Volume 4, Issue 3, 2020
CPC-EM Full-Text Issue
Clinicopathological Cases from the University of Maryland
Case Presentation: A 36-year-old incarcerated male presented to the emergency department (ED) after an episode concerning for syncope. The patient had nystagmus and ataxia on initial examination.
Discussion: There is a broad differential diagnosis for syncope, and for patients presenting to the ED we tend to focus on cardiogenic and neurologic causes. This case takes the reader through the differential diagnosis and systemic work-up of a patient presenting to the ED with syncope.
Introduction: Patients in the emergency department may experience sudden decompensation despite initially appearing stable.
Case Presentation: A 37-year-old transgender man presented to the emergency department (ED) with several months of fevers, myalgias, and weight loss. The patient acutely became febrile, tachycardic, and hypotensive after an initially reassuring assessment in the ED.
Discussion: This case takes the reader through the differential diagnosis and work-up of the decompensating patient initially presenting with subacute symptoms.
Astonishing Cases and Images in Emergency Medicine
Case Presentation: A 37-year-old man presented from jail reporting foreign body ingestion of a sprinkler head. While initial radiography did not reveal the foreign body, subsequent imaging with computed tomography demonstrated the sprinkler head. When confronted with this discrepancy the patient admitted to having the sprinkler head in his possession and choosing to swallow it after his initial radiography.
Discussion: This case demonstrates the importance of maintaining a high threshold for real illness in situations where there is suspected malingering, a situation not infrequently encountered in the emergency department.
Medical Legal Case Report
Duty to Warn in the Emergency Department: Three Medical Legal Cases That Illustrate Providers’ Broad Risk and Liability
This article presents three medical-legal cases that define a physician’s duty to warn and include caveats on medical practice within the scope of the law. Some physicians may not recognize that these legal and liability requirements extend not only to physical danger, but also to infectious diseases, medical illness, and drug effects.
Using Lung Point-of-care Ultrasound in Suspected COVID-19: Case Series and Proposed Triage Algorithm
Introduction: First detected in December 2019, the severe acute respiratory syndrome coronavirus 2 pandemic upended the global community in a few short months. Diagnostic testing is currently limited in availability, accuracy, and efficiency. Imaging modalities such as chest radiograph (CXR), computed tomography, and lung ultrasound each demonstrate characteristic findings of coronavirus disease 2019 (COVID-19). Lung ultrasound offers benefits over other imaging modalities including portability, cost, reduced exposure of healthcare workers as well as decreased contamination of equipment such as computed tomography scanners.
Case Series: Here we present a case series describing consistent lung ultrasound findings in patients with confirmed COVID-19 despite variable clinical presentations and CXR findings. We discuss a triage algorithm for clinical applicability and utility of lung point-of-care ultrasound in the setting of COVID-19 and advocate for judicious and targeted use of this tool.
Conclusion: Lung point-of-care ultrasound can provide valuable data supporting diagnostic and triage decisions surrounding suspected cases of COVID-19. Prospective studies validating our proposed triage algorithm are warranted.
- 2 supplemental videos
Introduction: Frequent thrombotic complications have been reported in patients with severe coronavirus disease 2019 (COVID-19) infection. The risk in patients with mild disease is unknown.
Case Report: We report a case series of three individuals recently diagnosed with COVID-19, who presented to the emergency department with chest pain and were found to have pulmonary emboli. The patients had mild symptoms, no vital sign abnormalities, and were negative according to the pulmonary embolism rule-out criteria.
Conclusion: This suggests that patients with active or suspected COVID-19 should be considered at elevated risk for pulmonary embolism when presenting with chest pain, even without common risk factors for pulmonary embolism.
Introduction: There is recent evidence that coronavirus disease 2019 (COVID-19) infection results in a prothrombotic state that may increase the risk of venous thromboembolism. Both COVID-19 infection and pulmonary emboli can present with dyspnoea, tachypnoea, hypoxaemia and an elevated D-dimer. Identifying a pulmonary embolus in a patient with COVID-19 and differentiating it from the typical clinical and biochemical features of COVID-19 is challenging.
Case Reports: We report four cases, and reviewed two further cases in the literature, of a pulmonary embolus in patients who presented to the emergency department with COVID-19 and no other risk factor for a pulmonary embolus.
Conclusion: We identified a series of atypical features that should raise suspicion for a pulmonary embolus: pleuritic chest pain; haemoptysis; atrial fibrillation; tachycardia; hypotension; late onset deterioration; evidence of right heart strain; or a disproportionally elevated D-dimer in comparison to ferritin.
Introduction: The evaluation of an unstable peripartum patient in the emergency department includes a differential diagnosis spanning multiple organ systems. Splenic artery aneurysm (SAA) is one of those rare diagnoses with potentially high morbidity and mortality.
Case Series: This case series explores two unusual cases of postpartum SAAs. Despite differences in presentation, both patients had a ruptured SAA.
Conclusion: Often, SAAs are misdiagnosed. Early diagnosis is key, especially for the fetus. If the patient presents in shock, the expedited diagnosis and treatment can be lifesaving for both the mother and the fetus.
Alternative Diagnostic Strategy for the Assessment and Treatment of Pulmonary Embolus: A Case Series
Introduction: Ferumoxytol-enhanced magnetic resonance angiography (FeMRA) can be used as an alternate and safe method to diagnose patients with compromised renal function who present with acute pulmonary embolus in the emergency department (ED) setting.
Case Report: A 62-year old man with a history of renal transplant and lymphoproliferative disease described new onset of breathlessness. His clinical symptoms were suggestive of pulmonary embolus. He underwent FeMRA in the ED to avoid exposure to intravenous iodinated contrast. FeMRA demonstrated a left main pulmonary artery embolus, which extended to the left interlobar pulmonary artery. Afterward, the patient initiated anticoagulation therapy. With preserved renal function he was able to continue his outpatient chemotherapy regimen.
