Clown of a different kind

[Guest guest]

An interesting case that I saw as a resident on a rotation in the Neurology

department at Northwestern University , Chicago in 1998 which was very

interesting

A 32 year old police officer presented to the neurology department with c/o

feeling funny and looking funny.The story goes that on a beat with a fellow

police officer one night the lady cop was in hot pursuit of a couple of car

thieves in the south side of Chicago and rammed into a pole in their patrol car

and let the thieves go. The cops returned home with a bruised ego as the thieves

had run away and also a bruised back and chest due to the crash. Everything went

well for a little while until she realized that at the gym she was being stared

at in a funny way ......exertion-induced asymmetric reaction of the skin of the

face and head; the right side showed normal flushing and sweating, while the

contra lateral side remained pale and dry. Harlequin(Clown) syndrome was first

coined by Lance and Drummond in 1988.

Arleccino (Harlequin) was a character in the travelling improvisational

theater originating in Venice in the 16th century, known as Comedia Dell’ Arte.

This remained popular until the 18th century, but many of the characters are

still recognizable today – Columbine, Pagliacci and Pulcinella, a woman-chasing

hunchback who was the forerunner of Punch. The first Harlequin masks were

grotesque and the term Harlequin syndrome was therefore applied to a severe form

of congenital ichthyosis with rudimentary ears, ectropion and ‘fish mouth’

appearance. But later, Harlequin masks became less sinister and more

sophisticated with diamond-shaped colourful patterns, or blackening of one half

of the face .This appearance came to mind when patients who flushed and sweated

excessively on one side of the face in hot weather, or after exercise,

particularly obvious when the sweating area was demonstrated by the application

of alizarin powder like in my case... Incidently this case was

presented by my wife Namita and won the First prize in various local clinical

vignette competitions and the American Association of Physicians of Indian

origin National meet and then went on to win the 2nd prize in American college

of Physicians contest in Chicago in 1999..here is an abstract from the ACP web

page

" The Officer And The Clown " Harlequin Syndrome: The Sudden Onset Of Unilateral

Flushing And Sweating With Contralateral Loss Of Sweating Namita S. Sachdeva,

M.D.

St. ph Hospital, Chicago, IL

This is the report of a 32-year-old young lady who was involved in a motor

vehicle accident and was hit by the steering wheel on her chest. She noticed

hyperhidrosis on her right side of the body and anhidrosis on her left side

immediately after the accident. With no other abnormality on exam an MRI of

head, neck, and CT scan of the same were normal. EMG study done then also was

normal. A thermoregulatory sweat test confirms her unilateral hyperhidrosis and

flushing with contralateral anhidrosis. She has symptoms still eight months down

the road. On review of literature, reports of hyperhidrosis and contralateral

anhidrosis have been reported in patients with exertion and trauma in only five

patients. This is a Harlequin Syndrome and the lesion is the torsion of the

anterior radicular artery which supplies the thoracic cord at the 3rd segment.

It has also been reported with non-traumatic conditions like cerebral infarction

and lung cancer - as a paraneoplastic syndrome in

adenocarcinoma of the lung.

References

Lance et al: Harlequin syndrome. J Neurol Neurosurg Psychiatry

1988;51(5):635-642.

Umeki S et al: Harlequin syndrome due to left apical ca of lung. Rinsho

Shinkaigaku 1990; 30(l):94-99.

Rousseux M, et al: Hyperhidrosis in lateral medullar infarct. Stroke

1996;27:991-995.

The case was presented in the first person, Namita presenting the case in a

funny format as the police officer with cartoon slides and with in a strict time

frame of 5 minutes..... a requirement of the competition.

Ashish

---------------------------------

Sick sense of humor? Visit Yahoo! TV's Comedy with an Edge to see what's on,

when.

[Guest guest]

That's interesing ! Congratulations, Namita !

Ashish, d'you think you could post the presentation on this group? I'd love

to see it .

Prabha'84

ashish sachdeva wrote:

An interesting case that I saw as a resident on a rotation in the

Neurology department at Northwestern University , Chicago in 1998 which was very

interesting

A 32 year old police officer presented to the neurology department with c/o

feeling funny and looking funny.The story goes that on a beat with a fellow

police officer one night the lady cop was in hot pursuit of a couple of car

thieves in the south side of Chicago and rammed into a pole in their patrol car

and let the thieves go. The cops returned home with a bruised ego as the thieves

had run away and also a bruised back and chest due to the crash. Everything went

well for a little while until she realized that at the gym she was being stared

at in a funny way ......exertion-induced asymmetric reaction of the skin of the

face and head; the right side showed normal flushing and sweating, while the

contra lateral side remained pale and dry. Harlequin(Clown) syndrome was first

coined by Lance and Drummond in 1988.

