mortality. Allergy to food substances has been with us always and is likely to remain with us for a long time; hence, the importance of good history taking and early recognition of the signs and symptoms as well as the offending agent cannot be overemphasized if significant morbidity and mortality are to be prevented. While allergy to vegetables in the Brassica family (broccoli, cabbage, turnip, cauliflower, mustard) is well known and well described in the literature,’ previous reactions to celery cited in the literature have been limited to phytophotodermatitis occurring mostly in food handlers, grocery workers, and farmers.je5 Reactions often occur within the first hour of exposure. However, this patient’s reaction occurred approximately 3 hours later. It is not clear whether this was due to delay in recognition by the patient or if this delay had led to the severity of the signs and symptoms.
MD
MD
Bon Secours Hospital Grosse Pointe, MI
1. Blaiss MS, McCants MI, Lehrer SB: Anophylaxis to cabbage: Detection of allergens. Ann Allergy 1967;56:246-250 2. Berkley SF, Hightower AW, Beier RC, et al: Dermatitis in grocery workers associated with high natural concentrations of furonocoumarins in celery. Ann Intern Med 1966;105:351-355 3. Maso MJ, Ruszkowski AM, Bauerle J. et al: Celery phytophotodermatitis in a chef. Arch Dermatol 1991;127:912-913 (letter) 4. Pauli G, Bessot JC, Braun PA, et al: Celery allergy: Clinical and biological study of 20 cases. Ann Allergy 1966;60:243-246 5. Seligman PJ, Mathias CG, O’Malley MA, et al: Phytophotodermatitis from celery among grocery store workers. Arch Dermat01 1987;123:1478-1482
FICTITIOUS HYPOXIA-A RESULT OF MISCONNECTION OF OXYGEN TUBING TO A WALL SOURCE OF AIR To the Editor:-Previous case reportsrmJ have communicated potentially lethal complications resulting from inadvertent misconnections to wall oxygen sources. I report a case of fictitious hypoxemia as a result of inadvertent misconnection of oxygen tubing to a wall source of medical air in a recently renovated emergency department A 68-year-old woman arrived in the emergency department with a complaint of “trouble breathing” for the preceding 5 days. She had a long previous history of chronic obstructive pulmonary disease and congestive heart failure including one documented respiratory arrest. The dyspnea was described as slowly increasing in intensity and was associated with a mild. nonproductive cough. There was no fever, wheezing, chest pain. or hemoptysis. Functional enquiry was otherwise unremarkable. Her medications included furosemide. captopril, prednisone, digoxin, thyroxine, diltiazem. enteric-coated aspirin, and ranitidine. The patient was afebrile, and had a pulse rate of 80, a respiratory rate of 30, and a blood pressure of 120/65. No cyanosis was noted. Chest auscultation revealed diffuse diminution of air entry, with no adventitious sounds. Cardiac examination was normal. Other than very mild epigastric tenderness, the physical examination was unremarkable. lnitial investigations included multiple hematologic and biochemical tests, as well as a chest radiograph and arterial blood gas determination (radial artery, performed by the author). Complete blood cell count, calcium, glucose. urea, electrolytes, liver function tests, and cardiac enzymes were normal. Electrocardiogram revealed a sinus rhythm with occasional premature atria1 and ventricular beats, leftward axis, and nonspecific ST-T wave changes. The chest radiograph showed congestive heart failure, with diffuse pulmonary plethora, mild interstitial pulmonary edema, and small bilateral pleural effusions. Blood gas determination (done on oxygen delivered by nasal prongs at 3 L/min) showed pH of 7.47, PcoZ of 37, PO, of 79, bicarbonate of 26, base excess of + 3, and oxygen saturation of 96%. A diagnosis of congestive heart failure was made. The patient was
CORRESPONDENCE
on a11patients who present to the emergency department to look for incidental findings’? I believe that before readers cite or consider the review by Mace as an authoritative and balanced assessment of the problems surrounding the use of cervical spine radiology in emergency medicine, they should carefully reread the primary sources reviewed. KENNETH J. RHEE, MD University of California, Davis Medical Center Sacramento, CA
STEPHEN HOERLER, JONAH UKIWE,
References 1. Mace SE: The unstable occult cervical spine fracture. Am J Emerg Med 1992;10:136-142 2. Thambyrajah K: Fractures of the cervical spine with minimal or no symptoms. Med J Malaysia 1972;26:244-249 3. Haines JD: Occult cervical spine fractures. Postgrad Med 1986;80:73-77. 4. Williams C, Bernstein T, Jelenko C: Essentiality of the lateral cervical spine radiograph. Ann Emerg Med 1961;10:196-204 5. Walter J, Doris P, Shaffer M: Clinical presentation of patients with acute cervical spine injury. Ann Emerg Med i984;13:512-515 6. Mace SE: Unstable occult cervical spine fracture. Ann Emerg Med 1991;20:1373-1375 E&or’s
Reactions commonly occur with raw celery ingestion and less commonly with cooked celery, indicating that the mediating chemical substances (furanucoumarin and psoralen) are heat labile. Pauli et al4 also reported a higher incidence of allergic reaction to the root then to the leaves. Food allergy is a rising cause of morbidity and mortality. Adequate history taking and physical examination leading to early recognition of signs and symptoms would help identify the offending agent and prevent further occurrences and potential consequences.
note: The author did not elect to reply to the above letter.