Conclusion: This case highlights a safe imaging technique for emergency physicians to diagnose pulmonary embolus and subsequently guide anticoagulation therapy for patients in whom use of conventional contrast is contraindicated.
Decompression of Subdural Hematomas Using an Intraosseous Needle in the Emergency Department: A Case Series
Introduction: Traumatic subdural hematomas beget significant morbidity and mortality if not rapidly decompressed. This presents a unique challenge to the emergency physician without immediate neurosurgical support.
Case Report: We report two cases of patients in Los Angeles County with traumatic subdural hematomas and clinical deterioration in the emergency department (ED) who were treated with decompression using an intraosseous needle drill.
Discussion: We believe these cases represent the first use of this technique to temporize a subdural hematoma in the ED.
Introduction: As severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) spreads across the globe, physicians face the challenges of a contagious pandemic including which patients to isolate, how to conserve personal protective equipment, and who to test. The current protocol at our hospital is to place anyone with new cough, dyspnea, or fever into airborne and contact precautions and consider them for testing. Unfortunately, the symptomatic presentations of coronavirus disease 2019 (COVID-19) are proving more variable than previously thought.
Case Report: Our case of COVID-19 presented with headache and then progressed to a meningitis-like illness with co-existing shingles rash.
Conclusion: COVID-19 can have a variety of initial presentations that are not the classic respiratory symptoms and fever. These presenting symptoms of COVID-19 can include a meningitis-like illness, as our case report indicates. The wide variety of presentations of COVID-19 may warrant widespread testing to identify cases, protect healthcare workers, and prevent the spread of this pandemic
Introduction: During the coronavirus disease 2019 (COVID-19) pandemic, emergency providers are not only seeing an increasing number of patients with COVID-19 infections, but also associated complications and sequelae of this viral illness.
Case Report: We present the case of a 28-year-old female patient who presented after a confirmed COVID-19 infection with lower back pain, bilateral symmetric upper and lower extremity numbness, and urinary retention. The patient was diagnosed with acute transverse myelitis. She required intravenous corticosteroids and plasma exchange with significant improvement in symptoms and minimal residual effects.
Conclusion: This case illustrates the importance of prompt recognition and treatment of sequelae of COVID-19 infections.
Introduction: Neurologic symptoms present as significant complications of coronavirus disease 2019 (COVID-19) infection. This report describes a novel manifestation of tremors triggered by severe acute respiratory syndrome coronavirus 2 infection.
Case Presentation: We describe a case of a 46-year-old man with COVID-19 infection complicated by a bilateral intention tremor and wide-based gait. Although neurological manifestations have been reported related to COVID-19, tremulousness has not yet been described.
Conclusion: Considering the evolving diversity of neurologic manifestations in this infection, emergency physicians should be vigilant of possible COVID-19 infection in patients presenting with unexplained neurologic symptoms.
Optimizing Non-invasive Oxygenation for COVID-19 Patients Presenting to the Emergency Department with Acute Respiratory Distress: A Case Report
Introduction: The novel coronavirus (COVID-19) pandemic has led to an increase in the number of patients presenting to the emergency department (ED) with severe hypoxia and acute respiratory distress. With limited resources and ventilators available, emergency physicians working at a hospital within the epicenter of the United States outbreak developed a stepwise, non-invasive oxygenation strategy for treating COVID-19 patients presenting with severe hypoxia and acute respiratory distress.
Case Report: A 72-year-old male suspected of having the COVID-19 virus presented to the ED with shortness of breath. He was found to be severely tachypneic, febrile, with rales in all lung fields. His initial oxygen saturation registered at SpO2 (blood oxygenation saturation) 55% on room air. Emergency physicians employed a novel non-invasive oxygenation strategy using a nasal cannula, non-rebreather, and self-proning. This approach led to a reversal of the patient’s respiratroy distress and hypoxia (SpO2 88-95%) for the following 24 hours.This non-invasive intervention allowed providers time to obtain and initiate high-flow nasal cannula and discuss end-of-life wishes with the patient and his family.
Conclusion: Our case highlights a stepwise, organized approach to providing non-invasive oxygenation for COVID-19 patients presenting with severe hypoxia and acute respiratory distress. This approach primarily employs resources and equipment that are readily available to healthcare providers around the world. The intent of this strategy is to provide conventional alternatives to aid in the initial airway management of confirmed or suspected COVID-19 patients.
Cardioembolic Stroke in a Patient with Coronavirus Disease of 2019 (COVID-19) Myocarditis: A Case Report
Introduction: There is a growing body of literature detailing coronavirus 2019 (COVID-19) cardiovascular complications and hypercoagulability, although little has been published on venous or arterial thrombosis risk.
Case Report: In this report, we present a single case of cardioembolic stroke in the setting of COVID-19 related myocarditis, diagnosed via cardiac magnetic resonance imaging and echocardiography. COVID-19 infection was confirmed via a ribonucleic acid polymerase chain reaction assay.
Conclusion: Further research is needed to evaluate the hypercoagulable state of patients with COVID-19 to determine whether prophylactic anticoagulation may be warranted to prevent intracardiac thrombi and cardioembolic disease in patients with COVID-19 related myocarditis.
Introduction: The novel coronavirus disease 2019 (COVID-19) presents a challenge for healthcare providers in terms of diagnosis, management, and triage of cases requiring admission.
Case Report: A 47-year-old male with symptoms suspicious for COVID-19, pulse oximetry of 93% on room air, and multifocal pneumonia was risk stratified and safely discharged from the emergency department (ED) despite having moderate risk of progression to acute respiratory distress syndrome. He had resolution of his symptoms verified by telephone follow-up.
Conclusion: Various risk-stratifying tools and techniques can aid clinicians in identifying COVID-19 patients who can be safely discharged from the ED.
Background: Coronavirus disease 2019 (COVID-19) has spread throughout the world since late 2019. Symptoms appear after a two-week incubation period and commonly include fever, cough, myalgia or fatigue, and shortness of breath.