Arleccino (Harlequin) was a character in the travelling improvisational theater

originating in Venice in the 16th century, known as Comedia Dell’ Arte. This

remained popular until the 18th century, but many of the characters are still

recognizable today – Columbine, Pagliacci and Pulcinella, a woman-chasing

hunchback who was the forerunner of Punch. The first Harlequin masks were

grotesque and the term Harlequin syndrome was therefore applied to a severe form

of congenital ichthyosis with rudimentary ears, ectropion and ‘fish mouth’

appearance. But later, Harlequin masks became less sinister and more

sophisticated with diamond-shaped colourful patterns, or blackening of one half

of the face .This appearance came to mind when patients who flushed and sweated

excessively on one side of the face in hot weather, or after exercise,

particularly obvious when the sweating area was demonstrated by the application

of alizarin powder like in my case... Incidently this case was

presented by my wife Namita and won the First prize in various local clinical

vignette competitions and the American Association of Physicians of Indian

origin National meet and then went on to win the 2nd prize in American college

of Physicians contest in Chicago in 1999..here is an abstract from the ACP web

page

" The Officer And The Clown " Harlequin Syndrome: The Sudden Onset Of Unilateral

Flushing And Sweating With Contralateral Loss Of Sweating Namita S. Sachdeva,

M.D.

St. ph Hospital, Chicago, IL

This is the report of a 32-year-old young lady who was involved in a motor

vehicle accident and was hit by the steering wheel on her chest. She noticed

hyperhidrosis on her right side of the body and anhidrosis on her left side

immediately after the accident. With no other abnormality on exam an MRI of

head, neck, and CT scan of the same were normal. EMG study done then also was

normal. A thermoregulatory sweat test confirms her unilateral hyperhidrosis and

flushing with contralateral anhidrosis. She has symptoms still eight months down

the road. On review of literature, reports of hyperhidrosis and contralateral

anhidrosis have been reported in patients with exertion and trauma in only five

patients. This is a Harlequin Syndrome and the lesion is the torsion of the

anterior radicular artery which supplies the thoracic cord at the 3rd segment.

It has also been reported with non-traumatic conditions like cerebral infarction

and lung cancer - as a paraneoplastic syndrome in

adenocarcinoma of the lung.

References

Lance et al: Harlequin syndrome. J Neurol Neurosurg Psychiatry

1988;51(5):635-642.

Umeki S et al: Harlequin syndrome due to left apical ca of lung. Rinsho

Shinkaigaku 1990; 30(l):94-99.

Rousseux M, et al: Hyperhidrosis in lateral medullar infarct. Stroke

1996;27:991-995.

The case was presented in the first person, Namita presenting the case in a

funny format as the police officer with cartoon slides and with in a strict time

frame of 5 minutes..... a requirement of the competition.

Ashish

---------------------------------

Sick sense of humor? Visit Yahoo! TV's Comedy with an Edge to see what's on,

when.

[Guest guest]

Hey Prabha! Thanks! Over the years I have a good selection of cases that I have

saved.South Africa was absolutely a gold mine...from delivering a monster

baby(with two heads who did not survive) by C-section of course, finding solid

bones in the rectum of a patient, inserting chest drains out in the open field

with no local anesthesia in a pneumothorax, debriding brain tissue in the ER in

trauma patients when the OR was too busy in the real accident seasons during

Christmas and Easter,Finding patients with abdominal stabs laying calmly in the

ER under sheets when you uncovered them one would find feet and feet of

Intestines just disemboweled to your shock and they would do so well even with

so much delay..... working...operating non stop for 36 hours on a holiday week

end, amputating the male organs which were rotting secondary to gangrene due to

ash being smeared on it in the initiating ceremonies for young males of the

Xhosa tribes who were circumcised by the witch

doctors with no anesthesia and then had ash smeared on it and were kept

isolated till the organs became so gangrenous that you could smell them a mile

away in the ER....and so many more cases which come to mind.....and I was lucky

enough to have been the Chief resident of our residency program in Chicago as a

4th year assignment,where the one hour morning report everyday was like an

assembly. The Chief Resident conducts the report with interesting cases either

from the previous night or otherwise. We had 77 residents( 1st year, 2nd year

and the 3rd yr Internal Medicine as well as some transitional residents who do a

first year Internal medicine residency and then go to other fields like

Radiology etc... and an entourage of 20 odd Medical students rotating with us

plus the program director and the other consultants that we used to invite

relevant to the case( It used to be quite intimidating at times and an art to

deflect some of the questions that where thrown at you back

to the residents....slides of every day cases where made to make it interesting

and a good learning experience(thanks to a very supportive audio visual

department). Unfortunately as we are still living out of boxes one year after

moving to sdale from Louisville( still looking for that dream home) all my

old floppies and slides etc are in storage...will positively share a lot with

you all when we are settled.

Ashish

Prabha Desikan wrote:

That's interesing ! Congratulations, Namita !

