Volume 7, Issue 1, 2023
CPC-EM Full-Text Issue
Clinicopathological Cases from the University of Maryland
45-year-old Male with Bilateral Lower Extremity Wounds, Swelling, and Rash
A 45-year-old male presented to the emergency department (ED) with bilateral lower extremity pain, swelling, and associated atypical rash in the setting of polysubstance use and unstable housing. Laboratory tests showed an elevated white blood cell count and inflammatory markers.
A Benign Mimic of Dangerous Neck Pathology: A Case Report of Longus Colli Calcific Tendonitis
Introduction: Longus colli calcific tendonitis (LCCT) is a calcium deposition disease that causes acute or subacute atraumatic neck pain. It is important for the emergency physician to consider LCCT in the differential diagnosis because the clinical presentation of this benign condition may mimic life-threatening disease processes that require invasive diagnostic measures.
Case Report: We present a case of a 63-year-old female with atraumatic right-sided neck pain. On exam she had tenderness to palpation in the neck, as well as difficulty ranging her neck and opening her mouth. She underwent computed tomography of her neck with intravenous contrast, which showed calcific tendonitis of the longus colli muscle with retropharyngeal edema. She was seen by otolaryngology, underwent nasopharyngolaryngoscopy, and ultimately was discharged with antibiotics and corticosteroids.
Conclusion: The presentation of LCCT can mimic symptoms of dangerous causes of neck pain including retropharyngeal abscess and meningitis. Early diagnosis in the ED can potentially avoid more invasive diagnostic and therapeutic measures. While LCCT is thought to be self-limiting, it can be treated with non-steroidal anti-inflammatory medications and corticosteroids. If pain is controlled, patients can be discharged from the ED with no specialist follow-up required.
Bilateral Tubal Pregnancies Presenting 11 Days Apart: A Case Report
Introduction: Ectopic pregnancy is the most common cause of maternal mortality in the first trimester. Bilateral tubal pregnancy is the rarest subset with an estimated incidence of one in 725 to 1,580 ectopic pregnancies. Of the cases of bilateral tubal pregnancy reported in the literature, most were associated with the use of assisted reproductive techniques. Here we present the case of a patient, without a prior history of reproductive technology use, who underwent treatment for a tubal pregnancy and was subsequently found to have a second, contralateral tubal pregnancy 11 days later.
Case Report: A 35-year-old female gravida eight para two with a history of left tubal pregnancy and salpingectomy 11 days prior, presented to the emergency department (ED) with two days of left lower and upper quadrant abdominal pain. The patient’s last menstrual period had been several months prior. A physical examination revealed left lower quadrant abdominal tenderness, rebound, guarding, and left adnexal tenderness. Her vital signs were unremarkable, and her laboratory studies revealed normal white blood cell and hemoglobin values. Her human chorionic gonadotropin had tripled from her last presentation 11 days prior. Transvaginal ultrasound showed a possible ectopic pregnancy adjacent to the right ovary. She promptly underwent a right salpingectomy. Pathology findings confirmed a tubal pregnancy, and the patient’s postoperative course was uneventful.
Conclusion: This case highlights the importance of maintaining a high index of suspicion for ectopic pregnancy in all biologically female patients of reproductive age who present to the ED with abdominal pain.
Mysterious Pelvic Hematoma in a Patient Who Speaks a Rare Ethiopian Dialect: A Case Report
Introduction: In reporting this case of a patient with spontaneous iliac vein rupture, we highlight the importance of maintaining a high clinical suspicion of this vascular emergency in the at-risk patient.
Case Report: A 50-year-old female with an uncommon language barrier presented with left lower abdominal pain after falling. Initial imaging showed pelvic hematoma of unclear etiology. Repeat computed tomography showed expanding hematoma, and after hemodynamic decompensation, exploratory laparotomy revealed a ruptured iliac vein.
Conclusion: Although rare, spontaneous iliac vein rupture has a high mortality rate, even when identified early. This case serves as a reminder to consider this potentially fatal diagnosis in the at-risk group and highlights the need to remain vigilant in patients who present with unexplained shock. Additionally, this case is a reminder of our duty to provide emergency care that transcends language barriers.
Rare Adult-onset Citrullinemia Type 1 in the Postpartum Period: A Case Report
Introduction: Citrullinemia type 1 (CTLN1) is a urea cycle disorder caused by defective argininosuccinate synthetase leading to impaired ammonia elimination. Urea cycle disorders are typically diagnosed on neonatal screening but rarely can lie dormant until a metabolic stressor causes initial onset of symptoms in adulthood.
Case Report: A 23-year-old female presented four days postpartum to the emergency department (ED) obtunded and declined to the point of requiring intubation. Labs revealed hyperammonemia, and she was subsequently found to have CTLN1.