Case Report: A 32-year-old male with a history of opiate abuse presented to the emergency department with altered mental status. The patient was lethargic and hypoxic with improvement from naloxone. Official chest radiograph was read as normal; however, the treating clinicians noted bilateral interstitial opacities, raising concern for underlying infectious etiology. Opiates and cocaine were positive on drug screen, and an arterial blood gas on room air showed hypoxemia with respiratory acidosis. The patient was intubated during the treatment course due to persistent hypoxemia and for airway protection after resuscitation. The COVID-19 test was positive on admission, and later computed tomography showed ground-glass opacities. The patient was extubated and discharged after one week on the ventilator.
Conclusion: When screening patients at and during evaluation, physicans should consider a broad differential as patients with atypical presentations may be overlooked as candidates for COVID-19 testing. As screening and evaluation protocols evolve, we emphasize maintaining a high index of suspicion for COVID-19 in patients with atypical symptoms or presenting with other chief complaints in order to avoid spreading the disease
Acute Transverse Myelitis Secondary to Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2): A Case Report
Introduction: Respiratory viral illnesses are associated with diverse neurological complications, including acute transverse myelitis (ATM). Among the respiratory viral pathogens, the Coronaviridae family and its genera coronaviruses have been implicated as having neurotropic and neuroinvasive capabilities in human hosts. Despite previous strains of coronaviruses exhibiting neurotropic and neuroinvasive capabilities, little is known about the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and its involvement with the central nervous system (CNS). The current pandemic has highlighted the diverse clinical presentation of SARS-CoV-2 including a possible link to CNS manifestation with disease processes such as Guillain-Barré syndrome and cerebrovascular disease. It is critical to shed light on the varied neurological manifestation of SARS-CoV-2 to ensure clinicians do not overlook at-risk patient populations and are able to provide targeted therapies appropriately.
Case Report: While there are currently no published reports on post-infectious ATM secondary to SARS-CoV-2, there is one report of parainfectious ATM attributed to SARS-CoV-2 in pre-print. Here, we present a case of infectious ATM attributed to SARS-CoV-2 in a 24-year-old male who presented with bilateral lower-extremity weakness and overflow urinary incontinence after confirmed SARS-CoV-2 infection. Magnetic resonance imaging revealed non-enhancing T2-weighted hyperintense signal abnormalities spanning from the seventh through the twelfth thoracic level consistent with acute myelitis.
Conclusion: The patient underwent further workup and treatment with intravenous corticosteroids with improvement of symptoms and a discharge diagnosis of ATM secondary to SARS-CoV-2.
Introduction: The coronavirus disease of 2019 (COVID-19) caused by the novel severe acute respiratory syndrome coronavirus 2 is a global pandemic that expresses itself with a wide variety of presenting symptoms in patients. There is a paucity of literature describing the dermatologic manifestations of the virus, particularly in the United States.
Case Report: Here we present a case of COVID-19 that manifested with a purpuric rash on the lower extremities and a maculopapular eruption on the abdomen in a patient in acute diabetic ketoacidosis and normal platelet count.
Discussion: The reported presenting symptoms of patients with COVID-19 vary greatly. This is the first documented case of COVID-19 presenting with mixed cutaneous manifestations of a purpuric as well as maculopapular rash.
Conclusion: The cutaneous lesions associated with the COVID-19 infection may mimic or appear similar to other well-known conditions. We illustrate a case of COVID-19 infection presenting with purpuric rash on the lower extremities and a maculopapular rash on the abdomen.
Introduction: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) typically presents with respiratory illness and fever, however some rare neurologic symptoms have been described as presenting complaints. We report a case of an acute motor and sensory polyneuropathy consistent with Miller-Fisher Syndrome (MFS) variant of Guillain Barre Syndrome (GBS) as the initial symptom.
Case Report: A 31-year old Spanish speaking male presents with two months of progressive weakness, numbness, and difficult walking. He had multiple cranial nerve abnormalities, dysmetria, ataxia, and absent lower extremity reflexes. An extensive workup including infectious, autoimmune, paraneoplastic, metabolic and neurologic testing was performed. Initially SARS-CoV-2 was not suspected based on a lack of respiratory symptoms. However, workup revealed a positive SARS-CoV-2 polymerase chain reaction test as well as presence of Anti-Ganglioside – GQ1b (Anti-GQ1b) immunoglobulin G antibodies.
Discussion: Miller Fisher syndrome (MFS) is a variant of Guillain-Barre syndrome (GBS) characterized by a triad of ophthalmoplegia, ataxia, and areflexia. The patient’s exam and workup including Anti-GQ1b is consistent with MFS.
Conclusion: SARS-CoV-2 infection in patients can have atypical presentations similar to this neurologic presentation. Prompt recognition and diagnosis can minimize the risk of transmission to hospital staff and facilitate initiation of treatment.
Background: Point-of-care ocular ultrasound in the emergency department (ED) is an effective tool for promptly evaluating for several vision-threatening etiologies and can be used to identify more slowly progressing etiologies as well, such as cataract formation within the lens.
Case Report: A 62-year-old female presented to the ED with a two-day history of painless vision loss of the left eye as well as reduced vision for the prior 30 days.
Conclusion: Point-of-care ultrasound was performed and showed calcification of the lens consistent with cataract.
Introduction: The life- or limb-threatening differential diagnosis for upper extremity swelling can include deep vein thrombosis (DVT), infectious processes, and compartment syndrome. Chronic anatomic abnormalities such as axillary vein stenosis are rarely a consideration in the emergency department.
Case Report: We present a 26-year-old female with history of Chiari type 1 malformation who presented with acute left arm swelling. Initial workup, including point-of-care ultrasound, revealed the presence of significant soft tissue swelling without evidence of DVT.
Conclusion: Further workup revealed an early, localized rhabdomyolysis secondary to axillary vein stenosis or venous thoracic outlet syndrome, also known as Paget-Schroetter syndrome.