Ashish, d'you think you could post the presentation on this group? I'd love to

see it .

Prabha'84

ashish sachdeva wrote:

An interesting case that I saw as a resident on a rotation in the Neurology

department at Northwestern University , Chicago in 1998 which was very

interesting

A 32 year old police officer presented to the neurology department with c/o

feeling funny and looking funny.The story goes that on a beat with a fellow

police officer one night the lady cop was in hot pursuit of a couple of car

thieves in the south side of Chicago and rammed into a pole in their patrol car

and let the thieves go. The cops returned home with a bruised ego as the thieves

had run away and also a bruised back and chest due to the crash. Everything went

well for a little while until she realized that at the gym she was being stared

at in a funny way ......exertion-induced asymmetric reaction of the skin of the

face and head; the right side showed normal flushing and sweating, while the

contra lateral side remained pale and dry. Harlequin(Clown) syndrome was first

coined by Lance and Drummond in 1988.

Arleccino (Harlequin) was a character in the travelling improvisational theater

originating in Venice in the 16th century, known as Comedia Dell’ Arte. This

remained popular until the 18th century, but many of the characters are still

recognizable today – Columbine, Pagliacci and Pulcinella, a woman-chasing

hunchback who was the forerunner of Punch. The first Harlequin masks were

grotesque and the term Harlequin syndrome was therefore applied to a severe form

of congenital ichthyosis with rudimentary ears, ectropion and ‘fish mouth’

appearance. But later, Harlequin masks became less sinister and more

sophisticated with diamond-shaped colourful patterns, or blackening of one half

of the face .This appearance came to mind when patients who flushed and sweated

excessively on one side of the face in hot weather, or after exercise,

particularly obvious when the sweating area was demonstrated by the application

of alizarin powder like in my case... Incidently this case was

presented by my wife Namita and won the First prize in various local clinical

vignette competitions and the American Association of Physicians of Indian

origin National meet and then went on to win the 2nd prize in American college

of Physicians contest in Chicago in 1999..here is an abstract from the ACP web

page

" The Officer And The Clown " Harlequin Syndrome: The Sudden Onset Of Unilateral

Flushing And Sweating With Contralateral Loss Of Sweating Namita S. Sachdeva,

M.D.

St. ph Hospital, Chicago, IL

This is the report of a 32-year-old young lady who was involved in a motor

vehicle accident and was hit by the steering wheel on her chest. She noticed

hyperhidrosis on her right side of the body and anhidrosis on her left side

immediately after the accident. With no other abnormality on exam an MRI of

head, neck, and CT scan of the same were normal. EMG study done then also was

normal. A thermoregulatory sweat test confirms her unilateral hyperhidrosis and

flushing with contralateral anhidrosis. She has symptoms still eight months down

the road. On review of literature, reports of hyperhidrosis and contralateral

anhidrosis have been reported in patients with exertion and trauma in only five

patients. This is a Harlequin Syndrome and the lesion is the torsion of the

anterior radicular artery which supplies the thoracic cord at the 3rd segment.

It has also been reported with non-traumatic conditions like cerebral infarction

and lung cancer - as a paraneoplastic syndrome in

adenocarcinoma of the lung.

References

Lance et al: Harlequin syndrome. J Neurol Neurosurg Psychiatry

1988;51(5):635-642.

Umeki S et al: Harlequin syndrome due to left apical ca of lung. Rinsho

Shinkaigaku 1990; 30(l):94-99.

Rousseux M, et al: Hyperhidrosis in lateral medullar infarct. Stroke

1996;27:991-995.

The case was presented in the first person, Namita presenting the case in a

funny format as the police officer with cartoon slides and with in a strict time

frame of 5 minutes..... a requirement of the competition.

Ashish

---------------------------------

Sick sense of humor? Visit Yahoo! TV's Comedy with an Edge to see what's on,

when.

[Guest guest]

Good one,very interesting case discussion.

BTW,any involvement of the pupil,to add to the case..

Meaning any signs of sympathetic pupillary postganglionic involvement..was

noticed...along with ur stated clinical features...suggesting...Horner's like

syndrome...??.

Bye.

Shyam(84)

Congrats..to ur better half..Ashish.

Clown of a different kind

An interesting case that I saw as a resident on a rotation in the Neurology

department at Northwestern University , Chicago in 1998 which was very

interesting

A 32 year old police officer presented to the neurology department with c/o

feeling funny and looking funny.The story goes that on a beat with a fellow

police officer one night the lady cop was in hot pursuit of a couple of car

thieves in the south side of Chicago and rammed into a pole in their patrol car

and let the thieves go. The cops returned home with a bruised ego as the thieves

had run away and also a bruised back and chest due to the crash. Everything went

well for a little while until she realized that at the gym she was being stared

at in a funny way ......exertion-induced asymmetric reaction of the skin of the

face and head; the right side showed normal flushing and sweating, while the

contra lateral side remained pale and dry. Harlequin(Clown) syndrome was first

coined by Lance and Drummond in 1988.

