Journal of the Royal College of Physicians of Edinburgh

Hypnale hypnale is a small pit viper that is known as the hump-nosed pit viper (HNV) or ‘Merrem's hump-nosed pit viper’ and is endemic to Sri Lanka and the Western Ghats of South India. Previously, it was thought that this viper bite would result in mild systemic or local envenomation, however, we now know that HNV bites could cause severe systemic toxicity and mortality. The most common systemic toxicity of this viper envenomation is coagulopathy, which is known as ‘Hypnale coagulopathy'. Hypnale coagulopathy is quite different from the haemotoxicity caused by other vipers. In this paper, an effort has been made to discuss the unique and unpredictable nature of this coagulopathy due to Hypnale envenomation.

Ethics, at its core, relates to our practices and their moral justification. The practice of medicine, by definition, takes place in a fundamentally ethical context. In ordinary circumstances the goals to which physicians direct their medical practices are held tacitly, but sometimes fresh examination of these is occasioned. This conceptual article considers a range of approaches that have been taken to the notion of health, ancient and modern, historical and contemporary, beginning with the socio-cultural, then the health political, and finally the medical philosophical. Although these are contrasting perspectives, each are bound up with questions of values and of the relation between the objective and subjective. The contrast is discussed between the idea of health as a positive and dynamic condition in terms of functional ability, and characterisations of health as purely the absence of disease. Finally, a typology of theories of health is proposed along ontological and epistemological lines.

Epstein-Barr virus (EBV) associated acute liver failure (ALF) is an exceedingly uncommon event. Despite this, EBV-associated ALF has a very high fatality rate. When looking at the number of reported cases of EBV-associated ALF requiring an emergency liver transplant, we see even fewer numbers. This presents challenges to clinicians in the diagnosis, awareness and appropriate case management. There is limited information in the medical literature about the hepatic demonstration and complications of EBV. We therefore report a case of EBV-associated ALF in a 17-year-old immunocompetent female who was treated successfully with an orthotopic liver transplantation.

We present the case of a 56-year-old female brought to the Emergency Department via routine ambulance transport with complaints of blurred vision and malaise. She was screened by ambulance crew using the facial arm speech time (FAST) tool and a basic top-to-toe assessment as per current routine. The examining practitioner performed a thorough assessment of the patient, revisiting the initial examination findings, and establishing new clinical features of visual field deficit and pan-systolic murmur. The likely diagnosis of septic emboli or stroke with infective endocarditis was identified through the power of rigorous history taking and examination. These were then supported by investigation with blood tests and imaging. This prompted discussion with a tertiary centre and subsequent transfer for further investigation and management. The patient's journey shows that there may indeed be a role for a more comprehensive (but not exhaustive) initial screening from ambulance services in order to help appropriately stream specific patients to hospital in a timelier manner (to meet the thrombolysis window). This case supports the addition of V (visual fields) to the FAST screening tool.

Testicular cancer is the most common malignancy in young men. We discuss four cases of germ cell tumours (GCTs) presenting to general practitioners and physicians where there were notable preventable delays in the diagnosis and management. This diagnostic delay is associated with a more advanced stage of disease, and subsequent increased treatment-related morbidity and decreased survival. Our series highlights the variety of ways in which GCTs may present and we discuss the importance of prompt diagnosis through a thorough history and examination, early measurement of serum tumour markers and appropriate multidisciplinary team discussion. GCTs are highly curable cancers in the majority of patients and delays in management can, therefore, have devastating consequences.

Systemic lupus erythematosus (SLE) is a rare autoimmune disorder in a physician's practice, commonly presenting in young females. It is rare for SLE to present at a late age. Though SLE is idiopathic, sometimes it can present as an adverse reaction to drugs. Quite a few drugs are implicated in this process. However, there are no reports of levetiracetam causing SLE. Here, we present a case of 62-year-old female presenting with SLE after consumption of levetiracetam for 1 year for her epilepsy. Erythematosus rash was her main symptom. This was associated with a strong positivity of antinuclear antibody. The symptoms remitted completely after the discontinuation of levetiracetam, suggesting them to be because of drug-induced lupus (DIL). DIL differs from SLE in being mild, affecting atypical age groups and resolving completely on withdrawal of the drug.

