Selected Clinical Notes and Letters to the Editor are accepted for publication after review by the Editor and will be published promptly. Published letters should be 250 words or less and contain not more than three references. They can be directed either at material appearing in the Archives or can report new observations, particularly of a therapeutic 'nature, that deserve rapid attention. Clinical Notes can be up to 500 words in length and contain one photograph or line drawing, plus not more than five references. The vehicle is suitable for reporting negative studies, brief clinical observations, or therapeutic successes where the nature of the findings is insufficient to deserve a full-length paper.

Ulnar

Neuropathy

in

Bicycle

Riders

To the Editor.\p=m-\Thearticle in the Archives (32:130, 1975) by Eckman et al, "Ulnar Neuropathy in Bicycle Riders," was very interesting. However, the authors' contention that this entity in bicycle riders has not been reported previously is in error. This is a well-documented problem among serious cyclists, and it has been described by several authors. The first report of this complication of cycling was published in 1895.1 Bicycles were only a few years old, but ulnar nerve compression was recognized in some of the competitors of the first cycling classic, Paris-Brest-Paris. Since that time, the problem has been reported in both racing and touring

cyclists.2,3 Eckman and his coauthors discuss the treatment of this neuropathy, but fail to stress that this problem can be prevented by very specific alterations in the bicycle. (I have detailed this in several bicycle publications [Bike World 1:24, 1972; Bike Book Quarterly 1:24, 1974; Bicycling 13:9, 1972].)0 At the American College of Sports Medicine 1974 meeting in Knoxville, Tenn, I reported my experience of 117 cases of ulnar neuropathies in cyclists seen in a four-year period. Every one of these patients returned to cycling without a recurrence of the neuropathy by making the proper adjustments in his bicycle and/or cycling technique. C. S. HOYT, MD Univ of California San Francisco, CA 94122

References 1. Destot M:

Paralysie cubitale par l'usage de la bicyclette. Gaz H\l=o^\p69:1176-1177, 1896. 2. Stiegler G: \l=U"\berdie radfahrerlahmung des ulnaris. Munch Med Wochenschr 42:1796\x=req1797, 1927. 3. Guillain G, et al: Les paralysies du nerf cubitale chez les cyclists. Bull Soc Med H\l=o^\pParis 56:489-492, 1940. nervus

and copper concentrations, in conjunction with the lack of neurologic disease (despite the advanced hepatic dysfunction) and the typical clinical picture of PBC. Apparently, not all patients with pigmented corneal rings have Wilson disease. N. P. Goldstein, MD Mayo Clinic Rochester, MN 55901

plasmin

1. Fleming CR, Dickson ER, Hollenhorst RW, et al: Pigmented corneal rings in a patient with

primary biliary cirrhosis. 69:220-225, 1975.

Cranial Pneumatocele\p=m-\A Clue to the Diagnosis of Occult Epidural Abscess The spontaneous appearance of air on skull roentgenograms, referred to as cranial pneumatocele or pneumocephalus, is uncommon. Most of the reported cases are related to head trauma, with communication between one of the sinuses or mastoids and the epidural or subdural space.1 We have recently observed a patient in whom the roentgenographic clue suggested the diagnosis of epidural abscess.

Report of a Case.\p=m-\A15-year-old boy had a seven-day history of malaise, intermittent chills, nausea and vomiting, hallucinations, and bifrontal headaches. He had fallen nine days prior to admission, striking the midfrontal region of his

head, without loss of consciousness or amnesia. On examination, his temperature was 39.8 C and

he had a stiff neck. There was no external evidence of infection or cerebrospinal fluid (CSF) rhinorrhea. Results of neurological examination were normal. A lumbar puncture showed an opening pressure of 180 mm H2O, 22 white blood cells (WBCs) (70% lymphocytes), and normal fasting glucose (75 mg/100 ml with a concomí-

a

Cirrhosis

To the Editor.\p=m-\Sincethe presence of KayserFleischer rings has been deemed pathognomic of Wilson disease (hepatolenticular degeneration), I would like to call your attention to an exception to that rule.1 A patient with primary biliary cirrhosis (PBC) was found by slit-lamp examination to have pigmented corneal rings that were similar to Kayser-Fleischer rings. Although the exact nature of these corneal rings is unknown, this patient with PBC had increased hepatic, serum, and urine copper levels. Wilson disease was excluded, despite the presence of these pigmented corneal rings, by the serum cerulo-

Downloaded From: http://archneur.jamanetwork.com/ by a University of Pittsburgh User on 06/19/2015

view (center) level.

glucose level of 105 mg/100 ml) and protein (45 mg/100 ml) levels. A skull roentgeno¬ gram demonstrated an epidural collection of air extending posteriorly to the coronal suture and

the frontal view (Figure). Sinus x-ray films disclosed no apparent fracture, although the left maxillary sinus was opacified. The brain scan and electroencephalo¬ gram were not helpful. The patient continued to spike temperatures to 40.6 C with sterile cultures of blood, CSF, and urine. Serial CSF determina¬ tions showed an increased CSF pressure to 240 mm H20, a protein rise to 100 mg/100 ml, and a cell count between 20 and 33/cu mm, all lympho¬ cytes. The patient became increasingly lethargic. Carotid angiography on the seventh hospital day followed by exploratory burr holes exposed a putrid frontal epidural abscess. Group D nonenterococcal Streptococcus was grown from both the abscess and the blood, and Eikenella corrodens was grown only from the abscess. Following removal of a bone flap plus therapy with chloramphenicol palmitate and penicillin sodium, the patient recovered. an

apparent air fluid level

on

Comment.—Epidural abscess may be diagnostically elusive. This is particularly true in cases of insidious onset without focal neurological pro¬ gression.2 As in the present case, the CSF may only subtly reflect parameningeal infection early on, and the brain scan and electroencephalogram may not provide enough useful information to justify arteriography in a neurologically well patient. The presence of epidural air in such an instance, though uncommon,3 should provide the impetus for further investigation to rule out this potentially fatal but treatable lesion. One of the pathogens isolated from the abscess cavity, E corrodens, is an anaerobe, the impor¬ tance of which in the

of human disease has only recently been recognized.4 The organism has been implicated in several cases of central cause

system (CNS) infection, including one each of epidural abscess, intracerebral abscess, nervous

and

meningitis.4-5 The organism has distinctive

lateral skull roentgenogram (left) extends posteriorly to coronal suture. Brow\x=req-\up reveals movement of air rostrally. On frontal view (right), there appears to be air-fluid

Collection of air

Pigmented Corneal Rings in Patient With Primary Biliary

Gastroenterology

tant blood

on

Letter: Ulnar neuropathy in bicycle riders.

Selected Clinical Notes and Letters to the Editor are accepted for publication after review by the Editor and will be published promptly. Published le...
4MB Sizes 0 Downloads 0 Views