Arleccino (Harlequin) was a character in the travelling improvisational

theater originating in Venice in the 16th century, known as Comedia Dell' Arte.

This remained popular until the 18th century, but many of the characters are

still recognizable today - Columbine, Pagliacci and Pulcinella, a woman-chasing

hunchback who was the forerunner of Punch. The first Harlequin masks were

grotesque and the term Harlequin syndrome was therefore applied to a severe form

of congenital ichthyosis with rudimentary ears, ectropion and 'fish mouth'

appearance. But later, Harlequin masks became less sinister and more

sophisticated with diamond-shaped colourful patterns, or blackening of one half

of the face .This appearance came to mind when patients who flushed and sweated

excessively on one side of the face in hot weather, or after exercise,

particularly obvious when the sweating area was demonstrated by the application

of alizarin powder like in my case... Incidently this case was

presented by my wife Namita and won the First prize in various local clinical

vignette competitions and the American Association of Physicians of Indian

origin National meet and then went on to win the 2nd prize in American college

of Physicians contest in Chicago in 1999..here is an abstract from the ACP web

page

" The Officer And The Clown " Harlequin Syndrome: The Sudden Onset Of Unilateral

Flushing And Sweating With Contralateral Loss Of Sweating Namita S. Sachdeva,

M.D.

St. ph Hospital, Chicago, IL

This is the report of a 32-year-old young lady who was involved in a motor

vehicle accident and was hit by the steering wheel on her chest. She noticed

hyperhidrosis on her right side of the body and anhidrosis on her left side

immediately after the accident. With no other abnormality on exam an MRI of

head, neck, and CT scan of the same were normal. EMG study done then also was

normal. A thermoregulatory sweat test confirms her unilateral hyperhidrosis and

flushing with contralateral anhidrosis. She has symptoms still eight months down

the road. On review of literature, reports of hyperhidrosis and contralateral

anhidrosis have been reported in patients with exertion and trauma in only five

patients. This is a Harlequin Syndrome and the lesion is the torsion of the

anterior radicular artery which supplies the thoracic cord at the 3rd segment.

It has also been reported with non-traumatic conditions like cerebral infarction

and lung cancer - as a paraneoplastic syndrome in

adenocarcinoma of the lung.

References

Lance et al: Harlequin syndrome. J Neurol Neurosurg Psychiatry

1988;51(5):635-642.

Umeki S et al: Harlequin syndrome due to left apical ca of lung. Rinsho

Shinkaigaku 1990; 30(l):94-99.

Rousseux M, et al: Hyperhidrosis in lateral medullar infarct. Stroke

1996;27:991-995.

The case was presented in the first person, Namita presenting the case in a

funny format as the police officer with cartoon slides and with in a strict time

frame of 5 minutes..... a requirement of the competition.

Ashish

---------------------------------

Sick sense of humor? Visit Yahoo! TV's Comedy with an Edge to see what's on,

when.

[Guest guest]

I thought you had built yourself a dream home....was very inspired reading

that-houses in the UK are so stuck in n design ...I hope one day to

emulate you and try to build us one and was hoping to get tips from you when

it finally happens...if!!!

82

>

>Reply-To: mgims

>To: mgims

>Subject: Re: Clown of a different kind

>Date: Sat, 11 Aug 2007 21:58:07 -0700 (PDT)

>

>Hey Prabha! Thanks! Over the years I have a good selection of cases that I

>have saved.South Africa was absolutely a gold mine...from delivering a

>monster baby(with two heads who did not survive) by C-section of course,

>finding solid bones in the rectum of a patient, inserting chest drains out

>in the open field with no local anesthesia in a pneumothorax, debriding

>brain tissue in the ER in trauma patients when the OR was too busy in the

>real accident seasons during Christmas and Easter,Finding patients with

>abdominal stabs laying calmly in the ER under sheets when you uncovered

>them one would find feet and feet of Intestines just disemboweled to your

>shock and they would do so well even with so much delay.....

