Tuesday, 17 February 2009

Leeches, Placentas and Asthma

Dear Bloggers

I wanted to share a really unusual case with you. This relates to a female patient with many years of chronic asthma who was recently hospitalised in a distant hospital.

She had worsening asthma several days before admission and despite her wheeze improving with steroids and bronchodilator treatment, her SpO2 was low at rest.

Her physical examination was consistent with chronic obstructive lung disease evidenced by 'bounding pulses', a hypertrophied accessory respiratory muscles, tracheal 'tug', a 'barrel chest' and purse-lip respiration. She had mild polyphonic wheeze throughout both lung fields. Legs were mildly oedematous.

There was a concern why the SpO2 was not improving despite effective anti-asthma therapy.

Pulmonary embolism was considered a possibility and her Well's Prediction Score showed moderate risk. V/Q scanning was performed with both ventilation and perfusion parts completed. It revealed multiple pulmonary emboli. Hence, the cause for the low SpO2 had been found which had probably resulted in the exacerbation of asthma in the first place.

Lower limb ultrasonography revealed bilateral DVTs !!

However, not only that, some very strange areas of calcification had been noticed on the plain chest Xray. This is where things get even more interesting. The calcifications were only in the breast tissue and predominantly in the lateral tail of the each breast. It was considered that this might be old age related involutional change with subsequent calcification. However, the tissue affected was quite extensive. Macrocalcification is usually of no consequence. It is the microcalcification and laterality of such findings that make one suspicious of cancer.

When the patient was later asked about the breast abnormalities she revealed that she had received novel asthma treatment some years before which entailed the implantation of placental tissue into her breasts!!! Yes, believe it.

Quite frankly, the thought of leeches comes to mind, used in the dark ages as a treatment for every ailment by the apothocaries of their day. However, on doing further research, and let me tell you it was not so easy, it turns out that the first description on medline of such a technique was in Brazil in 1968. It also became an established alternative treatment in some institutions in Asia with it being reported as a potential therapy for chronic inflammatory disease even up to 20 years ago.

The mechanism with respect to how this novel treatment was supposed to work has not been fully elucidated but suffice it to say, that people underwent such trials of therapy to try and quiesce their chronic inflammatory disease.

This is not standard treatment and not supported by any of the major world respiratory societies. It is considered to be no better than standard pharmacological therapy.

Although this might not be at all relevant to the rest of the Western world, it is worth knowing for doctors practising in Asia who may see unusual areas of calcification in breast or other soft tissues in patients with chronic inflammatory diseases such as asthma, atopic dermatitis or even rheumatoid arthritis. Go back to your patient and ask about the soft tissue problem as they may just tell you they had such a treatment. Of course, common things being common, it is usually involutional change :-)

Just as Plombage treatment for Tuberculosis was commonplace in the UK (insertion of pin-pong balls into the chest of tuberculosis suffers to collapse the lung in the pre-antibiotic era) there are other treatments which have been performed in other countries to treat a variety of diseases. Placental tissue implantation for treating asthma is one of those interesting facets of medicine that one never expects to see. It makes medicine ever more exciting for me.

This is a very good example of why evidence based medical practise needs to be applied when considering investigation and treatment of patients. Without rigorous analysis of existing or new therapies and applying the use of the evidence to every day patient scenarios, we might still be giving patients potentially inefficacious treatments.

Now, where did I leave those leeches.....?

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