Conclusion: Urea cycle disorders presenting in adulthood are a rare etiology for the common ED complaint of altered mental status. The low incidence makes these treatable disorders easy to overlook leading to potentially significant morbidity and mortality. Therefore, it is important to recognize the risk factors that can trigger an acute metabolic derangement. This case highlights common risk factors for metabolic stress, possible presenting symptoms, and the positive outcome achievable when recognized and treated in a timely fashion.
A Rare Cause of Headache and an Unorthodox Transfer: A Case Report
Introduction: Emergency department (ED) crowding and hospital diversion times are increasing nationwide, with negative effects on patient safety and an association with increased mortality. Crowding in referral centers makes transfer of complex or critical patients by rural emergency physicians (EP) more complicated and difficult. We present a case requiring an unorthodox transfer method to navigate extensive hospital diversion and obtain life-saving neurosurgical care.
Case Report: We present the case of a previously healthy 21-year-old male with two hours of headache and rapid neurologic decompensation en route to and at the ED. Computed tomography revealed obstructive hydrocephalus recognized by the EP, who medically managed the increased intracranial pressure (ICP) and began the transfer process for neurosurgical evaluation and management. After refusal by six referral centers in multiple states, all of which were on diversion, the EP initiated an unorthodox transfer procedure to the institution at which he trained, ultimately transferring the patient by air. Bilateral external ventricular drains were placed in the receiving ED, and the patient ultimately underwent neurosurgical resection of an obstructive colloid cyst.
Conclusion: First, our case illustrates the difficulties faced by rural EPs when attempting to transfer critical patients when large referral centers are refusing transfers and the need for improvements in facilitating timely transfers of critically ill, time-sensitive patients. Second, EPs should be aware of colloid cysts as a rare but potentially catastrophic cause of rapid neurologic decline due to increased ICP, and the ED management thereof, which we review.
Emergency Department Treatment Provides Immediate and Durable Relief Following Vaccine Injury: A Case Report
Introduction: Intramuscular administration of vaccines into the deltoid muscle is the recommended route for most vaccines in adults. Ectopic injection into the subdeltoid/subacromial bursa can produce an inflammatory bursitis that is associated with significant long-term morbidity.
Case Report: We describe a novel approach to treatment of this condition: ultrasound-guided administration of dexamethasone by the emergency physician within six hours of vaccine administration. This approach resulted in complete and durable long-term resolution of symptoms with no functional impairment.
Conclusion: This outcome is superior to that described for usual care, and the approach is well-suited to emergency physicians.
A Case Report of Ruptured Popliteal Aneurysm in the Setting of Blunt Trauma
Introduction: Popliteal artery aneurysms are in most cases asymptomatic but cause significant complications if ruptured. An acute popliteal aneurysm rupture is relatively rare, and few cases have been documented secondary to blunt trauma. Common presenting signs and symptoms include distal limb ischemia and absent dorsalis pedis pulses. Timely management and recognition of this rare presentation are crucial as this condition can result in limb loss or death if not treated in a timely manner.
Case Report: An 80-year-old man with history of hypertension presented to the emergency department complaining of inability to feel sensation below his left knee after falling from ground level. Physical examination was pertinent for bounding radial and femoral pulses bilaterally, although absent dorsalis pedis and posterior tibial pulses to the left lower extremity. Computed tomography angiography identified occlusion of the left superficial femoral arterial lumen associated with a ruptured popliteal aneurysm, approximately eight centimeters in size. He immediately received unfractionated heparin and was admitted to the hospital for left medial thigh exploration and decompressive dermatofasciotomy.
Conclusion: After confirmation of popliteal aneurysmal rupture with advanced imaging, heparinization and vascular surgery consultation are critical steps that should be taken to prevent limb loss.
Bilateral Erector Spinae Plane Block for Man o’ War Stings: A Case Report
Introduction: The Portuguese man o’ war, an aquatic invertebrate, is responsible for a large proportion of cnidarian stings worldwide. Cnidaria is a phylum that contains the genus Physalia. These injuries result in severe pain and skin irritation, which are often difficult to control. Traditionally, cnidarian stings have been treated by emergency physicians with warm water, vinegar and, in severe cases, opioids. However, no concrete guidelines have been established for pain management in man o’ war stings.
Case Report: Regional anesthesia (RA) is an increasingly used method of pain control in the emergency department. In the case of a 41-year-old female experiencing severe pain from a Portuguese man o’ war sting, RA with an erector spinae plane block (ESPB) provided her with rapid and long-lasting pain relief.
Conclusion: The standard of care has yet to be defined when managing pain from Physalia physalis stings. Although this is the first documented use of ESPB for treatment of cnidarian stings, RA should be considered by any emergency physician when treating injuries caused by a Portuguese man o’ war.