>working...operating non stop for 36 hours on a holiday week end, amputating

>the male organs which were rotting secondary to gangrene due to ash being

>smeared on it in the initiating ceremonies for young males of the Xhosa

>tribes who were circumcised by the witch

> doctors with no anesthesia and then had ash smeared on it and were kept

>isolated till the organs became so gangrenous that you could smell them a

>mile away in the ER....and so many more cases which come to mind.....and I

>was lucky enough to have been the Chief resident of our residency program

>in Chicago as a 4th year assignment,where the one hour morning report

>everyday was like an assembly. The Chief Resident conducts the report with

>interesting cases either from the previous night or otherwise. We had 77

>residents( 1st year, 2nd year and the 3rd yr Internal Medicine as well as

>some transitional residents who do a first year Internal medicine residency

>and then go to other fields like Radiology etc... and an entourage of 20

>odd Medical students rotating with us plus the program director and the

>other consultants that we used to invite relevant to the case( It used to

>be quite intimidating at times and an art to deflect some of the questions

>that where thrown at you back

> to the residents....slides of every day cases where made to make it

>interesting and a good learning experience(thanks to a very supportive

>audio visual department). Unfortunately as we are still living out of boxes

>one year after moving to sdale from Louisville( still looking for that

>dream home) all my old floppies and slides etc are in storage...will

>positively share a lot with you all when we are settled.

> Ashish

>

>Prabha Desikan wrote:

> That's interesing ! Congratulations, Namita !

>

>Ashish, d'you think you could post the presentation on this group? I'd love

>to see it .

>

>Prabha'84

>

>

>

>ashish sachdeva wrote:

>An interesting case that I saw as a resident on a rotation in the Neurology

>department at Northwestern University , Chicago in 1998 which was very

>interesting

>

>A 32 year old police officer presented to the neurology department with c/o

>feeling funny and looking funny.The story goes that on a beat with a fellow

>police officer one night the lady cop was in hot pursuit of a couple of car

>thieves in the south side of Chicago and rammed into a pole in their patrol

>car and let the thieves go. The cops returned home with a bruised ego as

>the thieves had run away and also a bruised back and chest due to the

>crash. Everything went well for a little while until she realized that at

>the gym she was being stared at in a funny way ......exertion-induced

>asymmetric reaction of the skin of the face and head; the right side showed

>normal flushing and sweating, while the contra lateral side remained pale

>and dry. Harlequin(Clown) syndrome was first coined by Lance and Drummond

>in 1988.

>Arleccino (Harlequin) was a character in the travelling improvisational

>theater originating in Venice in the 16th century, known as Comedia Dell’

>Arte. This remained popular until the 18th century, but many of the

>characters are still recognizable today – Columbine, Pagliacci and

>Pulcinella, a woman-chasing hunchback who was the forerunner of Punch. The

>first Harlequin masks were grotesque and the term Harlequin syndrome was

>therefore applied to a severe form of congenital ichthyosis with

>rudimentary ears, ectropion and ‘fish mouth’ appearance. But later,

>Harlequin masks became less sinister and more sophisticated with

>diamond-shaped colourful patterns, or blackening of one half of the face

>.This appearance came to mind when patients who flushed and sweated

>excessively on one side of the face in hot weather, or after exercise,

>particularly obvious when the sweating area was demonstrated by the

>application of alizarin powder like in my case... Incidently this case was

>presented by my wife Namita and won the First prize in various local

>clinical vignette competitions and the American Association of Physicians

>of Indian origin National meet and then went on to win the 2nd prize in

>American college of Physicians contest in Chicago in 1999..here is an

>abstract from the ACP web page

> " The Officer And The Clown " Harlequin Syndrome: The Sudden Onset Of

>Unilateral Flushing And Sweating With Contralateral Loss Of Sweating Namita

>S. Sachdeva, M.D.

>St. ph Hospital, Chicago, IL

>This is the report of a 32-year-old young lady who was involved in a motor

>vehicle accident and was hit by the steering wheel on her chest. She

>noticed hyperhidrosis on her right side of the body and anhidrosis on her

>left side immediately after the accident. With no other abnormality on exam

>an MRI of head, neck, and CT scan of the same were normal. EMG study done

>then also was normal. A thermoregulatory sweat test confirms her unilateral

>hyperhidrosis and flushing with contralateral anhidrosis. She has symptoms

>still eight months down the road. On review of literature, reports of

>hyperhidrosis and contralateral anhidrosis have been reported in patients

>with exertion and trauma in only five patients. This is a Harlequin

>Syndrome and the lesion is the torsion of the anterior radicular artery

>which supplies the thoracic cord at the 3rd segment. It has also been

>reported with non-traumatic conditions like cerebral infarction and lung

>cancer - as a paraneoplastic syndrome in

>adenocarcinoma of the lung.

>References

>Lance et al: Harlequin syndrome. J Neurol Neurosurg Psychiatry

>1988;51(5):635-642.

>Umeki S et al: Harlequin syndrome due to left apical ca of lung. Rinsho

>Shinkaigaku 1990; 30(l):94-99.

>Rousseux M, et al: Hyperhidrosis in lateral medullar infarct. Stroke

>1996;27:991-995.

>

>The case was presented in the first person, Namita presenting the case in a

>funny format as the police officer with cartoon slides and with in a strict

>time frame of 5 minutes..... a requirement of the competition.

>

>Ashish

>

>---------------------------------

>Sick sense of humor? Visit Yahoo! TV's Comedy with an Edge to see what's

>on, when.

