Articles in Press
Articles in Press
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.
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.
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.
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: 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.
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.
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.
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.
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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.
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.
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.
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.
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.
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
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.
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.
Images in Emergency Medicine
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.
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 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.
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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.
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.