Volume 7, Issue 2, 2023
CPC-EM Full-Text Issue
Clinicopathological Cases from the University of Maryland
44-year-old Man with Hemoptysis and Hypoxemic Respiratory Failure: A Case Report
Introduction: Hemoptysis can be a highly alarming presentation in the emergency department (ED). Even seemingly minor cases may represent potentially lethal underlying pathology. It requires thorough evaluation and careful consideration of a broad differential diagnosis.
Case Presentation: A 44-year-old man presented to the ED with a concern of hemoptysis in the setting of recent fever and myalgias.
Discussion: This case takes the reader through how to approach the differential diagnosis and diagnostic work-up of hemoptysis in the ED setting and then reveals the surprising final diagnosis.
The Pectoralis Block: A Case Series of a Novel Modality for Acute Pain Control in the Emergency Department
Introduction: Regional anesthesia has long been used in a perioperative setting for the treatment of both pre- and postoperative pain. Recently, this skill has been brought into the emergency department (ED) as a modality for treating acute pain as the pendulum shifts away from an opiate-based armamentarium and toward a multimodal future. In this case series, we describe a way to use the pectoralis nerve block I and II in the treatment of pain with regard to breast abscesses and/or breast cellulitis managed in the ED.
Case Series: This paper describes three cases, all of which consist of a painful complaint in the thoracic region. The first was a patient diagnosed with a breast abscess. The second patient was diagnosed with breast cellulitis. Finally, the third patient was diagnosed with a large breast abscess that extended into the axilla. All three sustained immense relief with the pectoralis block.
Conclusion: While further research is needed on a larger scale, preliminary data suggests that the ultrasound-guided pectoralis nerve block is an effective and safe modality of acute pain control in regard to breast and axillary abscesses along with breast cellulitis.
A Cluster of Neuroinvasive Adenovirus Infections on a College Campus: Case Series
Introduction: We present six adenovirus cases that emerged from a cluster of respiratory illnesses within a college population. Two patients required intensive care with complicated hospital courses and experienced residual symptoms. Four additional patients were evaluated in the emergency department (ED) with two additional diagnoses of neuroinvasive disease. These cases represent the first known occurrences of neuroinvasive adenovirus infections in healthy adults.
Case Series: An individual presented to the ED with fever, altered mental status, and seizures after being found unresponsive in his apartment. His presentation was concerning for significant central nervous system pathology. Shortly after his arrival, a second individual presented with similar symptoms. Both required intubation and admission to a critical care setting. Over a 24-hour period, four additional individuals presented to the ED with moderate severity symptoms. All six individuals tested positive for adenovirus in their respiratory secretions. A provisional diagnosis of neuroinvasive adenovirus was made after consultation with infectious diseases.
Conclusion: This cluster of cases appears to represent the first known reported diagnosis of neuroinvasive adenovirus in healthy young individuals. Our cases were also unique in demonstrating a significant spectrum of disease severity. Over 80 individuals in the broader college community ultimately tested positive for adenovirus in respiratory samples. As respiratory viruses continue to challenge our healthcare systems, new spectrums of disease are being discovered. We believe clinicians should be aware of the potential severity of neuroinvasive adenovirus disease.
Myocardial Bridge of the Left Anterior Descending Artery Causing Pseudo-Wellens’ Syndrome: A Report of Two Cases
Introduction: Wellens’ syndrome represents an important, at times overlooked, spectrum of left anterior descending (LAD) coronary artery occlusion, spontaneous reperfusion, and impending reocclusion. Once considered pathognomonic for a thromboembolic coronary event, an increasing number of clinical scenarios have been demonstrated to result in pseudo-Wellens’ syndrome, each requiring unique forms of assessment and management.
Case Report: We describe two clinical presentations in which myocardial bridging (MB) of the LAD led to clinical and electrophysiologic presentations of a pseudo-Wellens’ syndrome.
Conclusion: These reports represent a rare cause of pseudo-Wellens’ syndrome attributed to MB of the LAD. Transient ischemia secondary to myocardial compression of the traversing LAD leads to intermittent angina and electrocardiogram changes that are typical in patients presenting with Wellens’ syndrome secondary to an occlusive coronary event. As with other previously reported pathophysiologic mechanisms that have been shown to mimic Wellens’ syndrome, myocardial bridging should be considered in patients presenting with a pseudo-Wellens’ syndrome.
