rive s e r u m titer, a CSF lab profile c o n s i s t e n t w i t h Lyme disease, and d o c u m e n t e d vasculitis on angiogram that responds to IV Rocephin ® strongly suggests CNS Lyme disease as the cause (as stated in Halperin's article). There is n o doubt that there is a need for m o r e accurate ways to m a k e the diagnosis of active Lyme disease, both CNS or peripheral, and b e t t e r w a y s to m o n i t o r r e s p o n s e treatment. Gerard X Brogan, Jr, M D D e p a r t m e n t of Emergency Medicine State University of N e w York Stony Brook 1. Reik L, Steers AC, Bartenhagen NH, et ah Neurologic abnormalities of
Lyme disease. Medicine 1979;58:281-294. 2. Stiernstedt G: Tick-borne Borrelia infection in Sweden. Scand J Infect Dis 1985;45:1-70. 3. Pachner AR, Steere AC: Neurological findings of Lyme disease. Yale ] Biol Med 1984;57:481-483. 4. Pachner AR: Spirochetal diseases of the CNS. NeuroI Clin 1986;4: 207-222. 5. Uldry PA, Regli F, BogousslavskyJ: Cerebral angiopathy and recurrent strokes following Borrelia burgdorferi infection. J Neurol Neurosurg Psychiatry 1987;50:1703-1704. 6. Reik L: Disseminated vasculomyelinepathy: An immune complex disease. Ann Neurol 1980;7:291-296. 7. Halperin JJ, Luft BJ, Anand AK, et ah CNS Lyme disease (letter).Neurol ogy 1990;40:190.
Central Cord Syndrome To the Editor: The neurologic deficit described in " T r a u m a t i c Central Cord Syndrome in a Patient W i t h Os O d o n t o i d e u m " by M c G o l d r i c k and Marx [December 1989;18:1358-1361], was a t t r i b u t e d to a central cord s y n d r o m e when, in fact, I believe the s y m p t o m s can be m o r e accurately explained by a paralysis' of Bell. A central cord s y n d r o m e involves a spinal cord injury from bulging of the l i g a m e n t a flava against the anterior vertebral bodies during flexion of the cervical spine. 1 This injury causes injury to the central p o r t i o n of the spinal cord (hence the n a m e central cord injury) and results in w e a k n e s s of the arms greater than the legs, loss of bladder function, and a variable degree of sensory loss. T h e vict i m s are u s u a l l y elderly, and the level of injury is u s u a l l y in the lower cervical spine. The paralysis of Bell is an injury to the p y r a m i d a l decussation, u s u a l l y as a result of posterior d i s p l a c e m e n t of the odontoid. A n a t o m i c a l l y , the p y r a m i d a l decussation of the cervical cord is directly posterior to the odontoid, and this a c c o u n t s for its p o t e n t i a l for. i n j u r y w h e n e v e r the odontoid is displaced. I believe the neurologic s y m p t o m s t h a t occurred in this p a t i e n t and the p a t h o p h y s i o l o g y that was proposed to account for this deficit are m o s t l i k e l y explained by paralysis of Bell and n o t a central cord s y n d r o m e as reported by the author. David J Dula, M D Emergency Medicine Geisinger Medical Center Danville, Pennsylvania
1. Schneider RD, Crosby EC: Traumatic spinal cord syndromes and their management. J Clin Neurosurg 1972;20:424-492.
In Reply: Dr Dula brings up the p o i n t that the neurologic deficits described in our patient could be explained by a "cruciate paralysis of Bell," w h i c h involves injury to t h e p y r a m i d a l tract decussation. The "cruciate paralysis" as described by Bell i n v o l v e s s e l e c t i v e b i l a t e r a l arm p a r a l y s i s or tetraplegia. A lesion involving the rostral crossing fibers of the p y r a m i d a l decussation m a y s i m u l a t e the neurologic pattern of " a c u t e central cervical cord injury s y n d r o m e . " In fact, two of t h e cases presented in Bell's original paper involved a neurologic p a t t e r n that was initially classified as acute central cervical cord syndrome. O u r p a t i e n t p r e s e n t e d w i t h w e a k n e s s of t h e a r m s greater than the legs w i t h o u t apparent sensory loss and loss of bladder function. We feel this p a t t e r n of neurologic deficit is c o n s i s t e n t w i t h central cord syndrome. John McGoldrick, M D John Marx, M D D e p a r t m e n t of Emergency Medicine Denver General Hospital Denver, Colorado
Sensitivity, Specificity & Positive & Negative Predictive Values To the Editor." T h e article, "Fracture of the Carpal N a v i c u l a r - Efficacy of C l i n i c a l Findings and I m p r o v e d D i a g n o s i s W i t h Six-View R a d i o g r a p h y " by M e h t a and Brautigan [March 19:11 November 1990
1990;19:225-257], contains an error in statistical calculation. Table 1 compares t h e results of four- and six-view r a d i o g r a p h y in d i a g n o s i n g f r a c t u r e s of t h e n a v i c u l a r .