Introduction: Diplopia is an uncommon emergency department (ED) complaint representing only 0.1% of visits, but it has a large differential. One cause is a cranial nerve palsy, which may be from a benign or life-threatening process.
Case Report: A 69-year-old female presented to the ED with two days of diplopia and dizziness. The physical exam revealed a sixth cranial nerve palsy isolated to the left eye. Imaging demonstrated an intracavernous internal carotid artery aneurysm. The patient was treated with embolization by neurointerventional radiology.
Discussion: The evaluation of diplopia is initially divided into monocular, usually from a lens problem, or binocular, indicating an extraocular process. Microangiopathic disease is the most common cause of sixth nerve palsy; however, more serious etiologies may be present, such as an intracavernous internal carotid artery aneurysm, as in the patient described. Imaging modalities may include computed tomography or magnetic resonance imaging.
Conclusion: Some causes of sixth nerve palsy are benign, while others will require more urgent attention, such as consideration of an intracavernous internal carotid artery aneurysm.
Introduction: Cerebrovascular accidents (CVA) of the posterior circulation are a rare complication of migraine, and present with atypical CVA symptomatology.
Case Report: A 49-year-old-male presented with complaint of persistent visual aura and resolved mild cephalgia. His exam corroborated his reported incomplete left inferior quadrantanopia, and was confirmed by immediate formal optometry evaluation. Occipital CVA was confirmed on admission.
Conclusion: Migrainous strokes of posterior circulation should be considered as a potential diagnosis in any headache patient with persistent visual aura. This case suggests that incorporation of formal visual field testing in the emergent setting can shorten the time required for diagnosis in certain circumstances.
Background: Nicotiana glauca is a plant known to cause acute toxicity upon ingestion or dermal exposure due to the nicotinic alkaloid, anabasine. Nicotinic alkaloids cause toxicity by acting as agonists on nicotinic-type acetylcholine receptors (nAChRs). Initial stimulation of these receptors leads to symptoms such as tachycardia, miosis, and tremors. The effects of high doses of nicotinic alkaloids are biphasic, and eventual persistent depolarization of nAChRs at the neuromuscular junction occurs. This causes apnea, paralysis, and cardiovascular collapse.
Case Report: In this report, we present a case of respiratory arrest due to nicotinic alkaloid poisoning from the ingestion of Nicotiana glauca. The diagnosis was suspected after the patient’s family gave a history of the patient ingesting a plant prior to arrival. They were able to also provide a physical sample of the plant.
Conclusion: The phone application, “Plant Snap”, determined the plant species and helped confirm the diagnosis. This case describes how modern technology and thorough history taking can combine to provide the best possible patient care.
Introduction: Disseminated tuberculosis (TB) is rare, affects any organ system, and presents mainly in immunocompromised populations. Typical presentation is non-specific, posing a challenge for diagnosis.
Case Report: This case presents an immunocompetent male presenting with severe headaches with meningeal signs. Lab and lumbar puncture results suggested bacterial meningitis, yet initial cerebral spinal fluid cultures and meningitis/encephalitis polymerase chain reaction were negative. A chest radiograph (CXR) provided the only evidence suggesting TB, leading to further tests showing dissemination to the brain, spinal cord, meninges, muscle, joint, and bone.
Discussion: This case stands to acknowledge the difficulty of diagnosis in the emergency department (ED), and the need for emergency physicians to maintain a broad differential including disseminated TB as a possibility from the beginning of assessment. In this case, emergency physicians should be aware of predisposing factors of disseminated TB in patients presenting with non-specific symptoms. They should also acknowledge that TB may present atypically in patients with minimal predisposing factors, rendering the need to further investigate abnormal CXR images despite lab results inconsistent with TB.
Conclusion: While this diagnosis is easily missed, early identification in the ED can lead to optimal treatment.
Introduction: Patients with acute unilateral upper and lower facial palsy frequently present to the emergency department fearing they have had a stroke, but many cases are benign Bell’s palsy.
Case Report: We present a rare case of a medial pontomedullary junction stroke causing upper and lower hemifacial paralysis associated with severe dysphagia and contralateral face and arm numbness.
Conclusion: Although rare, pontine infarct must be considered in patients who present with both upper and lower facial weakness. Unusual neurologic symptoms (namely diplopia, vertigo, or dysphagia) and signs (namely gaze palsy, nystagmus, or contralateral motor or sensory deficits) should prompt evaluation for stroke.
Introduction: Copper is an uncommon source of metal toxicity in children that requires a high index of suspicion for diagnosis.
Case Report: We describe the unique presentation of a 12-month-old girl who developed acute onset of vomiting and diarrhea after ingestion of a copper-contaminated birthday cake.
Conclusion: This case highlights the presentation, evaluation, and management of the rare pediatric patient who presents with copper poisoning. This case also illuminates the public health implications of potential metal poisoning when using non-edible decorative products in homemade and commercially prepared baked goods.
Euglycemic Diabetic Ketoacidosis Precipitated by SGLT-2 Inhibitor Use, Pericarditis, and Fasting: A Case Report
Introduction: Diabetic ketoacidosis (DKA) is a potentially life-threatening complication of diabetes mellitus. Less prevalent is euglycemic DKA (eDKA)—DKA with serum glucose less than 200 mg/dL; however, it is increasing in frequency with the introduction of sodium glucose cotransporter 2 (SGLT-2) inhibitors for treatment of type 2 diabetes.
Case Report: We report a case of SGLT-2 inhibitor-associated eDKA presenting with concurrent acute pericarditis.
Discussion: Our case suggests that the cause of eDKA can be multifactorial when decreased oral intake occurs in the setting of an acute cause of physiologic stress.
Conclusion: Prompt recognition of eDKA in the emergency department may allow earlier diagnosis and treatment directed at one or more of its underlying causes.