Acute Intracranial Subdural Hematoma Masquerading as a Postpartum Headache: A Case Report
Introduction: An acute subdural hematoma is a collection of blood in the space between the dural and arachnoid membranes overlying the brain. Head trauma is the most common cause. Less frequently, low cerebrospinal fluid pressure, due to a spontaneous or iatrogenic cerebrospinal fluid leak can result in a subdural hematoma.
Case Report: We discuss the case of a 26-year-old woman who presented with a frontal headache following epidural anesthesia for vaginal delivery. The differential diagnosis included spinal headache, postpartum hypercoagulability, dural sinus thrombosis, and intracranial hemorrhage or mass. Her vital signs and physical examination were normal. A computed tomography of the brain revealed an acute subdural hematoma along the left frontal cerebral hemisphere, without midline shift or mass effect. A blood patch was placed with complete resolution of her symptoms.
Conclusion: This case illustrates an unusual case of an acute subdural hematoma in the postpartum period following epidural anesthesia for labor pain management. It was thought to be caused by intracranial hypotension following epidural anesthesia and a cerebrospinal fluid leak.
Nebulized Ketamine Used for Managing Ankle Fracture in the Prehospital Emergency Setting: A Case Report
Introduction: Acute traumatic limb injury is a common complaint of patients presenting to the emergency department (ED). Ketamine is an effective analgesic administered via intravenous (IV), intranasal (IN), intramuscular (IM), and nebulized routes in the ED. It has also been used in the prehospital setting via IV, IM, and IN routes. Recent studies have proposed the prehospital use of nebulized ketamine via breath-actuated nebulizer (BAN) as a noninvasive and effective method of analgesic delivery, as well as an alternative to opioid analgesia.
Case Report: We present a case of a patient with right ankle fracture after a 12-foot fall who subsequently received 0.75 milligrams per kilogram of nebulized ketamine via BAN in the prehospital setting. The patient reported improvement of pain from 8/10 to 3/10 on the pain scale without need for additional pain medication during prehospital transport. This report supports the use of nebulized ketamine via BAN in the prehospital setting for acute traumatic limb injuries.
Conclusion: The use of nebulized ketamine via BAN in the prehospital setting may be an effective analgesic option for the management of patients with acute traumatic limb injuries, particularly in those with difficult IV access, where mucosal atomization devices are not accessible, or where opioid-sparing treatments are preferable.
Images in Emergency Medicine
Shoulder Abduction While Using the Bougie: A Common Mistake
Case Presentation: A 72-year-old female presented to the emergency department (ED) with exacerbation of chronic obstructive pulmonary disease and congestive heart failure. The patient required intubation for airway protection and hypercapnic respiratory failure. The ED team used a video laryngoscope, Macintosh 3 blade and bougie as the endotracheal tube delivery device. Despite a grade 2a Cormack-Lehane airway view, the bougie repeatedly missed left posterolateral to the airway. During these missed attempts, the emergency medicine (EM) resident’s shoulder was noted to be abducted. The EM resident then readjusted his technique by adducting the shoulder. which allowed the tip of the bougie to pass the vocal cords resulting in successful intubation.
Discussion: The bougie is a useful endotracheal tube delivery device when used properly. Optimal body mechanics and device orientation are critical to successful use. Shoulder abduction while using the bougie is a frequent mistake, which can lead to left posterolateral malposition in relation to the glottis/airway. In this brief review our goal is to aid the intubating clinician in optimal use of the bougie, yielding more successful endotracheal tube passage.
Man with Pleuritic Chest Pain
Case Presentation: We describe a case of epipericardial fat necrosis.
Discussion: Epipericardial fat necrosis is an inflammatory condition in which the pericardial fat pad necrotizes resulting in surrounding inflammation. This condition mimics more ominous pathology in clinical presentation and radiographic findings. Management is supportive with oral analgesics.
A Rare Malposition of a Left Internal Jugular Central Venous Catheter into the Left Internal Mammary Vein
Case Presentation: We describe a case of left internal jugular central venous access with rare malpositioning into the internal mammary vein. Despite various confirmatory measures at the time of placement including ultrasonography of the internal jugular vein, as well as blood gas analysis consistent with venous blood by oxygen saturation and good venous flow in all three ports of the catheter, subsequent imaging confirmed misplacement into the internal mammary vein.
Discussion: Central venous access is a frequently used procedure by emergency physicians for a variety of indications. Emergency physicians must be facile with both the technical process of central venous catheter placement, as well as possible pitfalls and complications of the procedure. Common complications, such as bleeding, pneumothorax, arterial injury, infection, and hematomas, are usually well known; less frequently encountered is malposition of the catheter despite seemingly appropriate placement.