LARYNGEAL EDEMA FROM CELERY ALLERGIC REACTION To the Editor:-Allergy to celery (Apium gravedens) and other food produce has been described by various investigators. However, these are uncommon; moreover, they are most commonly seen in grocery workers and farm produce handlers. To our knowledge, no previous cases of celery allergy have been reported to cause significant laryngeal edema. We describe a case of a 54-year-old woman brought into the emergency department of our hospital because of increasing difficulty with breathing. On the day of presentation, the patient had eaten only raw celery. About 3 hours later she began to experience shortness of breath. Physical examination revealed a middle-age woman in severe respiratory distress. Blood pressure and pulse were normal. Respiratory rate was 36 and labored. Physical findings included facial edema and stridor. The rest of the physical and laboratory examinations were unremarkable. The patient’s condition continued to deteriorate despite initial aggressive management. She was later intubated and placed on mechanical ventilation. On the third day of admission she was discharged home. The mediators of allergic reaction to celery are naturally occurring chemical substances, principally furanscoumarin and psoralen.’ Other reactions are thought to be due to the fungus Sclerorina sclerorium. This case illustrates the rising importance of food as a potential source of allergic reactions that could lead to significant morbidity and mortality. Allergy to food substances has been with us always and is likely to remain with us for a long time; hence, the importance of good history taking and early recognition of the signs and symptoms as well as the offending agent cannot be overemphasized if significant morbidity and mortality are to be prevented. While allergy to vegetables in the Brassica family (broccoli, cabbage, turnip, cauliflower, mustard) is well known and well described in the literature,’ previous reactions to celery cited in the literature have been limited to phytophotodermatitis occurring mostly in food handlers, grocery workers, and farmers.je5 Reactions often occur within the first hour of exposure. However, this patient’s reaction occurred approximately 3 hours later. It is not clear whether this was due to delay in recognition by the patient or if this delay had led to the severity of the signs and symptoms.
MD
MD
Bon Secours Hospital Grosse Pointe, MI
1. Blaiss MS, McCants MI, Lehrer SB: Anophylaxis to cabbage: Detection of allergens. Ann Allergy 1967;56:246-250 2. Berkley SF, Hightower AW, Beier RC, et al: Dermatitis in grocery workers associated with high natural concentrations of furonocoumarins in celery. Ann Intern Med 1966;105:351-355 3. Maso MJ, Ruszkowski AM, Bauerle J. et al: Celery phytophotodermatitis in a chef. Arch Dermatol 1991;127:912-913 (letter) 4. Pauli G, Bessot JC, Braun PA, et al: Celery allergy: Clinical and biological study of 20 cases. Ann Allergy 1966;60:243-246 5. Seligman PJ, Mathias CG, O’Malley MA, et al: Phytophotodermatitis from celery among grocery store workers. Arch Dermat01 1987;123:1478-1482
FICTITIOUS HYPOXIA-A RESULT OF MISCONNECTION OF OXYGEN TUBING TO A WALL SOURCE OF AIR To the Editor:-Previous case reportsrmJ have communicated potentially lethal complications resulting from inadvertent misconnections to wall oxygen sources. I report a case of fictitious hypoxemia as a result of inadvertent misconnection of oxygen tubing to a wall source of medical air in a recently renovated emergency department A 68-year-old woman arrived in the emergency department with a complaint of “trouble breathing” for the preceding 5 days. She had a long previous history of chronic obstructive pulmonary disease and congestive heart failure including one documented respiratory arrest. The dyspnea was described as slowly increasing in intensity and was associated with a mild. nonproductive cough. There was no fever, wheezing, chest pain. or hemoptysis. Functional enquiry was otherwise unremarkable. Her medications included furosemide. captopril, prednisone, digoxin, thyroxine, diltiazem. enteric-coated aspirin, and ranitidine. The patient was afebrile, and had a pulse rate of 80, a respiratory rate of 30, and a blood pressure of 120/65. No cyanosis was noted. Chest auscultation revealed diffuse diminution of air entry, with no adventitious sounds. Cardiac examination was normal. Other than very mild epigastric tenderness, the physical examination was unremarkable. lnitial investigations included multiple hematologic and biochemical tests, as well as a chest radiograph and arterial blood gas determination (radial artery, performed by the author). Complete blood cell count, calcium, glucose. urea, electrolytes, liver function tests, and cardiac enzymes were normal. Electrocardiogram revealed a sinus rhythm with occasional premature atria1 and ventricular beats, leftward axis, and nonspecific ST-T wave changes. The chest radiograph showed congestive heart failure, with diffuse pulmonary plethora, mild interstitial pulmonary edema, and small bilateral pleural effusions. Blood gas determination (done on oxygen delivered by nasal prongs at 3 L/min) showed pH of 7.47, PcoZ of 37, PO, of 79, bicarbonate of 26, base excess of + 3, and oxygen saturation of 96%. A diagnosis of congestive heart failure was made. The patient was