Annals of Emergency Medicine
1354/175
CORRESPONOENCE
W h i l e the s e n s i t i v i t y of the four-view study is correctly reported to be 83%, the specificity and positive predictive values are given as 70% and 83%, respectively. Their correct values are both 100%. The sensitivity, specificity, and positive predictive value given for the six-view study are all correctly reported as 100%. Perhaps the u t i l i t y of the additional two radiographic views that are part of the six-view study is best illustrated by the negative predictive value, w h i c h was n o t given in this article. By the data presented, the negative predictive
value of the four views is 69%, while that of the six views is 100%. This supports the authors' conclusion that neither i m m o b i l i z a t i o n nor follow-up is needed given a negative six-view study, provided that larger clinical studies verify the results of this investigation.
Howard Blumstein, MD Medical College of Pennsylvania Philadelphia
Echocardiography to Rule Out Metastatic Disease To the Editor. We w o u l d l i k e to c o m m e n t on t h e case c o n f e r e n c e "Ethical Considerations in Emergency D e p a r t m e n t Management of T e r m i n a l l y Ill Patients" by Strange et al [October 1989;18:1085-1088[. This case discussion involved the ethics of aggressive t r e a t m e n t and resuscitation in a 78year-old m a n w i t h k n o w n c a r c i n o m a of the l u n g (diagnosed two m o n t h s prior to the presentation) who appare n t l y developed an acute m y o c a r d i a l infarction. This n e w diagnosis was based on " E C G changes c o m p a t i b l e w i t h a c u t e a n t e r o l a t e r a l m y o c a r d i a l i n f a r c t i o n , " a l t h o u g h the specifics of these ECG changes are not given. We consider the discussion following the case presentation to be an excellent one and our only concern was w i t h the initial diagnostic possibilities in this patient. In any k n o w n cancer p a t i e n t who presents w i t h p r i m a r y cardiac s i g n s / s y m p t o m s , the possibility of cardiac metastases m u s t be e n t e r t a i n e d . T h e i m p r o v e d s u r v i v a l afforded by today's aggressive, m u l t i m o d a l i t y t r e a t m e n t of many malignancies has increased the frequency with w h i c h m e t a s t a t i c d i s e a s e is seen in c l i n i c a l p r a c t i c e . 1 M e t a s t a t i c disease to the heart is one specific area where an increased incidence has been noted.~, 3 The m o s t comm o n p r i m a r y t u m o r responsible for cardiac m e t a s t a s e s is carcinoma of the bronchus, w i t h breast, leukemias, lymphomas, and m a l i g n a n t m e l a n o m a s listed in order of decreasing frequency. T h e i n c i d e n c e of m e t a s t a s e s to the heart, i n c l u d i n g t h e p e r i c a r d i u m , ranges from 1.5% to 20.6% of autopsies on patients w i t h k n o w n m a l i g n a n t disease.4, 5 This patient, then, w i t h no previous k n o w n cardiac history and who presented w i t h a chief c o m p l a i n t of weakness, was found to have an abnormal ECG two m o n t h s after having lung cancer diagnosed. Electrocardiographic changes in m e t a s t a t i c disease are q u i t e nonspecific, although H a r t m a n et al have proposed that prolonged and p r o n o u n c e d l o c a l i z e d S-T s e g m e n t e l e v a t i o n in the absence of Q w a v e s is a p a t h o g n o m i c sign of m y o c a r d i a l t u m o r invasion. 6 Our only suggestion, w i t h regard to this patient, is that a bedside 2D echocardiogram could have been definitive in d e t e r m i n i n g the presence or absence of m e t a s t a t i c cardiac disease~, 2 and that w i t h this knowledge, the decisions regarding aggressive I C U support versus palliative treatm e n t or specific oncologic therapy m a y be less controversial. 176/1355