Acute Acalculous Cholecystitis from Infection with Epstein–Barr Virus in a Previously Healthy Child: A Case Report
Background: Acute cholecystitis is the acute inflammation of the gallbladder. In adults it is most frequently caused by a gallstone(s) obstructing outflow from the cystic duct, leading to gallbladder distention and edema with eventual development of biliary stasis and bacterial overgrowth, often requiring operative management. However, in children acalculous cholecystitis is more common and is often the result of an infectious process.
Case Report: Here we present a case of acute acalculous cholecystitis caused by infection with Epstein-Barr virus in an otherwise healthy three-year-old male.
Conclusion: Acalculous cholecystitis is an uncommon but potentially significant complication of Epstein-Barr virus infection in the pediatric population. Emergency providers should consider this diagnosis in any child being evaluated for EBV with the complaint of abdominal pain.
Introduction: Pneumocephalus (PNC) is most commonly associated with trauma or intracranial surgery, less commonly secondary to an infectious source, and is rarely caused by barotrauma.
Case report: A 32-year-old woman presented to the emergency department with complaint of resolved left-sided facial droop and a lingering paresthesia of her left upper extremity after a cross-country flight. Computed tomography demonstrated several foci of air in the subdural space consistent with PNC.
Conclusion: For PNC to occur there must be a persistent negative intracranial pressure gradient, with or without an extracranial pressure change. In this case the pressure change occurred due to cabin pressure.
Respiratory Failure Due to a Large Mediastinal Mass in a 4-year-old Female with Blast Cell Crisis: A Case Report
Introduction: Symptomatic leukostasis is an exceptionally atypical presentation of blast crisis; and when coupled with an enlarged neoplastic mediastinal mass in a four-year-old female, an extremely rare and challenging pediatric emergency arises.
Case Report: We present a unique case of a four-year-old female who arrived via emergency medical services in cardiopulmonary arrest with clinical and radiographic evidence suggestive of bilateral pneumothoraces, prompting bilateral chest tube placement. Further evaluation revealed a large mediastinal mass and a concurrent white blood cell count of 428,400 per milliliter (/mL) (4,400-12,900/mL), with a 96% blast differential, consistent with complications of T-cell acute lymphoblastic leukemia.
Conclusion: This case highlights how pulmonary capillary hypoperfusion secondary to leukostasis, coupled with a ventilation/perfusion mismatch due to compression atelectasis by an enlarged thymus, resulted in this patient’s respiratory arrest. Furthermore, the case highlights how mediastinal masses in pediatric patients present potential diagnostic challenges for which ultrasound may prove beneficial.
Introduction: The iliopsoas muscle is a rare place for an abscess to collect. While these abscesses can have high mortality, they are often misdiagnosed. The use of point-of-care ultrasound (POCUS) can aid in earlier diagnosis.
Case Report: A 45-year-old male presented to the emergency department (ED) with severe lower back pain. The pain radiated to both of his legs and was associated with fever, weight loss, and malaise. The differential diagnosis for this patient was broad. A POCUS was performed at the bedside and revealed bilateral iliopsoas abscesses. This finding was then confirmed by computed tomography.
Conclusion: In this case report we will discuss how to identify an iliopsoas abscess using POCUS in ED patients, and the utility of POCUS to facilitate an expedited diagnosis.
A Case Report: Point-of-care Ultrasound in the Diagnosis of Post-Myocardial Infarction Ventricular Septal Rupture
Introduction: Ventricular septal rupture (VSR) is a rare complication of ST-elevation myocardial infarction (STEMI), typically discovered post-revascularization.
Case report: We present the first case of VSR detected on point-of-care ultrasound (POCUS) in the emergency department immediately prior to emergent angiography, with management positively affected by this discovery. The VSR was quickly confirmed via right heart catheterization. Subsequently, hemodynamic stability was achieved using an intra-aortic balloon pump. A delayed surgical VSR repair, with concomitant coronary artery bypass grafting, was implemented for definitive management.
Conclusion: This case highlights the utility of POCUS in a STEMI patient with a suspected mechanical complication.
- 1 supplemental video
Introduction: A thyroglossal duct cyst (TGDC) is a congenital malformation in the neck. Surgical management is often recommended due to risk of recurrent infections and rare possibility of malignancy.
Case Report: Herein, we describe the case of an adult presenting with tender neck mass and fever. She had a history of previous surgical excision of her TGDC as a child. On evaluation she was found to have a recurrent TGDC complicated by acute infection via computed tomography imaging.
Conclusion: In patients who have had previous surgical intervention to remove a TGDC, recurrence with infection should remain a diagnostic consideration.
Introduction: Abdominal pain is a common chief complaint that can represent a wide breadth of diagnoses, ranging from benign to life-threatening. As our diagnostic tools become more sophisticated, we are able to better identify more causes of potentially life-threatening diseases. One such disease that is relatively unfamiliar to clinicians is spontaneous isolated celiac artery dissection (SICAD).
Case Report: We describe a case of a 46-year-old man who presented to our emergency department with a chief complaint of abdominal pain and was found to have a SICAD and was successfully treated with anticoagulation, antihypertensives, and observation.
Conclusion: It is important for emergency physicians to keep this potentially life-threatening condition in mind and to know the appropriate first steps once identified.
Spinal Arteriovenous Fistula, A Manifestation of Hereditary Hemorrhagic Telangiectasia: A Case Report
Introduction: Hereditary hemorrhagic telangiectasia (HHT) is an autosomal dominant disorder characterized by arteriovenous malformations (AVM). HHT can have neurological manifestations.
Case Report: A 32-year-old woman with a history of HHT presented to the emergency department with acute partial paralysis of the right leg, urinary retention, and right-sided back and hip pain. Magnetic resonance imaging of the spine demonstrated multiple, dilated blood vessels along the cervical spine, diffuse AVMs in the lumbar and thoracic spine, and a new arteriovenous fistula at the twelfth thoracic (T12) vertebral level. Her symptoms improved after endovascular embolization of the fistula.
