Funtabulously Frivolous Friday Five 276

Just when you thought your brain could unwind on a Friday, you realise that it would rather be challenged with some good old fashioned medical trivia FFFF, introducing the  Funtabulously Frivolous Friday Five 276

Question 1

A 44-year-old patient, an actor performing in fire-blowing shows for the past several years, without other comorbidities, was admitted acutely to the hospital due to 38°C fever, haemoptysis, pleuritic chest pain and dyspnea. What is the diagnosis?

Fire eaters lung

Reveal the funtabulous answer

Fire Eaters Lung (FEL).

Three days before the onset of symptoms the patient aspirated liquid kindling for the grill resulting in an exogenous lipoid pneumonia. This pneumonia requires the patient to have inhaled plant, animal or mineral fats.

The acute form can occur in fire eaters, although the largest series of FEL consisted of 17 patients. Children are also at risk via accidental ingestions. A chronic form occurs in the elderly who have swallowing difficulties, most commonly secondary to oily laxatives.

Mineral and plant oils induce minimal or moderate inflammatory reaction in lung parenchyma. They are not metabolized by tissue enzymes, but undergo emulsification and become engulfed by macrophages which, with time, may disintegrate and release oily substances surrounded by fibrous tissue and giant cells. On the other hand, animal fats are hydrolyzed by pulmonary lipases to free fatty acids and induce severe inflammatory reaction presenting with local edema and alveolar hemorrhage. Fatty acids may remain in alveoli or be phagocytized by macrophages, which migrate into the interlobular septa and cause their thickening. Inflammatory response may destroy alveolar walls and interstituum leading to lung fibrosis.

Clinically, acute lipoid pneumonia presents most often with cough, dyspnea, fever and occasionally haemoptysis. Patients with chronic exogenous lipoid pneumonia are often diagnosed incidentally in radiological studies.

Diagnosis is by a combination of history, non-specific chest X-ray signs (although consolidation is largely in the lower zones or right middle lobe), high-resolution CT showing and bronchoalveolar lavage revealing fat cells.

Due to very few cases, treatment recommendations have limited evidence. Steroids for a few months +/- antibiotics are a common theme.

Amendment – from a keen FFFF follower. It would appear yet again medically naive individuals have named it ‘Fire Eaters Lung’ when in fact it should be ‘Fire Breathers lung’:

Fire breathing is when you put a substance in your mouth (traditionally hydrocarbon based fluids but more frequently powders now) and “spit” it at a flame, producing a fire ball. While the fuel is a fine spray in the air, there is a risk of aspiration.
Fire eating is when a stick with a wick that has been dipped in fuel and lit, is placed inside the mouth and extinguished (or not based on the trick). There is no fuel droplets so aspiration is unlikely (and you breathe out while the flame is near you to not inhale the smoke)

Nat O’Halloran – 2019

Reference: Fall A et al. Exogenous lipoid pneumonia – a case report of a fire-eater. Pol J Radiol. 2012;77(4):60-64


Question 2

An Australian man was saved by his phone in March 2019 when he was shot with an arrow. But how many pedestrians actually die from looking at their phone while crossing the road in the USA?

Saved by a mobile phone.

Reveal the funtabulous answer

6,000, well, maybe.

According to the Governors Highway Safety Association report nearly 6,000 pedestrians were struck and killed by cars in 2017. It is difficult to parse out if these were directly related to phone use but you would have to go back 25 years to have the same death toll on pedestrians. Phone use and marijuana are being blamed by some sources as we are almost at an autonomous era of driving.

So HEAD UP, PHONE DOWN, or put in a shirt pocket if you are in Australia, it might just save your life.


Question 3

I know for my regular readers, this will be shocking news but I’ve been called a NERD in my time. But medically, what is a NERD?

Reveal the funtabulous answer

NSAID-exacerbated respiratory disease.

Also known as Aspirin-exacerbated respiratory disease (AERD) or Aspirin-induced asthma and rhinitis (AIAR). It has a 2% – 25% prevalence in the asthma population.

NSAIDs and Aspirin block COX-1 enzyme resulting in the reduction of thromboxane and prostaglandins. In patient’s with aspirin-induced asthma, this results in the overproduction of pro-inflammatory leukotrienes resulting in an exacerbation or allergy-like symptoms.  

Reference: Ledford DK et al. Aspirin or Other Nonsteroidal Inflammatory Agent Exacerbated Asthma. Journal of Allergy and Clinical Immunology: In Practise.https://doi.org/10.1016/j.jaip.2014.09.009


Question 4

A patient presents after a short dive with a rash on her abdomen. What is the diagnosis?

Reveal the funtabulous answer

Skin Bends.

Although it’s important to make sure this isn’t a reaction from the wetsuit, skin bends is one of the manifestations of decompression illness.