>

>

[Guest guest]

Shyam, No our case did not it was a pure Harlequin syndrome, but yes if you

refer to the article below you will see various situations were you can have a

horners with the harlequinsyndrome Harlequin syndrome - one face of many

etiologies Gunnar Wasner, Rainer Maag, Janne Ludwig, s Binder, Jörn

Schattschneider, Stingele and Ralf Baron Nature Clinical Practice

Neurology (2005) 1, 54-59

doi:10.1038/ncpneuro0040 Also exertional right-sided hemifacial flushing

and sweating with slightly dilated pupils with absent constriction to light and

a tonic near response and redilatation, features like these are consistent with

Adie syndrome.In patients whose Neurological examination is otherwise normal,

including preservation of deep tendon reflexes and Magnetic resonance imaging of

brain and spine is also normal. The combination of unilateral loss of sudomotor

and vasomotor activity without loss of ocular sympathetic innervation fulfills

the diagnosis of Harlequin syndrome. The combination of Harlequin and Adie

syndromes has been called Ross syndrome. It gets more and more

interesting......

Ashish

---------------------------------

Got a little couch potato?

Check out fun summer activities for kids.

[Guest guest]

we actually did build one in Louisville, Kentucky in 2001...It took a

good one year to build from scratch, we had believed that we would settle down

in the Land of the Kentucky Derby and did put our heart and soul into it, but we

moved from their in 2006 and sold it.......It is not a job for the weak

hearted.....builders are builders , they have the same ethics all over the

world.....it is the same painful, but very satisfying experience in the end

though.....What are the various designs in vogue in UK now...I am very

curious....At present we are trying hard to find a house that would suit our

heart, soul and pocket......very very tough...Like even my 11 year old

says... " Mom , Dad I think you are going to end up building a house here too " !!

Ashish

Sinha wrote:

I thought you had built yourself a dream home....was very inspired reading

that-houses in the UK are so stuck in n design ...I hope one day to

emulate you and try to build us one and was hoping to get tips from you when

it finally happens...if!!!

82

>From: ashish sachdeva

>Reply-To: mgims

>To: mgims

>Subject: Re: Clown of a different kind

>Date: Sat, 11 Aug 2007 21:58:07 -0700 (PDT)

>

>Hey Prabha! Thanks! Over the years I have a good selection of cases that I

>have saved.South Africa was absolutely a gold mine...from delivering a

>monster baby(with two heads who did not survive) by C-section of course,

>finding solid bones in the rectum of a patient, inserting chest drains out

>in the open field with no local anesthesia in a pneumothorax, debriding

>brain tissue in the ER in trauma patients when the OR was too busy in the

>real accident seasons during Christmas and Easter,Finding patients with

>abdominal stabs laying calmly in the ER under sheets when you uncovered

>them one would find feet and feet of Intestines just disemboweled to your

>shock and they would do so well even with so much delay.....

>working...operating non stop for 36 hours on a holiday week end, amputating

>the male organs which were rotting secondary to gangrene due to ash being

>smeared on it in the initiating ceremonies for young males of the Xhosa

>tribes who were circumcised by the witch

> doctors with no anesthesia and then had ash smeared on it and were kept

>isolated till the organs became so gangrenous that you could smell them a

>mile away in the ER....and so many more cases which come to mind.....and I

>was lucky enough to have been the Chief resident of our residency program

>in Chicago as a 4th year assignment,where the one hour morning report

>everyday was like an assembly. The Chief Resident conducts the report with

>interesting cases either from the previous night or otherwise. We had 77

>residents( 1st year, 2nd year and the 3rd yr Internal Medicine as well as

>some transitional residents who do a first year Internal medicine residency

>and then go to other fields like Radiology etc... and an entourage of 20

>odd Medical students rotating with us plus the program director and the

>other consultants that we used to invite relevant to the case( It used to

>be quite intimidating at times and an art to deflect some of the questions

>that where thrown at you back

> to the residents....slides of every day cases where made to make it

>interesting and a good learning experience(thanks to a very supportive

>audio visual department). Unfortunately as we are still living out of boxes

>one year after moving to sdale from Louisville( still looking for that

>dream home) all my old floppies and slides etc are in storage...will

>positively share a lot with you all when we are settled.

> Ashish

>

>Prabha Desikan

wrote:

> That's interesing ! Congratulations, Namita !

>

>Ashish, d'you think you could post the presentation on this group? I'd love

>to see it .

