rive serum titer, a CSF lab profile cons is ten t w i th Lyme disease, and documented vascul i t i s on angiogram that re- sponds to IV Rocephin ® strongly suggests CNS Lyme dis- ease as the cause (as s tated in Halper in ' s article). There is n o doubt that there is a need for more accurate ways to make the diagnosis of active Lyme disease, both CNS or per ipheral , and be t t e r ways to m o n i t o r response t reat- ment .

Gerard X Brogan, Jr, M D Depar tmen t of Emergency Medicine State Universi ty of N e w York Stony Brook

1. Reik L, Steers AC, Bartenhagen NH, et ah Neurologic abnormalities of

Lyme disease. Medicine 1979;58:281-294. 2. Stiernstedt G: Tick-borne Borrelia infection in Sweden. Scand J Infect Dis 1985;45:1-70. 3. Pachner AR, Steere AC: Neurological findings of Lyme disease. Yale ] Biol Med 1984;57:481-483. 4. Pachner AR: Spirochetal diseases of the CNS. NeuroI Clin 1986;4: 207-222. 5. Uldry PA, Regli F, Bogousslavsky J: Cerebral angiopathy and recurrent strokes following Borrelia burgdorferi infection. J Neurol Neurosurg Psy- chiatry 1987;50:1703-1704. 6. Reik L: Disseminated vasculomyelinepathy: An immune complex dis- ease. Ann Neurol 1980;7:291-296. 7. Halperin JJ, Luft BJ, Anand AK, et ah CNS Lyme disease (letter). Neurol ogy 1990;40:190.

Central Cord Syndrome

To the Editor: The neurologic deficit described in "Traumat ic Central

Cord Syndrome in a Pat ient Wi th Os Odon to ide um" by McGoldr i ck and Marx [December 1989;18:1358-1361], was a t t r ibuted to a central cord syndrome when, in fact, I be- lieve the symptoms can be more accurate ly explained by a paralysis' of Bell.

A central cord syndrome involves a spinal cord injury from bulging of the l igamenta flava against the anter ior vertebral bodies during f lexion of the cervical spine. 1 This injury causes injury to the central por t ion of the spinal cord (hence the name central cord injury) and results in weakness of the arms greater than the legs, loss of bladder function, and a variable degree of sensory loss. The vic- t ims are usual ly elderly, and the level of injury is usual ly in the lower cervical spine.

The paralysis of Bell is an injury to the pyramida l de- cussation, usual ly as a resul t of poster ior d i sp lacement of the odontoid. Anatomical ly , the pyramida l decussat ion of the cervical cord is direct ly poster ior to the odontoid, and this accounts for i ts po ten t i a l for. in jury w h e n e v e r the odontoid is displaced.

I bel ieve the neurologic symptoms tha t occurred in this pa t ien t and the pa thophys io logy that was proposed to ac- count for this deficit are mos t l ike ly explained by paral- ysis of Bell and not a central cord syndrome as reported by the author.

David J Dula, MD Emergency Medicine Geisinger Medical Center Danville, Pennsylvania

1. Schneider RD, Crosby EC: Traumatic spinal cord syndromes and their management. J Clin Neurosurg 1972;20:424-492.

In Reply: Dr Dula brings up the poin t that the neurologic deficits

described in our pat ient could be explained by a "crucia te paralysis of Bell," which involves injury to the pyramida l tract decussat ion. The "crucia te paralysis" as described by Bell involves se lec t ive b i l a t e ra l arm para lys is or te t ra- plegia. A les ion involving the rostral crossing fibers of the pyramidal decussa t ion m a y s imula te the neurologic pat- tern of "acute central cervical cord injury syndrome." In fact, two of the cases presented in Bell's original paper in- volved a neurologic pa t te rn that was in i t ia l ly classified as acute central cervical cord syndrome.

Our p a t i e n t p r e s e n t e d w i t h w e a k n e s s of the a rms greater than the legs wi thou t apparent sensory loss and loss of bladder function. We feel this pa t te rn of neurologic deficit is cons is ten t w i th central cord syndrome.

John McGoldrick, M D John Marx, M D Depar tment of Emergency Medicine Denver General Hospital Denver, Colorado

Sensitivity, Specificity & Positive & Negative Predictive Values

To the Editor." The article, "Fracture of the Carpal Navicular - Effi-

cacy of Cl in ica l Findings and Improved Diagnos i s W i t h Six-View Radiography" by M e h t a and Braut igan [March

1990;19:225-257], contains an error in s ta t is t ica l calcula- tion. Table 1 compares the results of four- and six-view r a d i o g r a p h y in d i agnos ing f rac tu res of the nav icu la r .

19:11 November 1990 Annals of Emergency Medicine 1354/175

CORRESPONOENCE

While the sens i t iv i ty of the four-view study is correct ly reported to be 83%, the specif ici ty and posi t ive predict ive values are given as 70% and 83%, respectively. Their cor- rect values are both 100%. The sensit ivi ty, specificity, and posi t ive predict ive value given for the six-view s tudy are all correct ly reported as 100%.

Perhaps the u t i l i ty of the addit ional two radiographic views that are part of the six-view s tudy is best i l lus t ra ted by the negative predict ive value, which was not given in this article. By the data presented, the negative predict ive

value of the four views is 69%, whi le that of the six views is 100%. This supports the authors ' conclus ion that nei- ther immobi l i za t ion nor fol low-up is needed given a nega- tive six-view study, provided that larger cl inical s tudies verify the resul ts of this invest igat ion.