Deep-tissue soreness and tenderness are the most frequently reported symptoms along with areas that are bruised or blotchy. The surface of the skin may or may not be tender.

The exact cause and mechanism of skin bends is not clearly understood, and accurate predictors of individuals’ susceptibility do not yet exist. Based on the reports DAN® receives, the symptoms most commonly occur in areas of the body with the most fatty (adipose) tissue. This includes the abdomen, thighs, triceps area, buttocks and, in women, the breasts.

According to DAN Research, approximately 20 percent of divers who experience skin bends have accompanying neurological symptoms. Any diver who presents with potential skin bends should be placed on oxygen and seek medical evaluation; neurological symptoms may be subtle and your local diver expert should be consulted.

Reference: Divers Alert Network. – Incident Insights, skin bends.


Question 5

What is an autopathograph? How does it relate to Tic Douloureux?

Reveal the funtabulous answer

Authopathograph: The practice of keeping a diary of one’s disease

Authopathograph’s were fashionable in the first half of the nineteenth century. The habit probably stemmed from the “cathartic” effect it had on the patients who often suffered a great deal throughout their illnesses owing to the frequent lack of efficacious therapies. Autopathographs written by learned patients contribute to the history of medicine since they may provide information on the state of diagnostics and therapeutics in a given period.

Italian lawyer, Ruggero Ragazzi, suffered from tic douloureux and wrote an autopathography of his disease documenting a 2-decade history of essential trigeminal neuralgia.

The history of the tic douloureux, described by me, since I unfortunately suffer from it, is getting more and more ferocious and nearly always torments me with shooting pains. It began in 1803 and has continued to the present day, April 1821, and unfortunately will not leave me for as long as I live.

Ruggero Ragazzi

Tic Douloureux of Trigeminal Neuralgia

Due to the severe stabbing pain, some patients wince involuntarily, looking like they have a tic. It is characterised by recurrent brief episodes of unilateral electric shock-like pains, abrupt in onset and termination in the distribution of one or more divisions of the fifth cranial nerve that are typically triggered by innocuous stimuli.

First line therapy is carbamazepine.

References

  • André NA: Observations pratiques sur les maladies de V urèthre, et sur plusieurs faits convulsifs. Paris: Delaguette. 1756 [Surgeon Nicolas A. Andre supplied the first general description of trigeminal neuralgia distinguishing it from other types of facial pain]
  • Govoni V, Granieri E, Menini C. The history of the tic douloureux: autopathograph of an Italian lawyer who suffered from trigeminal neuralgia from 1803 to 1824. Journal of the History of the Neurosciences: Basic and Clinical Perspectives. 1996 Aug;5(2):169-89. [PMID 11619045]
  • Granieri E, Govoni V, De Gennaro R, Fazio P. An autopathography of tic douloureux at the beginning of the nineteenth century. Neurol Sci. 2010 Dec;31(6):849-58. [PMID 20872037]

…and finally

Kia Kaha Christchurch


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Funtabulously Frivolous Friday Five

Dr Neil Long BMBS FACEM FRCEM FRCPC. Emergency Physician at Burnaby Hospital in Vancouver. Loves the misery of alpine climbing and working in austere environments. Supporter of FOAMed, toxicology, tropical medicine, sim and ultrasound

2 Comments

  1. Hi, Emergency Registrar and Fire Performer here, just wanted to clear up some nomenclature in question 1.
    You first say the performer does “fire blowing” then state they have “fire eaters” lung.

    I know it has been traditionally known as Fire Eaters Lung however this comes from medical professionals not understanding the two different fire art forms.

    Fire breathing is when you put a substance in your mouth (traditionally hydrocarbon based fluids but more frequently powders now) and “spit” it at a flame, producing a fire ball. While the fuel is a fine spray in the air, there is a risk of aspiration.
    Fire eating is when a stick with a wick that has been dipped in fuel and lit, is placed inside the mouth and extinguished (or not based on the trick). There is no fuel droplets so aspiration is unlikely (and you breathe out while the flame is near you to not inhale the smoke)

    Fire breathing has the risks of aspiration and FEL and ARDS while the risks of fire eating mainly include burns of the face, mouth and possibly throat.

    Only a minority of fire performers still fire breathe as most of us now have flame projectors and don’t want to risk to our health. (I know many will consider all fire a risk but hey, cycling, diving and motorsports are dangerous too)

    • Thank you for providing further insight into FEL, and you are right about medical professionals (myself included) are naive between the differences of fire breathing and fire eating. FEL has so been named incorrectly it would seem, like a lot of medical terms. Again thank you for comments and I will adjust the answer. Keep up the good work and avoid aspirating hydrocarbons!!

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