Amiodarone is a common medication used widely in clinical practice. It is a triiodinated antiarrhythmic associated with a variety of adverse effects both pulmonary and extrapulmonary, the most serious being amiodarone-induced pulmonary toxicity (AIPT) or amiodarone lung. This can present with a variety of clinical syndromes ranging from subacute symptoms to an indolent and a progressive course thus mimicking an alternative diagnosis.

We report a case of amiodarone lung in a female who presented with an acute fulminant progressive pneumonitis despite being on very low dose (100 mg once daily) that proved fatal. Diagnosis was made on postmortem examination due to a diagnostic conundrum. Despite the steady decrease of AIPT with reduced dose, it is vital for the treating clinicians to monitor regularly for adverse effects and review the need for long-term use to prevent complications.

Late-onset hypogonadism (LOH) is a complex and highly debatable syndrome in ageing men, which is characterised by reduced testosterone levels associated with classical symptoms of androgen deficiency. This article discusses the complex issues surrounding its management related to patient-centric thresholds and therapeutic targets. It specifically highlights the need to consider symptoms as the starting point, the key milestones in the management and the target of treatment, while ensuring safety at all times. The diagnosis of LOH requires a high index of suspicion and early identification of symptoms followed by appropriate investigations. The threshold for initiation of treatment has to be person centric and requires individualised decisions. The dose, preparation, route and follow up after testosterone initiation also may vary among different people. A person-centred approach is key to the successful management of this complex, nebulous yet debilitating disease.

Telemedicine use has expanded rapidly to cope with increasing demand on services by delivering remote clinical review and monitoring of long-term conditions. Triaging individual patients to determine their suitability for telephone, video or face-to-face consultations is necessary. This is crucial in the context of COVID-19 to ensure doctor-patient safety. Telemedicine was shown to be safe and feasible in managing certain chronic diseases and providing patient education. When reviewing newly referred or long-term patients, different specialty clinics have different requirements for physical examination. Clinicians prefer face-to-face consultations at the initial visit to establish a doctor-patient relationship; telephone or video consultations are reasonable options for long-term patients where physical examination may not be needed. Video consultations, often aided by sophisticated devices and apps or medical assistants, are useful to facilitate remote physical examination. Most patients prefer telemedicine as it saves time and travel cost and provides better access to appointments.

During the late fifteenth century a new category of medical practitioner appeared in the German-speaking lands of the Holy Roman Empire: the Franzosenarzt or French pox doctor. Until now, there has been no dedicated study of these practitioners. Through an analysis of municipal records from Nuremberg (circa 1495 to 1560), this paper offers the first dedicated investigation of the Franzosenärzte in this city, focusing on uncovering their relationships with Nuremberg's civic and medical hierarchies. It demonstrates why the Franzosenärzte gained a footing within the city's municipal healthcare system, but remained subject to the suspicions of the civic and medical authorities. These suspicions, combined with a competitive medical marketplace and Nuremberg's economic difficulties, precipitated the disappearance of the Franzosenärzte from the city around 1557. Nevertheless, for a brief moment, the Franzosenärzte's practical expertise in treating the French pox unsettled Nuremberg's nascent medical hierarchy and the ambitions of the city's physicians.

Few people have been as successful in bringing together basic research, clinical science, and a contribution to military medicine as Professor Hugh MacLean. However, today he is almost forgotten. During World War 1, practicing within the realms of the new field of renal medicine, with minimal resources and in a military hospital, he conducted one of the first large-scale Medical Research Committee investigations into war nephritis involving 60,000 subjects. After the war he set up and practiced, amongst other specialties, in the field of veteran medicine and established the concept of the one-stop renal clinic. After achieving significant academic recognition, he was unfortunately affected by mental health problems, possibly related to his wartime experiences, which brought an illustrious career to an untimely end.