Bilateral Infectious Extensor Tenosynovitis: A Case Report
Introduction: Infectious extensor tenosynovitis is a rare infection spreading along the extensor tendons of the extremities. It presents a diagnostic challenge in the emergency department (ED) given the nonspecific signs and symptoms, as opposed to the more common flexor tenosynovitis that is diagnosed by the classic Kanavel signs on physical exam.
Case Report: Here we present a case of bilateral extensor tenosynovitis in a 52-year-old female denying past medical history who presented to the ED with two days of bilateral dorsal hand swelling and pain. She denied any risk factors such as direct trauma to the hands or intravenous drug use. The rare diagnosis was suspected in the ED due to a very high complement reactive protein level and a concerning point-of-care ultrasound. Extensor tenosynovitis was ultimately confirmed on computed tomography and by operative irrigation and drainage of the tendon sheaths.
Conclusion: This case demonstrates the importance of keeping extensor tenosynovitis on the differential when seeing a patient with dorsal extremity edema and pain, even if the findings occur bilaterally.
COVID-19-induced Acute Psychosis Resulting in a Suicide Attempt: A Case Report
Introduction: Psychosis associated with coronavirus disease 2019 (COVID-19) has been previously, but infrequently, reported in the literature. We present a rare case of COVID-19-associated severe psychosis and suicide attempt in an 80-year-old male with no personal or known family history of psychiatric disease. Our patient’s symptoms appeared to be longer lasting than most other reported cases in the available literature.
Case Report: After a COVID-19 diagnosis, our patient experienced fluctuating, long-lasting psychiatric symptoms over a six-month period. During this time, he was unable to function independently. Suggested mechanisms involve a multifactorial combination of neuroinflammation and increased societal stress due to the direct and indirect effects of the virus, respectively.
Conclusion: More research is needed to help identify risk factors, prognostic indicators, and a standard of care for psychosis associated with COVID-19.
Iatrogenic Rhinolith: A Case Report and Review of Literature
Introduction: Unilateral nasal obstruction is a common complaint with a broad differential diagnosis that includes anatomic asymmetry, unilateral infective or inflammatory conditions, and benign and malignant sinonasal masses. A rhinolith is an uncommon foreign body in the nose, which serves as a nidus for calcium salt deposition. The foreign body can be endogenous or exogenous in origin and may remain asymptomatic for many years before incidental discovery. When left untreated, stones may cause unilateral nasal obstruction, rhinorrhea, nasal discharge, epistaxis or, in rare cases, progressive destruction leading to septal/palatal perforation or oro-antral fistula. Surgical removal is an effective intervention with limited complications reported.
Case Report: This article describes a 34-year-old male who presented to the emergency department (ED) with unilateral obstructing nasal mass and epistaxis, which was found to be an iatrogenic rhinolith. Successful surgical removal was performed.
Conclusion: Epistaxis and nasal obstruction are common presentations to the ED. Rhinolith is an uncommon clinical etiology that if left undiagnosed may lead to progressive destructive disease; it should be included in the differential for any unilateral nasal symptoms of unclear origin. Appropriate work-up for any suspected rhinolith includes computed tomography, as biopsy is risky given the broad differential of unilateral nasal mass. When identified, surgical removal has a high success rate with limited complications reported.
Case Report of Malignant Hyperthermia in the Emergency Department
Introduction: Malignant hyperthermia (MH) is a rare but deadly condition that may be encountered in the emergency department (ED). This report highlights a case of a patient who initially presented for acute agitation with hypertension and tachycardia and provides explanation for how to manage MH.
Case Report: A 44-year-old male presented to the ED with altered mental status, eventually requiring intubation with etomidate and succinylcholine. Despite being afebrile initially, the patient developed a rectal temperature of 105.3° Fahrenheit (F) with significantly elevated arterial carbon dioxide levels after intubation. The treating team initiated cooling measures and dantrolene, leading to a positive outcome.
Conclusion: Clinicians should strive for expeditious recognition of MH and treatment with an updated institutional protocol.
