Diseases and "casual parentheses"

Wilfred Trotter, an English surgeon, once said: "Disease often tells its secrets in casual parentheses." This implies that we need to observe and listen carefully, often over a period of time, without prematurely concluding that we know what the problem is, if we are keen to make a correct diagnosis. In the Malaysian Family Physician there is a report of a young patient who presented with mild arthritis of the ankle joints after a short febrile illness.
I asked myself what I would have diagnosed at that point. I think I would have considered it to be part of a viral syndrome but would look carefully for evidence of septic arthritis.
A few days later this patient developed erythema nodosum - a localised painful inflammation of the subcutaneous tissue. Since erythema nodosum is the result of an immune response, I would at this stage have considered the possibility of a reactive arthritis and looked for infections in the urinary tract, gastrointestinal tract and also for streptococcal infections in the throat.
This case report in the Malaysian Family Physician has made me realise that the disease the patient really has is not what I am thinking about. The correct diagnosis revealed itself to the doctors only after yet more time. This appears to validate what Wilfred Trotter said.

Read the case report in the Malaysian Family Physician

Thrombolytic therapy in a patient with thrombocytopenia

A middle aged man was admitted to the hospital with dengue fever. He had a low platelet count of 60,000/cu.mm on admission. In the ward he developed chest pain and an acute anterior wall ST elevation myocardial infarction. The specialist in charge of the patient decided to administer Streptokinase believing that salvaging the ischemic myocardium outweighed the risk of bleeding. The patient had no bleeding complications from the Streptokinase even though his platelet count continued to fall to a level of 20000/cu.mm over the next few days.

This made me wonder if it was safe to administer thrombolytic therapy to people with pre-existing thrombocytopenia.

The evidence I found in the literature says that, if patients have no bleeding manifestations, it is relatively safe to administer thrombolytic therapy. Heparin, because of its potential to reduce platelet counts, may be more dangerous than Streptokinase. Even though this patient that I described above did not suffer any bleeding complications from thrombolysis, my intuitive feeling is that it is prudent to transfuse platelets if the platelet count is very low when thrombolytic therapy is contemplated.

Reference: An editorial in Clinical Cardiology