Conclusion: Spinal AVMs are thought to be more prevalent in patients with HHT. Given the high morbidity of arteriovenous fistulas, early recognition and intervention are critical.
Tranexamic Acid in a Case Report of Life-threatening Nontraumatic Hemorrhage in Immune Thrombocytopenic Purpura
Introduction: Immune thrombocytopenic purpura (ITP) is an autoimmune-mediated disorder in which the body produces antibodies that destroy platelets, causing an increased risk of bleeding and bruising. Tranexamic acid (TXA) is a medication that prevents clot breakdown and is used to treat uncontrolled bleeding.
Case Report: We present the case of an 11-year-old female with significant epistaxis and hypotension in the emergency department. Traditional therapies were initiated; however, the patient continued to have bleeding and remained hypotensive, so intravenous TXA was given. The patient’s bleeding then resolved.
Conclusion: TXA may be a safe and effective adjunct to traditional therapies for the treatment of life-threatening hemorrhage in ITP patients.
Point-of-care Echocardiogram as the Key to Rapid Diagnosis of a Unique Presentation of Dyspnea: A Case Report
Introduction: Dyspnea is commonly evaluated in the emergency department (ED).The differential diagnosis is broad. Due to the large volume of dyspneic patients evaluated, emergency physicians (EP) will encounter uncommon diagnoses. Early, liberal application of point-of-care ultrasound (POCUS) may decrease diagnostic error and improve care for these patients.
Case Report: We report a 48-year-old male presenting to the ED with cough and progressively worsening dyspnea for 11 months after multiple healthcare visits. Using POCUS, the EP was immediately able to diagnose a severe dilated cardiomyopathy (DCM) with left ventricular thrombus.
Conclusion: Given that non-ischemic DCM is one of the most common etiologies of heart failure, often presenting with respiratory symptoms, POCUS is key to rapid diagnosis and, along with modalities such as electrocardiography and chest radiograph, should be standard practice in the workup of dyspnea, regardless of age or comorbidities.
- 1 supplemental video
Introduction: We present the case of a patient with a spontaneous cervical epidural hematoma that presented with neck pain and mild, left arm parasthesia.
Case Report: A 59-year old man presented with sudden onset of severe neck pain, without history of injury or trauma. The patient also complained of associated left arm parasthesias that progressed to left arm and leg weakness while in the emergency department. Multiple diagnoses were considered and worked up; eventually the correct diagnosis was made with magnetic resonance imaging of the cervical spine.
Conclusion: Spontaneous cervical epidural hematoma typically presents with neck pain, and variable neurologic complaints. This case illustrates the challenge in making this uncommon but serious diagnosis.
Atypical Cause of Sepsis from Bilateral Iliopsoas Abscesses Seeded from Self-mutilation: A Case Report
Introduction: An iliopsoas abscess (IPA) is an abscess located adjacent to the iliopsoas and iliacus muscles. Although rare, their variable clinical presentations often lead to a delay in diagnosis.
Case report: We present a case of sepsis secondary to multiple IPAs that was missed despite multiple healthcare encounters. The patient had no classical risk factors for an IPA, and the abscesses were found to be seeded via hematogenous spread from self-inflicted cutting.
Conclusion: This case illustrates the importance of obtaining a complete history, including psychiatric screen, and performing a thorough examination when evaluating patients with low back pain to rule out overlooked sources of bacteremia.
Introduction: It is possible but rare for a pelvic coil to migrate to the pulmonary vasculature, which can cause cardiac damage, arrhythmias, pulmonary infarct, and thrombophlebitis. The few cases reported typically do not describe removal of the coils, as patients were asymptomatic.
Case report: A 39-year-old female with recent coil embolization of her left internal iliac and ovarian veins for pelvic congestion syndrome presented with one month of right-sided chest pain and dyspnea. Imaging revealed a migrated pelvic coil in the patient’s right main pulmonary artery with pulmonary infarcts and a pleural effusion.
Conclusion: Interventional radiology successfully removed the coil endovascularly, with significant symptom improvement. This prevented a more-invasive open surgical procedure and resolved symptoms without requiring long-term anticoagulation or monitoring.
Introduction: Abdominal pain is a common complaint seen in the emergency department (ED). We report a case of celiac artery aneurysm (CAA) in a male patient presenting with abdominal pain to the ED on two separate occasions, approximately 24 hours apart.
Case Report: On the initial visit the patient was discharged with undifferentiated abdominal pain after computed tomography imaging and laboratory investigations. On the repeat visit he was found to have a rapidly expanding CAA with rupture. He became unstable requiring intubation, blood transfusions, and emergent transfer to a tertiary care center for surgical management where, unfortunately, he died hours after failed operative management.
Conclusion: Although rare, abdominal pain caused by CAAs can rapidly progress to rupture and have a high mortality.
Introduction: Post-tonsillectomy hemorrhage is a potentially life-threatening, postoperative complication that is commonly encountered in the emergency department (ED).
Case Report: Herein, we describe the case of a 22-year-old male who presented to the ED with an active post-tonsillectomy hemorrhage. He rapidly became hypotensive and experienced an episode of syncope. Immediate interventions included intravenous fluids, emergency release blood and nebulized tranexamic acid (TXA). After completion of the nebulized TXA, the patient’s bleeding was controlled.
Conclusion: To our knowledge, this is the first case in the emergency medicine literature that describes the use of nebulized TXA in an adult to achieve hemostasis in post-tonsillectomy hemorrhage.
Introduction: Vision loss is an ophthalmologic emergency with broad differential requiring prompt medical attention.
Case Report: We describe a 55-year-old male presenting to the emergency department (ED) with unilateral, painless visual field deficit with ipsilateral conjunctivitis induced by a presumed foreign body. The patient described a foreign body sensation nine days prior to developing visual changes. In the ED, the patient was diagnosed with a retinal detachment using point-of-care ultrasonography, and emergent ophthalmologic consultation was obtained.
