correspondence

benefit from both beta-blockade and ACE inhibition. However, his blood pressure was typically only 110/70 mm Hg, so only one agent could be administered, and given the frequent ventricular ectopy, his doctors elected to treat with a low dose of metoprolol succinate. Dudzinski and Schrager ask readers to keep in mind the varied presentations of polyarteritis nodosa. A more exhaustive differential diagnosis for this patient would include polyarteritis nodosa, since it can result in both renal and myocardial infarction. However, this patient had no cutaneous lesions or neuropathy,3 had sinus bradycardia rather than tachycardia, and was found on angiography to have only a subtle irregularity of the midportion of the left anterior descending coronary artery; there was no evidence of aneurysms, obstruction, nodularity, dissection, or thrombosis, which would suggest polyarteritis nodosa. Moreover, since the left

ventricular apical aneurysm did not appear to be consistent with a myocardial infarction, it seemed unlikely that the aneurysm was the result of vasculitis or other pathology of the coronary artery. Therefore, although the diagnosis of polyarteritis nodosa could not be formally excluded, it seemed insufficiently likely to warrant discussion, particularly in view of the limited space available in the article. Eric M. Isselbacher, M.D.
Massachusetts General Hospital Boston, MA Since publication of the article, the author reports no further potential conflict of interest.
1. Rassi A Jr, Rassi A, Little WC, et al. Development and valida-

tion of a risk score for predicting death in Chagas heart disease. N Engl J Med 2006;355:799-808. 2. Rassi A Jr, Rassi A, Rassi SG. Predictors of mortality in chronic Chagas disease: a systematic review of observational studies. Circulation 2007;115:1101-8. 3. Stone JH. Polyarteritis nodosa. JAMA 2002;288:1632-9.

Myxedema Coma Induced by Ingestion of Raw Bok Choy

To the Editor: An 88-year-old Chinese woman was brought to the emergency department by her family, who reported that she had been lethargic and unable to walk or swallow for 3 days. She had been eating an estimated 1.0 to 1.5 kg of raw bok choy daily for several months in the belief that it would help control her diabetes. She had no previous history of thyroid disease. On examination the patient was lethargic. The temperature was 36.1C, the pulse 58 beats per minute, blood pressure 181/89 mm Hg, and the respiratory rate 22 breaths per minute. A pulse oximetry reading was 92%. She had periorbital edema and macroglossia, and her thyroid was not palpable; she also had pitting edema in her lower legs. Her skin was dry and her hair was coarse; a neurologic examination revealed clonus and hyperreflexia in the right leg due to a previous stroke. The remainder of her examination was normal. Laboratory testing was significant for serum levels of sodium (118 mmol per liter), thyrotropin (74.4 mIU per liter; 0.65 mIU per liter 4 months earlier; normal range, 0.4 to 4.0 mIU per liter), free thyroxine (undetectable; normal range, 0.7 to 2.2 ng per deciliter), and thyroid peroxidase antibodies (13 IU per milliliter; normal range, <20 IU per milliliter). The patient was intubated for hypoxemic and hypercarbic respiratory failure and admitted to the intensive care unit with a diagnosis of severe hypothyroidism with myxedema coma. She was treated with intravenous methylprednisolone and levothyroxine and was eventually discharged to a skilled nursing facility. Brassica rapa chinensis, otherwise known as bok choy or Chinese white cabbage, contains glucosinolates, a group of compounds that occur widely in the genus. Some of the breakdown products of glucosinolates, such as thiocyanates, nitriles, and oxazolidines, have been implicated for their inhibitory effects on the thyroid. Studies in the 1920s were the first to note the development of hypertrophic goiters in rabbits that were mainly fed a diet of cabbage.1 Interest in the possible goitrogenic properties of foodstuffs led to the discovery of 1,5-vinyl-2-thiooxazolidone in brassica seeds and in yellow turnips. The compound was termed a goitrin because it inhibited the uptake of iodine by the thyroid gland.2 In our patient, the problem was her consumption of considerable amounts of raw bok choy. When eaten raw, brassica vegetables release the enzyme myrosinase, which accelerates
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notices

