Free
Letters to the Editor  |   July 2008
Response
Article Information
Letters to the Editor   |   July 2008
Response
The Journal of the American Osteopathic Association, July 2008, Vol. 108, 352-353. doi:10.7556/jaoa.2008.108.7.352
The Journal of the American Osteopathic Association, July 2008, Vol. 108, 352-353. doi:10.7556/jaoa.2008.108.7.352
In his letter, Bradley D. Confer, OMS IV, states that the lactate dehydrogenase level and reticulocyte count should be used only as screening tests for hemolytic anemia, and that other laboratory tests should have been used to further develop the diagnosis of hemolytic anemia for the patient in our case report in JAOA—The Journal of the American Osteopathic Association (2007; 107:554-556). We agree with Mr Confer's statements, and we acknowledge that further testing should have been used to strengthen the diagnosis given. 
The confusing part of this case for the admitting physician was that the patient's medical record showed that she was given high doses (125 mg every 6 hr) of intravenous methylprednisolone and 4 units of packed red blood cells at the outlying hospital as treatment for her anemia—with no hemolytic analysis conducted at that time. Forty-eight hours posttreatment, the patient was transferred to our institution. The rheumatologist who was consulted believed that, considering the patient's history and clinical presentation of rheumatoid arthritis, the diagnosis of hemolytic anemia was probable. 
In their letter, Paul J. Shogan, DO, and Les R. Folio, DO, commented that the inverted grayscale images featured in our case report did not adequately show the findings described in the captions. Unfortunately, the images as viewed by the radiologists at our institution could not be converted into electronic files that were of publishable quality for the JAOA. 
We appreciate the Web links provided by Drs Shogan and Folio through the Uniformed Services University of the Health Sciences' MedPix database. These links allow the reader to view clinically useful images of both rheumatoid arthritis and tophaceous gout. 
Drs Shogan and Folio also commented on certain images that were excluded from our case report. Additional images of the patient's hands were included with our submitted manuscript, but they were removed during the editing process because of image quality and space constraints.