fi)hn M Tallon, MD Foothills Hospital David R Montoya, MD, FRCP(C) Calgary General Hospital Calgary, Alberta, Canada 1. Stark RM, Derloff JK, Glick }H, et ah Clinical recognition and management of cardiac metastatic disease: Observations in a unique case of alveolar soft-part sarcoma. Am J Med 1977;63:653-659. 2. Hanfling SM: Metastatic cancer to the heart: Review of the literature and report of 127 cases. Circulation 1960~22:474-483. 3. LockwoodWB, BroghamerWL Jr: The changing prevalence of secondary cardiac neoplasms as related to cancer therapy. Cancer 1980;45:2659-2662. 4. Lammers RJ, Bloor CM: Tumors of the heart and pericardium. Modern Concepts of Cardio~'~scular Disease 1986i551-554. 5. Rosenthal DS, Braunwald E: Hematological-ontological disorders and heart disease, in Braunwald E {ed): Heart Disease, ed 3. Philadelphia, Wig Saunders, 1988, p 1284-1305. 6. Hartman RB, Sehulman P: Pronounced and prolonged ST segment elevation: A pathognomic sign of tumour invasion to the heart. Arch Intern Med 1982;142:1917q919.
1~ Reply: I t h a n k Drs Tallon and M o n t o y a for t h e i r c o m m e n t s and the addition of another diagnostic p o s s i b i l i t y to the discussion of the case. It is indeed possible that this pat i e n t had m e t a s t a t i c disease involving the heart. A t the t i m e of his arrest and unsuccessful resuscitation, no addit i o n a l tests, e i t h e r cardiac e n z y m e s or e e h o c a r d i o g r a m , had been obtained. Your suggestion that bedside echoeardiography w o u l d have been definitive in ruling out metastases is also appreciated. T h i s is an e n t i t y t h a t is no doubt underdiagnosed. As for the ethical considerations, they seem to m e to r e m a i n pretty m u c h the same regardless of the etiology of the E C G a b n o r m a l i t y . In e i t h e r case, p h a r m a c o l o g i c or electrical therapy m a y have s o m e s h o r t - t e r m effect, but the underlying process r e m a i n s progressive and terminal.
Gary Strange, MD, FACEP University of Illinois Affiliated Hospitals Emergency Medicine Residency Chicago
Annals of Emergency Medicine
19:11 November 1990
Lyme disease. Medicine 1979;58:281-294. 2. Stiernstedt G: Tick-borne Borrelia infection in Sweden. Scand J Infect Dis 1985;45:1-70. 3. Pachner AR, Steere AC: Neurological findings of Lyme disease. Yale ] Biol Med 1984;57:481-483. 4. Pachner AR: Spirochetal diseases of the CNS. NeuroI Clin 1986;4: 207-222. 5. Uldry PA, Regli F, BogousslavskyJ: Cerebral angiopathy and recurrent strokes following Borrelia burgdorferi infection. J Neurol Neurosurg Psychiatry 1987;50:1703-1704. 6. Reik L: Disseminated vasculomyelinepathy: An immune complex disease. Ann Neurol 1980;7:291-296. 7. Halperin JJ, Luft BJ, Anand AK, et ah CNS Lyme disease (letter).Neurol ogy 1990;40:190.
Central Cord Syndrome To the Editor: The neurologic deficit described in " T r a u m a t i c Central Cord Syndrome in a Patient W i t h Os O d o n t o i d e u m " by M c G o l d r i c k and Marx [December 1989;18:1358-1361], was a t t r i b u t e d to a central cord s y n d r o m e when, in fact, I believe the s y m p t o m s can be m o r e accurately explained by a paralysis' of Bell. A central cord s y n d r o m e involves a spinal cord injury from bulging of the l i g a m e n t a flava against the anterior vertebral bodies during flexion of the cervical spine. 1 This injury causes injury to the central p o r t i o n of the spinal cord (hence the n a m e central cord injury) and results in w e a k n e s s of the arms greater than the legs, loss of bladder function, and a variable degree of sensory loss. T h e vict i m s are u s u a l l y elderly, and the level of injury is u s u a l l y in the lower cervical spine. The paralysis of Bell is an injury to the p y r a m i d a l decussation, u s u a l l y as a result of posterior d i s p l a c e m e n t of the odontoid. A n a t o m i c a l l y , the p y r a m i d a l decussation of the cervical cord is directly posterior to the odontoid, and this a c c o u n t s for its p o t e n t i a l for. i n j u r y w h e n e v e r the odontoid is displaced. I believe the neurologic s y m p t o m s t h a t occurred in this p a t i e n t and the p a t h o p h y s i o l o g y that was proposed to account for this deficit are m o s t l i k e l y explained by paralysis of Bell and n o t a central cord s y n d r o m e as reported by the author. David J Dula, M D Emergency Medicine Geisinger Medical Center Danville, Pennsylvania