the hydrolysis of glucosinolates; the cooking BLeedING aNd THrOMbOSING DISeaSeS: 2010 MaYO UPdate process largely deactivates the myrosinase in The Coagulation Conference and Wet Workshop will be 3 these vegetables. This case demonstrates the held in Rochester, MN, Aug. 36. Contact Diane Strain, Mayo Medical Laboratories, 3050 Supotential for nutritional factors to have a properior Dr. NW, Rochester, MN 55901; or call (507) 284-0286; found effect on health. or see http://www.mayomedicallaboratories.com/education/ coag2010; or e-mail strain.diane@mayo.edu. Michael Chu, M.D. Terry F. Seltzer, M.D.
New York University School of Medicine New York, NY michael.chu@nyumc.org Disclosure forms provided by the authors are available with the full text of this letter at NEJM.org.
1. Chesney AM, Clawson TA, Webster B. Endemic goiter in rab-

SMaLLPOX EradICatION aFter 30 YearS: LeSSONS, LeGaCIeS, aNd INNOVatIONS

The symposium will be held in Rio de Janeiro, Aug. 2427. Contact Sabin Vaccine Institute, 2000 Pennsylvania Ave. NW, Suite 7100, Washington, DC 20006; or call (202) 842-5025; or fax (202) 842-7689; or see http://www.smallpox2010.org.

bits. Bull Johns Hopkins Hosp 1928;43:261. 2. Astwood EB, Greer MA, Ettlinger MG. 1-5-Vinyl-2-thiooxazolidone, an antithyroid compound from yellow turnip and from Brassica seeds. J Biol Chem 1949;181:121-30. 3. Dekker M, Verkerk R, Jongen WM. Predictive modelling of health aspects in the food production chain: a case study on glucosinolates in cabbage. Trends Food Sci 2000;11:174-81.
Correspondence Copyright 2010 Massachusetts Medical Society.

CurreNt CHaLLeNGeS IN MedICaL COMMuNICatION: dIaGNOSING aNd CurING uNetHICaL PraCtICeS

The conference will be held in Warsaw, Poland, on Oct. 8. It is sponsored by the Polish Academy of Sciences. Contact Anna Sienkiewicz, Polish Academy of Sciences, 00901 Warsaw, Poland; or call (4822) 6566096; or fax (4822) 6203374; or e-mail medwriting@pan.pl; or see http://www .english.pan.pl.

INSTRUCTIONS FOR LETTERS TO THE EDITOR

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73rd ANNuaL COLON aNd ReCtaL SurGerY CONFereNCe

The conference will be held in Minneapolis, Oct. 2023. It is sponsored by the University of Minnesota Division of Colon and Rectal Surgery. Contact Colleen Jensen, P.O. Box 314, Lakeland, MN 55043; or call (612) 670-7810; or fax (612) 677-3200; or see http://www .colonrectalcourse.org; or e-mail info@colonrectalcourse.org.

CHeMOtHeraPY FOuNdatION SYMPOSIuM XXVII: INNOVatIVe CaNCer THeraPY FOr TOMOrrOW

The symposium will be held in New York, Nov. 913. It is presented by Mount Sinai School of Medicine and the Chemotherapy Foundation. Contact Jaclyn Silverman, Mount Sinai School of Medicine, 1 Gustave Levy Place, Box 1193, New York, NY 10029; or call (212) 866-2813; or fax (646) 215-7589; or e-mail jaclyn.silverman@ mssm.edu.

ReNaL WeeK 2010

The meeting will be held in Denver, Nov. 1621. It is presented by the American Society of Nephrology. Contact the American Society of Nephrology, 1725 I Street NW, Suite 510, Washington, DC 20006; or call (202) 659-0599; or see http://www.asn-online.org; or e-mail education@ asn-online.org.

HOt TOPICS IN NeONatOLOGY 2010

The meeting will be held in Washington, DC, Dec. 57. Contact Gail M. Murphy, 52 Overlake Park, Burlington, VT 05401; or call (802) 865-2283; or fax (802) 865-0241; or e-mail info@hottopics.org; or see http://www.hottopics.org.

notices
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