Tracheal stenting is a relatively safe and effective method for palliation of distressing airway symptoms in patients with anaplastic thyroid carcinoma. Early prophylactic tracheal stenting in anaplastic thyroid carcinoma may be an effective option to prevent development of airway compromise as the disease progresses.
supraventricular tachycardia. There was no apparent cause such as intercurrent illness, drug therapy, vomiting or diarrhoea. Renal function, plasma sodium and plasma cortisol were all within normal limits, as was 24 h potassium excretion (64 mmol/L at a time when plasma sodium was 2.8 mmol/L). Aldosterone and renin studies were not performed. The patient died after three months and necropsy was not done. COMMENTThis patient had features compatible with sporadic CJD (Box 1). The progressive worsening of hypokalaemia that accompanied his neurological deterioration raised the question whether CJD can affect potassium metabolism. This hypothesis is somewhat weakened by the presence of mild hypokalaemia a year before onset of symptoms. Clinically, the hypokalaemia and its effects were very hard to manage. The possible association with CJD deserves further exploration. After acute airway obstruction by a foreign body, removal of the offending object generally leads to swift recovery. A rare complication is negative-pressure pulmonary oedema. CASE HISTORYA previously healthy man aged 47 choked while eating a piece of boneless chicken breast, and a Heimlich manoeuvre was immediately performed. The apparent airway obstruction was improved but he continued to cough vigorously, producing blood-stained frothy sputum. He also reported increasing dyspnoea and retrosternal pain. On admission to hospital three hours after the incident the patient was still coughing and pulse oximetry showed an oxygen saturation of 92% on room air. On examination the trachea was central; percussion of the chest was dull over the right base and midzone with poor air entry and coarse crackles. No radio-opaque foreign body was visible on chest radiography but there was haziness in all lung fields except for the right middle lobe.Acute airway obstruction by a foreign body was diagnosed and the patient underwent urgent bronchoscopy and rigid endoscopic assessment of the bronchial tree. No foreign body was found, but copious frothy bloody secretions were suctioned from both main bronchi. Despite the appearance of the chest X-ray, the area of the right middle lobe bronchus was endoscopically no different from the remainder of the tracheo-bronchial tree. A rigid oesophagoscopy was also performed, but again no foreign body was retrieved. Oxygen saturation remained around 90% throughout this procedure despite administration of 100% oxygen. When extubation was attempted the patient became restless and was unable to maintain oxygenation. He was reintubated and transferred to the intensive care unit for ventilation. Treatment with intravenous metronidazole and cefuroxime was started.A CT scan of the chest did not reveal any focal lesion but over the next few days oxygenation became increasingly difficult to maintain. The patient had to be ventilated withA u g u s t 2 0 0 2
Pulmonary oedema is a well recognized complication of various neurological disorders but has seldom been reported in multiple sclerosis. CASE HISTORYA previously healthy woman of 46 became acutely dyspnoeic, without chest pain or palpitations. Two days earlier she had noted mild ankle swelling. On admission, heart rate was 110/min, respiratory rate 25 /min and blood pressure 100/60 mmHg. A 12-lead electrocardiogram (ECG) showed ST depression in the lateral chest leads but no Q-waves or other evidence of acute myocardial infarction. A chest X-ray revealed generalized pulmonary oedema with bilateral small pleural effusions (Figure 1). There was no evidence of infection and a ventilationperfusion scan was normal. An echocardiogram showed an akinetic intraventricular septum and anterior left ventricle wall with ejection fraction (EF) 39%. There was a small posterior pericardial effusion. It was noted that the basal and anterior wall impairment did not conform with standard coronary anatomy. Believed to be in cardiogenic shock, she was transferred to Harefield Hospital in case mechanical circulatory support became necessary.With intravenous inotropes and diuretics her condition improved; an angiotensin converting-enzyme inhibitor was introduced and the inotropic support was gradually tapered off. A coronary angiogram demonstrated normal coronary vasculature. Clinically, she made an excellent recovery, and myocardial recovery was likewise rapid: six days after the initial echocardiogram the EF had risen to 55% and on discharge 3 weeks later it was 69%.While in hospital, the patient complained of a constant tingling in both hands and intermittent slurring of speech. She had no numbness or weakness and there was no reported visual or sphincter disturbance. On further inquiry she revealed that, in the week before admission, she had had an episode of visual disturbance: when driving, everything had appeared to be 'moving up and down'. The effect was binocular and not affected by the direction of gaze. After two days this had subsided spontaneously. She also recalled neurological symptoms 10 years previously. She had woken one morning with weakness in the left arm and leg and poor coordination which caused her to fall over twice. At that time her leg and arm, but not her face, were numb and her speech was slurred as now. The symptoms resolved over a few days. Visual evoked potentials (VEPs) and a CT brain study were normal. 2 years before the current admission she had had paroxysms of head pain radiating to her left arm and associated with slurred speech but no limb weakness. More recently she had complained of similar pains in the right side of the head for several months. There was no history of Lhermitte's phenomenon.On neurological examination there were no objective abnormalities. Routine blood and biochemistry results were normal. The VEPs were still within normal limits but the cerebrospinal fluid (CSF) showed oligoclonal bands which were not matched in serum. An MRI brain study showed diffuse periventricular white ...
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