Howard Blumstein, MD Medical College of Pennsylvania Philadelphia

Echocardiography to Rule Out Metastat ic

To the Editor. We w o u l d l ike to c o m m e n t on the case confe rence

"Ethical Considera t ions in Emergency Depa r tmen t Man- agement of Termina l ly Ill Pat ients" by Strange et al [Octo- ber 1989;18:1085-1088[. This case discussion involved the ethics of aggressive t rea tment and resusci ta t ion in a 78- year-old m a n wi th k n o w n ca rc inoma of the lung (diag- nosed two months pr ior to the presentat ion) who appar- en t ly developed an acute myocardia l infarction. This new diagnosis was based on "ECG changes compa t ib l e wi th acute an te ro la te ra l myoca rd i a l in fa rc t ion , " a l though the specifics of these ECG changes are not given.

We consider the discussion fol lowing the case presenta- t ion to be an excel lent one and our only concern was wi th the ini t ia l diagnost ic possibi l i t ies in this patient.

In any k n o w n cancer pa t ien t who presents wi th p r imary cardiac s igns /symptoms, the poss ibi l i ty of cardiac meta- s tases m u s t be en ter ta ined . The improved surv iva l af- forded by today's aggressive, m u l t i m o d a l i t y t r ea tmen t of m a n y m a l i g n a n c i e s has inc reased the f r e q u e n c y w i t h w h i c h m e t a s t a t i c d i sease is seen in c l i n i ca l p rac t i ce . 1 Metas ta t ic disease to the heart is one specific area where an increased incidence has been noted.~, 3 The mos t com- mon pr imary tumor responsible for cardiac metas tases is carc inoma of the bronchus, wi th breast, leukemias , lym- phomas, and mal ignant me lanomas l is ted in order of de- creasing frequency. The inc idence of me tas t a ses to the heart , inc lud ing the pe r ica rd ium, ranges f rom 1.5% to 20.6% of autopsies on pat ients wi th known mal ignan t dis- ease.4, 5

This patient , then, wi th no previous known cardiac his- tory and who presented wi th a chief compla in t of weak- ness, was found to have an abnormal ECG two mon ths after having lung cancer diagnosed. Electrocardiographic changes in m e t a s t a t i c d isease are qui te nonspecif ic , al- though Ha r tman et al have proposed that prolonged and p ronounced loca l ized S-T segment e leva t ion in the ab- sence of Q waves is a p a t h o g n o m i c sign of myoc a rd i a l t umor invasion. 6

Our only suggestion, wi th regard to this patient , is that a bedside 2D echocardiogram could have been def ini t ive in de te rmin ing the presence or absence of me tas ta t i c car- diac disease~, 2 and that w i th this knowledge, the decisions regarding aggressive ICU support versus pal l ia t ive treat- men t or specific oncologic therapy may be less controver- sial.

Disease

fi)hn M Tallon, MD Foothills Hospital

David R Montoya, MD, FRCP(C) Calgary General Hospital Calgary, Alberta, Canada 1. Stark RM, Derloff JK, Glick }H, et ah Clinical recognition and manage- ment of cardiac metastatic disease: Observations in a unique case of alveo- lar soft-part sarcoma. Am J Med 1977;63:653-659. 2. Hanfling SM: Metastatic cancer to the heart: Review of the literature and report of 127 cases. Circulation 1960~22:474-483. 3. Lockwood WB, Broghamer WL Jr: The changing prevalence of secondary cardiac neoplasms as related to cancer therapy. Cancer 1980;45:2659-2662.

4. Lammers RJ, Bloor CM: Tumors of the heart and pericardium. Modern Concepts of Cardio~'~scular Disease 1986i551-554. 5. Rosenthal DS, Braunwald E: Hematological-ontological disorders and heart disease, in Braunwald E {ed): Heart Disease, ed 3. Philadelphia, Wig Saunders, 1988, p 1284-1305. 6. Hartman RB, Sehulman P: Pronounced and prolonged ST segment eleva- tion: A pathognomic sign of tumour invasion to the heart. Arch Intern Med 1982;142:1917q919.

1~ Reply: I thank Drs Tal lon and M o n t o y a for the i r c o m m e n t s

and the addi t ion of another diagnost ic poss ib i l i ty to the discussion of the case. It is indeed possible that this pa- t ien t had metas ta t i c disease involving the heart. At the t ime of his arrest and unsuccessful resusci ta t ion, no addi- t iona l tests , e i ther cardiac e nz yme s or eehocard iogram, had been obtained. Your suggestion that bedside echoear- diography would have been defini t ive in rul ing out meta- s tases is also appreciated. Th is is an e n t i t y tha t is no doubt underdiagnosed.

As for the ethical considerat ions, they seem to me to remain pre t ty much the same regardless of the et iology of the ECG abnormal i ty . In e i the r case, pha rmaco log ic or electr ical therapy may have some shor t - te rm effect, but the under lying process remains progressive and terminal .

Gary Strange, MD, FACEP University of Illinois Affiliated Hospitals

Emergency Medicine Residency Chicago

176/1355 Annals of Emergency Medicine 19:11 November 1990