Correspondence

Clinical Problem-Solving: One More Hypothesis

N Engl J Med 1993; 329:1821December 9, 1993

Article

To the Editor:

Thibault, in the Clinical Problem-Solving case “One More Hypothesis” (July 1 issue),1 interprets a white-cell count of 26,900 with a differential count of 91 percent neutrophils, 6 percent lymphocytes, 2 percent monocytes, and 1 percent band forms as indicating a “left shift.”

“Left shift” refers to “the presence of bands, metamyelocytes, and sometimes myelocytes in the blood”2. “Right shift” and “left shift” are currently used to describe opposite directions in myeloid maturation. For example, the rare hematologic disorder of myelokathexis involves bone marrow retention of myeloid elements with a “shift to the right in the myeloid compartment”3. The same could be said of the peripheral-blood smear of megaloblastic anemia with the hypersegmented neutrophil.

Because of the absence of band forms and the preponderance of mature neutrophils in the complete blood count in question, the shift would be to the right, not to the left.

Mark Walsh, M.D.
Michael McWilliams
Saint Joseph's Medical Center, South Bend, IN 46634

3 References

1. 1

   Thibault GE. One more hypothesis. N Engl J Med 1993;329:38-42
   Full Text | Web of Science | Medline

2. 2

   Bainton DF. Morphology of neutrophils and neutrophil precursors. In: Williams WJ, Beutler E, Erslev AJ, Lichtman MA, eds. Hematology. 4th ed. New York: McGraw-Hill, 1990:767.
   

3. 3

   Wetzler M, Talpaz M, Kellagher MJ, Gutterman JU, Kurzrock R. Myelokathexis: normalization of neutrophil counts and morphology by GM-CSF. JAMA 1992;267:2179-2180
   CrossRef | Web of Science | Medline

To the Editor:

Thibault takes readers through a fascinating and instructive chronology describing an elderly patient with multiple cholesterol emboli syndrome -- another example by which the Journal has disseminated information about this entity through thoughtful case presentations1-4.

There appears to be an emphasis on the subacute onset after catheterization or aortic surgery. Thibault states that it occurs “days or weeks” after angiography or aortic surgery. In a Case Record in the Journal, symptoms began two to three months after coronary catheterization,4 presumably because of a reaction of the immune system to the initial shower of emboli. Clinical observations and experimental models involving intraarterial infusion of sterile cholesterol emboli in rats seem to support this5. Cholesterol emboli may, however, produce acute effects by causing acute ischemia or vascular occlusion. Six patients with symptoms consistent with multiple cholesterol emboli syndrome have been reported to Sterling-Winthrop over a four-year period. All six had an acute onset during catheterization or shortly afterward. Multiple cholesterol emboli syndrome should therefore be considered when multisystem disease develops during or immediately after catheterization.

Manfred Hauben, M.D., M.P.H., D.T.M.H.
Sterling-Winthrop, Inc., New York, NY 10016

5 References

1. 1

   Case Records of the Massachusetts General Hospital (Case 25-1967). N Engl J Med 1967;276:1368-1377
   Full Text | Web of Science | Medline

2. 2

   Case Records of the Massachusetts General Hospital (Case 51-1973). N Engl J Med 1973;289:1360-1366
   Full Text | Web of Science | Medline

3. 3

   Case Records of the Massachusetts General Hospital (Case 33-1974). N Engl J Med 1974;291:406-412
   Full Text | Web of Science | Medline

4. 4

   Case Records of the Massachusetts General Hospital (Case 2-1991). N Engl J Med 1991;324:113-120
   Full Text | Web of Science | Medline

5. 5

   Cosio FG, Zager RA, Sharma HM. Atheroembolic renal disease causes hypocomplementaemia. Lancet 1985;2:118-121
   CrossRef | Web of Science | Medline

Author/Editor Response

Dr. Thibault replies:

To the Editor: I appreciate Walsh and McWilliams's clarification of the meaning of the term “left shift.” This appears to be one of many instances in which common usage has changed the meaning of a phrase from its original intent.

Dr. Hauben is correct that cholesterol embolization can cause acute organ dysfunction, although this appears to be much less common than the subacute course of the patient discussed in “One More Hypothesis.”

George E. Thibault, M.D.
Veterans Affairs Medical Center, West Roxbury, MA 02132

Citing Articles (1)

Citing Articles

1. 1

   Natividad Neri, Agustin Aviles, Sergio Cleto, Noe Diaz, Alejandra Talavera, Edna L. Garcia, Jose C. Diaz-Maqueo. (2001) Chemotherapy Plus Interferon-2b Versus Chemotherapy in the Treatment of Follicular Lymphoma. Journal of Hematotherapy <html_ent glyph="@amp;" ascii="&"/> Stem Cell Research 10:5, 669-674
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