A Case Report of a LVAD Driveline Infection Diagnosed by Point-of-care Ultrasound
Introduction: As the prevalence of patients with left ventricular assist devices (LVAD) presenting to the emergency department (ED) increases, clinicians must be aware of LVAD-associated infections.
Case Report: A well-appearing, 41-year-old male with history of heart failure status post prior-LVAD placement presented to the ED for swelling of his chest. What appeared initially as a superficial infection was further assessed with point-of-care ultrasound and found to represent a chest wall abscess involving the driveline, ultimately resulting in sternal osteomyelitis and bacteremia.
Conclusion: Point-of-care ultrasound should be considered an important tool in the initial assessment of potential LVAD-associated infection.
Droperidol in the Management of Phantom Limb Pain: Case Report
Introduction: Phantom limb pain (PLP) is a poorly understood phenomenon experienced by amputees. The pain is typically classified as neuropathic, and there is no established first-line therapy. Droperidol is an antipsychotic with a wide array of pharmacologic activity including gamma-aminobutyric acid-A channel modulation, μ opiate receptor potentiation, dopamine-2-receptor blockade, and alpha-2-receptor agonism. Due to this broad therapeutic activity, droperidol is used for many off-label indications.
Case Report: Our patient was a 25-year-old male with a history of lower limb amputation who presented for evaluation and management of an acute exacerbation of PLP. On arrival, the patient was in 10/10 pain (numeric pain rating scale) described as cramping and burning. He had been previously successfully managed with subdissociative ketamine. However, during a recent exacerbation he experienced an emergence reaction to ketamine. Literature guiding pharmacotherapy in the management of PLP is sparse and of low quality. Based on the prior emergence reaction to subdissociative ketamine we explored other pharmacotherapy options. Droperidol has a wide array of pharmacologic activity and is used off label for the management of some pain syndromes. Therefore, we administered an intravenous dose of droperidol 5 milligrams. Approximately 15 minutes after receiving droperidol the patient’s pain was visibly improved, and 30 minutes later he rated his pain at 3/10.
Conclusion: The success in treating this patient provides encouragement for future research and bolsters confidence that droperidol could be another tool in the management of complex pain syndromes.
Tension Pneumomediastinum and Coronary Artery Thrombosis Following a Motorcycle Accident: A Case Report
Introduction: Tension pneumomediastinum and coronary artery thrombosis (CAT) secondary to blunt polytrauma are, rare yet have the potential for serious complication.
Case Report: A 40-year-old man presented to the emergency department following a motorcycle accident. He was found to have multiple orthopedic injuries, pneumothorax, and pneumomediastinum. An electrocardiogram showed myocardial infarction. He developed obstructive shock physiology that resolved with mediastinal percutaneous needle drainage. Subsequent coronary angiography revealed acute thrombosis of the left circumflex artery.
Conclusion: This is a rare case of traumatic tension pneumomediastinum associated with coronary artery thrombosis requiring coronary stenting. Emergency physicians should be mindful of CAT in the setting of blunt chest injury.
Emergency-physician Performed, Ultrasound-guided Lateral Femoral Cutaneous Nerve Block for Meralgia Paresthetica: A Report of Two Cases
Introduction: Neuropathy of the lateral femoral cutaneous nerve, also known as meralgia paresthetica, causes pain and paresthesia to the anterolateral thigh. It commonly results from nerve irritation from extrinsic compression; however, it may occur spontaneously. Symptoms from this condition can be debilitating, and the pain may be ascribed to other conditions leading to delays in diagnosis. Peripheral nerve blockade can be useful both diagnostically and therapeutically for meralgia paresthetica.
Case Report: Two female patients in their sixties presented to the emergency department for chronic, atraumatic, left upper thigh pain. In both cases the patients had hyperalgesia and paresthesia to the anterolateral, upper thigh. The emergency physician performed an ultrasound-guided nerve block of the lateral femoral cutaneous nerve for each patient, which resulted in temporary, complete resolution of their pain.