>

>Prabha'84

>

>

>

>ashish sachdeva wrote:

>An interesting case that I saw as a resident on a rotation in the Neurology

>department at Northwestern University , Chicago in 1998 which was very

>interesting

>

>A 32 year old police officer presented to the neurology department with c/o

>feeling funny and looking funny.The story goes that on a beat with a fellow

>police officer one night the lady cop was in hot pursuit of a couple of car

>thieves in the south side of Chicago and rammed into a pole in their patrol

>car and let the thieves go. The cops returned home with a bruised ego as

>the thieves had run away and also a bruised back and chest due to the

>crash. Everything went well for a little while until she realized that at

>the gym she was being stared at in a funny way ......exertion-induced

>asymmetric reaction of the skin of the face and head; the right side showed

>normal flushing and sweating, while the contra lateral side remained pale

>and dry. Harlequin(Clown) syndrome was first coined by Lance and Drummond

>in 1988.

>Arleccino (Harlequin) was a character in the travelling improvisational

>theater originating in Venice in the 16th century, known as Comedia Dell’

>Arte. This remained popular until the 18th century, but many of the

>characters are still recognizable today – Columbine, Pagliacci and

>Pulcinella, a woman-chasing hunchback who was the forerunner of Punch. The

>first Harlequin masks were grotesque and the term Harlequin syndrome was

>therefore applied to a severe form of congenital ichthyosis with

>rudimentary ears, ectropion and ‘fish mouth’ appearance. But later,

>Harlequin masks became less sinister and more sophisticated with

>diamond-shaped colourful patterns, or blackening of one half of the face

>.This appearance came to mind when patients who flushed and sweated

>excessively on one side of the face in hot weather, or after exercise,

>particularly obvious when the sweating area was demonstrated by the

>application of alizarin powder like in my case... Incidently this case was

>presented by my wife Namita and won the First prize in various local

>clinical vignette competitions and the American Association of Physicians

>of Indian origin National meet and then went on to win the 2nd prize in

>American college of Physicians contest in Chicago in 1999..here is an

>abstract from the ACP web page

> " The Officer And The Clown " Harlequin Syndrome: The Sudden Onset Of

>Unilateral Flushing And Sweating With Contralateral Loss Of Sweating Namita

>S. Sachdeva, M.D.

>St. ph Hospital, Chicago, IL

>This is the report of a 32-year-old young lady who was involved in a motor

>vehicle accident and was hit by the steering wheel on her chest. She

>noticed hyperhidrosis on her right side of the body and anhidrosis on her

>left side immediately after the accident. With no other abnormality on exam

>an MRI of head, neck, and CT scan of the same were normal. EMG study done

>then also was normal. A thermoregulatory sweat test confirms her unilateral

>hyperhidrosis and flushing with contralateral anhidrosis. She has symptoms

>still eight months down the road. On review of literature, reports of

>hyperhidrosis and contralateral anhidrosis have been reported in patients

>with exertion and trauma in only five patients. This is a Harlequin

>Syndrome and the lesion is the torsion of the anterior radicular artery

>which supplies the thoracic cord at the 3rd segment. It has also been

>reported with non-traumatic conditions like cerebral infarction and lung

>cancer - as a paraneoplastic syndrome in

>adenocarcinoma of the lung.

>References

>Lance et al: Harlequin syndrome. J Neurol Neurosurg Psychiatry

>1988;51(5):635-642.

>Umeki S et al: Harlequin syndrome due to left apical ca of lung. Rinsho

>Shinkaigaku 1990; 30(l):94-99.

>Rousseux M, et al: Hyperhidrosis in lateral medullar infarct. Stroke

>1996;27:991-995.

>

>The case was presented in the first person, Namita presenting the case in a

>funny format as the police officer with cartoon slides and with in a strict

>time frame of 5 minutes..... a requirement of the competition.

>

>Ashish

>

>---------------------------------

>Sick sense of humor? Visit Yahoo! TV's Comedy with an Edge to see what's

>on, when.

>

>

[Guest guest]

Wow !!! I do hope to go to South Africa sometime - purely as a visitor, though.

I do hope you make / get your dream house soon !

Prabha'84

ashish sachdeva wrote:

Hey Prabha! Thanks! Over the years I have a good selection of cases

that I have saved.South Africa was absolutely a gold mine...from delivering a

monster baby(with two heads who did not survive) by C-section of course, finding

solid bones in the rectum of a patient, inserting chest drains out in the open

field with no local anesthesia in a pneumothorax, debriding brain tissue in the

ER in trauma patients when the OR was too busy in the real accident seasons

during Christmas and Easter,Finding patients with abdominal stabs laying calmly

in the ER under sheets when you uncovered them one would find feet and feet of

Intestines just disemboweled to your shock and they would do so well even with

so much delay..... working...operating non stop for 36 hours on a holiday week

end, amputating the male organs which were rotting secondary to gangrene due to

ash being smeared on it in the initiating ceremonies for young males of the

Xhosa tribes who were circumcised by the

witch

doctors with no anesthesia and then had ash smeared on it and were kept isolated

till the organs became so gangrenous that you could smell them a mile away in

the ER....and so many more cases which come to mind.....and I was lucky enough

to have been the Chief resident of our residency program in Chicago as a 4th

year assignment,where the one hour morning report everyday was like an assembly.