1. Schneider RD, Crosby EC: Traumatic spinal cord syndromes and their management. J Clin Neurosurg 1972;20:424-492.
In Reply: Dr Dula brings up the p o i n t that the neurologic deficits described in our patient could be explained by a "cruciate paralysis of Bell," w h i c h involves injury to t h e p y r a m i d a l tract decussation. The "cruciate paralysis" as described by Bell i n v o l v e s s e l e c t i v e b i l a t e r a l arm p a r a l y s i s or tetraplegia. A lesion involving the rostral crossing fibers of the p y r a m i d a l decussation m a y s i m u l a t e the neurologic pattern of " a c u t e central cervical cord injury s y n d r o m e . " In fact, two of t h e cases presented in Bell's original paper involved a neurologic p a t t e r n that was initially classified as acute central cervical cord syndrome. O u r p a t i e n t p r e s e n t e d w i t h w e a k n e s s of t h e a r m s greater than the legs w i t h o u t apparent sensory loss and loss of bladder function. We feel this p a t t e r n of neurologic deficit is c o n s i s t e n t w i t h central cord syndrome. John McGoldrick, M D John Marx, M D D e p a r t m e n t of Emergency Medicine Denver General Hospital Denver, Colorado
Sensitivity, Specificity & Positive & Negative Predictive Values To the Editor." T h e article, "Fracture of the Carpal N a v i c u l a r - Efficacy of C l i n i c a l Findings and I m p r o v e d D i a g n o s i s W i t h Six-View R a d i o g r a p h y " by M e h t a and Brautigan [March 19:11 November 1990
1990;19:225-257], contains an error in statistical calculation. Table 1 compares t h e results of four- and six-view r a d i o g r a p h y in d i a g n o s i n g f r a c t u r e s of t h e n a v i c u l a r .
Annals of Emergency Medicine
1354/175
CORRESPONOENCE
W h i l e the s e n s i t i v i t y of the four-view study is correctly reported to be 83%, the specificity and positive predictive values are given as 70% and 83%, respectively. Their correct values are both 100%. The sensitivity, specificity, and positive predictive value given for the six-view study are all correctly reported as 100%. Perhaps the u t i l i t y of the additional two radiographic views that are part of the six-view study is best illustrated by the negative predictive value, w h i c h was n o t given in this article. By the data presented, the negative predictive
value of the four views is 69%, while that of the six views is 100%. This supports the authors' conclusion that neither i m m o b i l i z a t i o n nor follow-up is needed given a negative six-view study, provided that larger clinical studies verify the results of this investigation.