Conclusion: Concurrent retinal detachment and conjunctivitis in a patient is extremely rare. Healthcare providers should be aware that foreign body-induced conjunctivitis could lead to retinal detachment.
Introduction: Rectal foreign bodies (RFB) pose a challenge to emergency physicians. Patients are not often forthcoming, which can lead to delays to intervention. Thus, RFBs require a heightened clinical suspicion. In the emergency department (ED), extraction may require creative methods to prevent need for surgical intervention.
Case Report: The authors present a case of a successful extraction of a RFB in the ED and review of the literature.
Conclusion: Retained RFBs are an unusually problematic reason for an ED visit. Thus, it is important for emergency physicians to be comfortable managing such cases appropriately.
Introduction: Lemierre syndrome is a rare, potentially fatal, septic thrombophlebitis of the internal jugular vein. Treatment includes intravenous antibiotics for Fusobacterium necrophorum, the most common pathogen, as well as consideration for anticoagulation therapy.
Case Report: A 27-year-old female presented with left-sided neck swelling and erythema. Computed tomography noted left anterior jugular vein thrombophlebitis and multiple cavitating foci, consistent with septic emboli. We report a rare case of Lemierre syndrome in which the thrombus was found in the anterior jugular vein, as opposed to the much larger internal jugular vein more traditionally associated with creating septic emboli.
Conclusion: Based on an individual’s clinical symptoms, history, and radiologic findings, it is important for physicians to consider Lemierre syndrome in the differential diagnosis, as the condition may rapidly progress to septic shock and death if not treated promptly. The use of anticoagulation therapy remains controversial, and there is a lack of established standard care because the syndrome is so rare.
Images in Emergency Medicine
Case Presentation: We describe an elderly male presenting to the emergency department with shortness of breath that progressed to hypoxic respiratory failure. Radiography and computed tomography findings were suggestive of coronavirus disease 2019 (COVID-19).
Discussion: We review the clinical presentation of COVID-19 and its complications. We also describe the characteristic presentation of COVID-19 on imaging. Our case illustrates the hallmark findings of bilateral and peripheral ground-glass opacities of COVID-19.
Introduction: Coronavirus disease 2019 (COVID-19) is caused by severe acute respiratory syndrome coronavirus 2. COVID-19 first occurred in Wuhan, China, in December 2019, and by March 2020 COVID-19 was declared a global pandemic.
Case Presentation: We describe a case of a 52-year-old female with past medical history of asthma, type 2 diabetes, and previous tobacco use who presented to the emergency department with dyspnea and was found to be positive for COVID-19. We discuss the computed tomographic finding of “crazy-paving” pattern in the patient’s lungs and the significance of this finding in COVID-19 patients.
Discussion: Emergency providers need to be aware of the different imaging characteristics of various stages of COVID-19 to appropriately treat, isolate, and determine disposition of COVID-19 infected patients. Ground-glass opacities are the earliest and most common imaging finding for COVID-19. Crazy-paving pattern is defined as thickened interlobular septa and intralobular lines superimposed on diffuse ground-glass opacities and should be recognized by emergency providers as a radiographic finding of progressive COVID-19.
Case Presentation: A 48-year-old male who presented with signs and symptoms suggestive of an upper respiratory infection was seen at an urgent care, he had a negative chest radiograph and was discharged. With no other cases of coronavirus disease 2019 (COVID-19) in the state, the patient presented to the emergency department two days later with worsening shortness of breath.
Discussion: There are a variety of findings on both chest radiograph and computed tomography of the chest that suggests COVID-19.
Background: Pulmonary artery dissection is a rare condition that is usually diagnosed in patients exhibiting chronic pulmonary arterial hypertension, congenital heart abnormalities or secondary to iatrogenic injury. Diagnosis is often made at autopsy as many patients experience sudden death when the pulmonary artery dissection progresses rapidly and ruptures into the pericardium, resulting in acute cardiac tamponade.
Case Presentation: We report a case of pulmonary artery dissection, which resulted from blunt thoracic trauma diagnosed in the emergency department.
Case Presentation: A 30-year-old healthy male presented with a complaint of chest pain after mild thoracic trauma sustained while rescuing stranded flood victims during Hurricane Harvey. Careful physical examination revealed a tender palpable cord along the lateral aspect of his chest consistent with a superficial thrombophlebitis.
Discussion: Mondor’s disease is a superficial thrombophlebitis with myriad underlying causes that can involve the thoracic wall. Although Mondor’s disease has been well described in the literature, this case describes a unique presentation in an austere environment with blunt trauma as the underlying cause.
Case Presentation: A 55-year-old woman with a history of end-stage renal disease, peripheral vascular disease, and multiple prior abdominal surgeries presented to the emergency department with three days of diffuse, severe, abdominal pain with accompanying nausea, emesis, and food intolerance. A computed tomography (CT) of her abdomen demonstrated a “whirl” of small bowel and mesenteric vessels, raising suspicion for mesenteric volvulus and resultant small bowel obstruction.
Discussion: Mesenteric volvulus is a low incidence, high mortality condition; therefore, early recognition and operative intervention are critical. Patients with a “whirl sign” on CT are more likely to require surgical intervention for their small bowel obstruction.
- 1 supplemental video
Keratolysis Associated with Methamphetamine Use – Incidental Diagnosis of Corneal Melt in a Patient with Acute Methamphetamine Intoxication
Case Presentation: A 38-year-old male presented to the emergency department with methamphetamine-induced agitation. Physical exam showed clouding of the left cornea, with gelatinous appearance and associated conjunctivitis, consistent with corneal melt, or keratolysis.
Discussion: Keratolysis is dissolution of the corneal stroma that can lead to corneal ulceration and vision loss. Smoking stimulants has been shown to be associated with this pattern of ocular injury, although this is a relatively rare presentation. Acute keratolysis is a unique complication of methamphetamine preparation and ingestion via smoking that can lead to corneal ulceration and loss of vision.