The Chief Resident conducts the report with interesting cases either from the

previous night or otherwise. We had 77 residents( 1st year, 2nd year and the 3rd

yr Internal Medicine as well as some transitional residents who do a first year

Internal medicine residency and then go to other fields like Radiology etc...

and an entourage of 20 odd Medical students rotating with us plus the program

director and the other consultants that we used to invite relevant to the case(

It used to be quite intimidating at times and an art to deflect some of the

questions that where thrown at you back

to the residents....slides of every day cases where made to make it interesting

and a good learning experience(thanks to a very supportive audio visual

department). Unfortunately as we are still living out of boxes one year after

moving to sdale from Louisville( still looking for that dream home) all my

old floppies and slides etc are in storage...will positively share a lot with

you all when we are settled.

Ashish

Prabha Desikan wrote:

That's interesing ! Congratulations, Namita !

Ashish, d'you think you could post the presentation on this group? I'd love to

see it .

Prabha'84

ashish sachdeva wrote:

An interesting case that I saw as a resident on a rotation in the Neurology

department at Northwestern University , Chicago in 1998 which was very

interesting

A 32 year old police officer presented to the neurology department with c/o

feeling funny and looking funny.The story goes that on a beat with a fellow

police officer one night the lady cop was in hot pursuit of a couple of car

thieves in the south side of Chicago and rammed into a pole in their patrol car

and let the thieves go. The cops returned home with a bruised ego as the thieves

had run away and also a bruised back and chest due to the crash. Everything went

well for a little while until she realized that at the gym she was being stared

at in a funny way ......exertion-induced asymmetric reaction of the skin of the

face and head; the right side showed normal flushing and sweating, while the

contra lateral side remained pale and dry. Harlequin(Clown) syndrome was first

coined by Lance and Drummond in 1988.

Arleccino (Harlequin) was a character in the travelling improvisational theater

originating in Venice in the 16th century, known as Comedia Dell’ Arte. This

remained popular until the 18th century, but many of the characters are still

recognizable today – Columbine, Pagliacci and Pulcinella, a woman-chasing

hunchback who was the forerunner of Punch. The first Harlequin masks were

grotesque and the term Harlequin syndrome was therefore applied to a severe form

of congenital ichthyosis with rudimentary ears, ectropion and ‘fish mouth’

appearance. But later, Harlequin masks became less sinister and more

sophisticated with diamond-shaped colourful patterns, or blackening of one half

of the face .This appearance came to mind when patients who flushed and sweated

excessively on one side of the face in hot weather, or after exercise,

particularly obvious when the sweating area was demonstrated by the application

of alizarin powder like in my case... Incidently this case was

presented by my wife Namita and won the First prize in various local clinical

vignette competitions and the American Association of Physicians of Indian

origin National meet and then went on to win the 2nd prize in American college

of Physicians contest in Chicago in 1999..here is an abstract from the ACP web

page

" The Officer And The Clown " Harlequin Syndrome: The Sudden Onset Of Unilateral

Flushing And Sweating With Contralateral Loss Of Sweating Namita S. Sachdeva,

M.D.

St. ph Hospital, Chicago, IL

This is the report of a 32-year-old young lady who was involved in a motor

vehicle accident and was hit by the steering wheel on her chest. She noticed

hyperhidrosis on her right side of the body and anhidrosis on her left side

immediately after the accident. With no other abnormality on exam an MRI of

head, neck, and CT scan of the same were normal. EMG study done then also was

normal. A thermoregulatory sweat test confirms her unilateral hyperhidrosis and

flushing with contralateral anhidrosis. She has symptoms still eight months down

the road. On review of literature, reports of hyperhidrosis and contralateral

anhidrosis have been reported in patients with exertion and trauma in only five

patients. This is a Harlequin Syndrome and the lesion is the torsion of the

anterior radicular artery which supplies the thoracic cord at the 3rd segment.

It has also been reported with non-traumatic conditions like cerebral infarction

and lung cancer - as a paraneoplastic syndrome in

adenocarcinoma of the lung.

References

Lance et al: Harlequin syndrome. J Neurol Neurosurg Psychiatry

1988;51(5):635-642.

Umeki S et al: Harlequin syndrome due to left apical ca of lung. Rinsho

Shinkaigaku 1990; 30(l):94-99.

Rousseux M, et al: Hyperhidrosis in lateral medullar infarct. Stroke

1996;27:991-995.

The case was presented in the first person, Namita presenting the case in a

funny format as the police officer with cartoon slides and with in a strict time

frame of 5 minutes..... a requirement of the competition.

Ashish

---------------------------------

Sick sense of humor? Visit Yahoo! TV's Comedy with an Edge to see what's on,

when.