Howard Blumstein, MD Medical College of Pennsylvania Philadelphia
Echocardiography to Rule Out Metastatic Disease To the Editor. We w o u l d l i k e to c o m m e n t on t h e case c o n f e r e n c e "Ethical Considerations in Emergency D e p a r t m e n t Management of T e r m i n a l l y Ill Patients" by Strange et al [October 1989;18:1085-1088[. This case discussion involved the ethics of aggressive t r e a t m e n t and resuscitation in a 78year-old m a n w i t h k n o w n c a r c i n o m a of the l u n g (diagnosed two m o n t h s prior to the presentation) who appare n t l y developed an acute m y o c a r d i a l infarction. This n e w diagnosis was based on " E C G changes c o m p a t i b l e w i t h a c u t e a n t e r o l a t e r a l m y o c a r d i a l i n f a r c t i o n , " a l t h o u g h the specifics of these ECG changes are not given. We consider the discussion following the case presentation to be an excellent one and our only concern was w i t h the initial diagnostic possibilities in this patient. In any k n o w n cancer p a t i e n t who presents w i t h p r i m a r y cardiac s i g n s / s y m p t o m s , the possibility of cardiac metastases m u s t be e n t e r t a i n e d . T h e i m p r o v e d s u r v i v a l afforded by today's aggressive, m u l t i m o d a l i t y t r e a t m e n t of many malignancies has increased the frequency with w h i c h m e t a s t a t i c d i s e a s e is seen in c l i n i c a l p r a c t i c e . 1 M e t a s t a t i c disease to the heart is one specific area where an increased incidence has been noted.~, 3 The m o s t comm o n p r i m a r y t u m o r responsible for cardiac m e t a s t a s e s is carcinoma of the bronchus, w i t h breast, leukemias, lymphomas, and m a l i g n a n t m e l a n o m a s listed in order of decreasing frequency. T h e i n c i d e n c e of m e t a s t a s e s to the heart, i n c l u d i n g t h e p e r i c a r d i u m , ranges from 1.5% to 20.6% of autopsies on patients w i t h k n o w n m a l i g n a n t disease.4, 5 This patient, then, w i t h no previous k n o w n cardiac history and who presented w i t h a chief c o m p l a i n t of weakness, was found to have an abnormal ECG two m o n t h s after having lung cancer diagnosed. Electrocardiographic changes in m e t a s t a t i c disease are q u i t e nonspecific, although H a r t m a n et al have proposed that prolonged and p r o n o u n c e d l o c a l i z e d S-T s e g m e n t e l e v a t i o n in the absence of Q w a v e s is a p a t h o g n o m i c sign of m y o c a r d i a l t u m o r invasion. 6 Our only suggestion, w i t h regard to this patient, is that a bedside 2D echocardiogram could have been definitive in d e t e r m i n i n g the presence or absence of m e t a s t a t i c cardiac disease~, 2 and that w i t h this knowledge, the decisions regarding aggressive I C U support versus palliative treatm e n t or specific oncologic therapy m a y be less controversial. 176/1355
fi)hn M Tallon, MD Foothills Hospital David R Montoya, MD, FRCP(C) Calgary General Hospital Calgary, Alberta, Canada 1. Stark RM, Derloff JK, Glick }H, et ah Clinical recognition and management of cardiac metastatic disease: Observations in a unique case of alveolar soft-part sarcoma. Am J Med 1977;63:653-659. 2. Hanfling SM: Metastatic cancer to the heart: Review of the literature and report of 127 cases. Circulation 1960~22:474-483. 3. LockwoodWB, BroghamerWL Jr: The changing prevalence of secondary cardiac neoplasms as related to cancer therapy. Cancer 1980;45:2659-2662. 4. Lammers RJ, Bloor CM: Tumors of the heart and pericardium. Modern Concepts of Cardio~'~scular Disease 1986i551-554. 5. Rosenthal DS, Braunwald E: Hematological-ontological disorders and heart disease, in Braunwald E {ed): Heart Disease, ed 3. Philadelphia, Wig Saunders, 1988, p 1284-1305. 6. Hartman RB, Sehulman P: Pronounced and prolonged ST segment elevation: A pathognomic sign of tumour invasion to the heart. Arch Intern Med 1982;142:1917q919.
1~ Reply: I t h a n k Drs Tallon and M o n t o y a for t h e i r c o m m e n t s and the addition of another diagnostic p o s s i b i l i t y to the discussion of the case. It is indeed possible that this pat i e n t had m e t a s t a t i c disease involving the heart. A t the t i m e of his arrest and unsuccessful resuscitation, no addit i o n a l tests, e i t h e r cardiac e n z y m e s or e e h o c a r d i o g r a m , had been obtained. Your suggestion that bedside echoeardiography w o u l d have been definitive in ruling out metastases is also appreciated. T h i s is an e n t i t y t h a t is no doubt underdiagnosed. As for the ethical considerations, they seem to m e to r e m a i n pretty m u c h the same regardless of the etiology of the E C G a b n o r m a l i t y . In e i t h e r case, p h a r m a c o l o g i c or electrical therapy m a y have s o m e s h o r t - t e r m effect, but the underlying process r e m a i n s progressive and terminal.
Gary Strange, MD, FACEP University of Illinois Affiliated Hospitals Emergency Medicine Residency Chicago
Annals of Emergency Medicine
19:11 November 1990