Case Presentation: A 70-year-old male with prior aorta endovascular aneurysm repair presented with progressive lower extremity weakness over the course of several hours. There was noted loss of palpable bilateral femoral pulses in the emergency department. Computed tomography angiography revealed a kinked and occluded aortic endograft. He subsequently underwent successful axillobifemoral bypass revascularization.
Discussion: Kinking of endograft limbs and occlusion has been reported in a small percentage of patients. Bilateral leg ischemia due to aortic endograft occlusion is rare.
Case Presentation: We describe a case of an acute myocardial infarction with an atypical electrocardiogram showing a de Winter T-wave pattern suggesting the 100% proximal left anterior descending artery occlusion seen on emergent cardiac catheterization.
Discussion: Timely recognition of acute myocardial ischemia is paramount for emergency providers. As highlighted in this case, It is important to be mindful of atypical electrocardiogram findings, such as de Winter T-waves, which suggest acute myocardial ischemia.
Case Presentation: A 33-year-old gravid female was brought to the emergency department after she collapsed in the street. Point-of-care ultrasound showed free fluid in the abdomen and confirmed an intrauterine pregnancy. Surgical teams were consulted, and cross-sectional imaging revealed a spontaneously ruptured splenic artery aneurysm (SAA). The patient was taken expeditiously to the operating room for splenic artery ligation and subsequent splenectomy.
Discussion: Ruptured SAA in pregnant patients is associated with significant mortality for both mother and fetus. Maintaining a high index of suspicion in the correct population is crucial to avoid diagnostic errors and provide definitive care with operative repair.
Case Presentation: Approximately 94% of patients with Hirschsprung’s disease (HD) are diagnosed before the age of five. In our case, a young adult with years of constipation presented to the emergency department with significant abdominal distention. He was ultimately diagnosed with HD, which was identified using computed tomography (CT).
Discussion: In HD, we find defects in gastric motility due to improper gut colonization. Without childhood recognition, HD often leads to chronic constipation and failure to thrive in adulthood. CT is a key step in identifying this rare adult diagnosis that should be considered in all patients with a history of chronic constipation.
Case Presentation: We report a patient with the triad of diabetic ketoacidosis, hypertriglyceridemia, and acute pancreatitis associated with computed tomography hypoperfusion complex and adrenal hyperdensity on abdominal imaging – an association not previously reported in diabetic ketoacidosis.
Discussion: Presence of Computed tomography hypoperfusion complex with hyperdense ‘Tubelight adrenals’ in a patient with diabetic ketoacidosis is associated with poor prognosis and thus serves to guide clinicians towards early and aggressive management.
Use of Point-of-care Ultrasound for the Seizing Infant: An Adjunct for Detection of Abusive Head Trauma
Case Presentation: An eight-week-old infant presented to the emergency department in cardiac arrest. Return of spontaneous circulation was obtained and the patient subsequently began seizing. Point-of-care ultrasound of the anterior fontanelle revealed an extra-axial fluid collection consistent with subdural hematoma (SDH).
Discussion: Abusive head trauma is still frequently missed on initial presentation. In addition to validated screening clinical prediction rules, point-of-care cranial ultrasound can be used as a noninvasive adjunct for detection of SDH related to abusive head trauma in infants with an open fontanelle.
- 3 supplemental videos
Case Presentation: In this case, we demonstrate how a small radiolucency in the proximal humerus can progress to an even larger problem within a few months in a patient without follow-up. Our patient’s ultimate diagnosis was renal cell carcinoma with metastasis to the right proximal humerus, completely obliterating the affected bone.
Discussion: In many underserved communities, patients have limited access to medical care, particularly specialty care. These patients often present to the emergency department and are unable to acquire appropriate follow-up. This situation illustrates the social issues that our patients face every day affecting their access to healthcare and ultimately necessary medical treatment.
Case Presentation: Here we present the case of a previously healthy 67-year-old female with carotid artery dissection as a result of penetrating ear trauma.
Discussion: Carotid artery dissection can result from unusual mechanisms of injury and present without typical symptoms or exam findings. If left untreated, devastating neurologic sequela can occur. Physicians must have a low threshold to obtain vascular imaging to appropriately manage such cases.
Case Presentation: A 58-year-old female with history of hepatitis C virus presented to the emergency department with a bilateral skin eruption to her feet for one year. Following skin biopsy, the patient was diagnosed with Necrolytic acral erythema (NAE). She was treated with clobetasol ointment, zinc supplementation, and mupirocin, which resulted in improvement in her symptoms.
Discussion: NAE is a rash described as sharply demarcated, lichenified plaques on the dorsal foot and is a rare extra-hepatic manifestation of hepatitis C. This case details a patient with a skin eruption consistent with NAE.
Case Presentation: We present a case of a 59-year-old male who presented to the emergency department with left upper arm pain that started suddenly after lifting some plywood a few days prior. Point-of-care ultrasound (POCUS) was performed, which revealed a rupture of the long head of the biceps tendon.
Discussion: Biceps tendon rupture is a relatively rare occurrence; however, rupture of the long head is more common than the short head. Being competent in bedside musculoskeletal POCUS is important for the emergency physician and can help expedite care in cases such as the one presented here.
Case Presentation: A 63-year-old male with a past medical history of end stage renal disease presented to the emergency department with painful, lower-extremity necrotic ulcerations. Ultrasound and computed tomography imaging showed concerns for calcium deposits. Biopsy confirmed the diagnosis of calciphylaxis, a rare lethal disease.
Discussion: Emergency physicians should keep this disease on their differential due to the high mortality rate.
Case Presentation: We describe a case of spontaneous partial segmental thrombosis of the corpus cavernosum (PSTCC).
Discussion: PSTCC is a rare condition in which thrombus formation occurs in the corpus cavernosum. This condition is managed in conjunction with a urologist, and management typically includes anticoagulation and pain control.