Conclusion: Meralgia paresthetica is an uncommon but painful condition that can elude diagnosis. Physical exam findings such as allodynia and hyperalgesia of the anterolateral thigh in the absence of back pain is suggestive of the diagnosis. Utrasound-guided nerve blockade can be helpful to the emergency physician to confirm the diagnosis and provide non-opioid pain relief to the patient.
Diagnosing Atypical Flutter in the Post-atrial Fibrillation Ablation Patient: A Case Report
Introduction: Late atrial arrhythmias after catheter ablation for atrial fibrillation occur in up to 30 percent of post-ablation patients and are increasingly encountered by emergency physicians. However, diagnosing the exact mechanism of the arrhythmia on the surface electrocardiogram (ECG) remains challenging due to atrial scarring leading to heterogeneous P-wave morphology.
Case Report: A 74-year-old male with a history of prior catheter ablation for atrial fibrillation presented with palpitations and subacute symptoms of heart failure. The patient’s ECG revealed narrow complex tachycardia with more P waves than QRS complexes. The differential diagnosis included typical flutter, atypical flutter, and focal atrial tachycardias with 2:1 conduction block. P waves were positive in V1 and across all precordial leads (absent precordial transition). This favors atypical flutter originating from the left atrium over typical cavotricuspid isthmus-dependent right atrial flutter. Transthoracic echocardiogram showed a reduced ejection fraction due to tachycardia-mediated cardiomyopathy. The patient underwent a repeat electrophysiology study and ablation, which confirmed the presence of an atypical flutter circuit using the mitral annulus, known as perimitral flutter. Repeat catheter ablation resulted in maintenance of sinus rhythm. At follow-up, his ejection fraction recovered.
Conclusion: Recognizing ECG findings suggestive of atypical flutter impacts initial emergency department decisions and triage as atypical flutter post-atrial fibrillation ablation is frequently resistant to rate-controlling medications and often requires cardiology and/or electrophysiology consultation if available.
Implanted Penile Prosthetic Visualized During Focused Assessment with Sonography for Trauma Examination: A Case Report
Introduction: This is a case report of an implanted penile prosthetic visualized during focused assessment with sonography for trauma (FAST) examination. The case represents a unique finding near the lateral bladder that may confound assessment of intraperitoneal fluid collections during initial assessment of trauma patients.
Case Report: A 61-year-old Black male was brought to the emergency department from a nursing facility for evaluation after sustaining a ground-level fall. A FAST exam demonstrated an abnormal fluid collection anterior and lateral to the bladder, later identified as an implanted penile prosthetic.
Conclusion: Focused assessment with sonography for trauma examinations are often performed on unidentified patients in a time-sensitive manner. Understanding of potential false-positive results is crucial to appropriate use of the tool. This report demonstrates a novel false-positive result that may be difficult to differentiate from a true intraperitoneal bleed.
Images in Emergency Medicine
Benign Episodic Mydriasis as a Cause of Isolated Anisocoria
Case Presentation: A 22-year-old female presented to the emergency department with a dilated right pupil and mild blurry vision. Physical examination revealed a dilated, sluggishly reactive right pupil, without other ophthalmic or neurologic abnormalities. Neuroimaging was normal. The patient was diagnosed with unilateral benign episodic mydriasis (BEM).
Discussion: BEM is a rare cause of acute anisocoria with an underlying pathophysiology that is not well understood. The condition has a female predominance and is associated with a personal or family history of migraine headaches. It is a harmless entity that resolves without intervention and results in no known permanent damage to the eye or visual system. Benign episodic mydriasis is a diagnosis of exclusion that may be considered only after the life- and eyesight-threatening causes of anisocoria.
Point-of-care Ultrasound Identification of Hepatic Abscess in the Emergency Department
Case Presentation: A 92-year-old female with past medical history of hypertension presented to the emergency department with pain in her right shoulder, right flank, and right upper quadrant of her abdomen. Point-of-care ultrasound (POCUS) and computed tomography imaging showed concerns for multiple large hepatic abscesses. Percutaneous drainage removed 240 milliliters of purulent fluid that identified Fusobacterium nucleatum, a rare cause of pyogenic liver abscess.
Discussion: Emergency physicians should keep hepatic abscess on their differential for right upper quadrant abdominal pain and can use POCUS for expeditious diagnosis.
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