No abstract

We report a case of electrical injury that occurred under unusual circumstances and led to bronchial perforation, mediastinal emphysema, and pneumothoraces. Despite severe bronchial mucosal damage the patient quickly made a full recovery. Pulmonary complications after electrical injury are well documented,1 2 but this pattern of injury has not, to our knowledge, been noted before. Case reportA previously fit 21 year old motor mechanic was admitted to a casualty department with severe chest pain and respiratory distress. He later described the events that had led to his injury. While working with a grinding tool he salivated through an air vent in the machine casing on to a live terminal. He noticed a blue flash that entered his mouth; he was then thrown away from the tool and was immediately aware of chest pain, difficulty in breathing, and swelling of his face.On admission to the casualty department cyanosis, haemoptysis, and surgical emphysema of head and neck were apparent. Fresh blood was noted in his mouth. The upper airway was patent, and bilateral pneumothoraces were confirmed by x ray examination. Circulation was stable, and no other injuries were apparent. Intercostal drains were inserted, with some improvement in breathing pattern. He was then transferred to this intensive care unit.Repeat x ray examinations showed partial re-expansion of both lungs, severe bilateral pulmonary shadowing suggesting pulmonary oedema, mediastinal emphysema, and massive gastric dilatation. Artificial ventilation was necessary because of respiratory failure due to severe pulmonary oedema and the large quantity of analgesia required for adequate pain relief. The programme of intermittent positive pressure ventilation followed methods that are standard to this unit.3 Over the next 48 hours the hypoxaemia worsened and lung compliance decreased. The alveolar arterial pressure gradient for oxygen was 45-7 kPa (343 mm Hg) (10 times the control value of 2-9-5-9 kPa (22-44 mm Hg)).Copious amounts of bloodstained tracheal aspirate were produced. Fibreoptic bronchoscopy showed blackened and haemorrhagic mucosa with necrotic slough. A perforation in the wall of the left main bronchus was noted, 2 cm distal to the carina. This had a base of necrotic tissue, suggesting that the perforation had sealed off.The tracheal aspirate decreased over the next six days, and gas exchange improved. The lung fields cleared, and the mediastinal emphysema resolved. Repeat bronchoscopy showed healthy regenerating bronchial mucosa with healing at the site of the perforation. On day 10 he was successfully weaned from the ventilator. A further problem was hypercatabolism with a urinary nitrogen loss in excess of 3-2 mol (45 g) a day; this was managed with intravenous feeding. He was discharged 12 days after admission and remained well, with no evidence of bronchial stenosis. CommentPulmonary complications of electrocution are well known and include haemorrhage necrotising tracheobronchitis,4 staphylococcal pneumonia,' pneumonitis, atelectasis, and pleural ...

Summary We report a case of scleromyxoedema in which cutaneous symptoms and signs improved spontaneously over a period of 15 years, despite persistence of a circulating monoclonal gammopathy.

There is evidence that reactive oxygen species and free radicals may be involved in the pathogenesis of photosensitivity in erythropoietic protoporphyria (EPP). Considering the well-known antioxidant properties of vitamin C, we investigated whether oral supplementation with this vitamin was photoprotective in patients with EPP. Twelve patients with EPP received either oral vitamin C 1 g daily or placebo, for 4 weeks, followed by a crossover period of another 4 weeks. Nine patients were already receiving beta carotene at entry and continued this at the same dose throughout the study. Patients compared their sunlight tolerance throughout each of the treatment periods with sunlight tolerance at entry on a 10 cm visual analogue scale; at the end of the study, they were asked to choose which treatment period they felt had been associated with least photosensitivity. Eight patients stated that they were able to tolerate sunshine better during the vitamin C period, 2 during the placebo period and 2 noticed no difference between the two periods. This distribution of preferences approached but did not reach statistical significance in favour of vitamin C. Visual analogue scores improved by a median of 1.2 cm in the vitamin C period. This change too approached but did not reach statistical significance. Although these results do not reach statistical significance, it appears possible that oral vitamin C may reduce photosensitivity in some patients with EPP. A larger study is necessary to confirm this impression.

No abstract

No abstract

No abstract

No abstract