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Articles that have been peer-reviewed and edited, but not yet assigned to an issue.

Case Report

The Case of the Lime-green Stool: A Case Report and Review of Occult Blood Testing in the Emergency Department

Introduction: Food dyes mimicking gastrointestinal (GI) hemorrhage have been described in literature. However, reports of food additives causing melanotic stools and falsely positive fecal occult blood tests (FOBT) are uncommon in literature.

Case Report: We present a case of a 93-year-old with FOBT positive melanotic stool, felt to be falsely positive due to food additives.

Conclusion: Evaluation for GI bleeding accounts for 0.3% of yearly visits to the emergency department (ED).1 While FOBT is commonly used, its clinical validity in the ED is not supported by guidelines. We showcase the limitations of the FOBT and review the causes of false positive FOBT.

Anchoring on COVID-19: A Case Report of Human Granulocytic Anaplasmosis Masquerading as COVID-19

Introduction: Human granulocytic anaplasmosis (HGA) is caused by Anaplasma phagocytophilum and transmitted through the deer tick. Most cases are mild and can be managed as an outpatient, but rare cases can produce severe symptoms.

Case Report: A 43-year-old male presented with severe respiratory distress mimicking coronavirus disease 2019 (COVID-19). Labs and imaging were consistent with COVID-19; however, polymerase chain reaction was negative twice. Peripheral smear revealed inclusion bodies consistent with HGA.

Conclusion: Human granulocytic anaplasmosis is an uncommon diagnosis and rarely causes severe disease. Recognition of unique presentations can aid in quicker diagnosis, especially when mimicking presentations frequently seen during the COVID-19 pandemic.

An Anomalous Cause of Deep Venous Thrombosis: A Case Report

Introduction: Lower extremity deep venous thrombosis (DVT) is a common diagnosis in the emergency department (ED). Deep venous thromboses can be the result of anatomical variation in the vasculature that predisposes the patient to thrombosis. May-Thurner syndrome (MTS) is one such anatomic variant defined by extrinsic compression of the left common iliac vein between the right common iliac artery and lumbar vertebrae.

Case Report: We report such a case of a 39-year-old woman with no risk factors for thromboembolic disease who presented to the ED with extensive unilateral leg swelling and was ultimately diagnosed with MTS.

Conclusion: This diagnosis is an important consideration particularly in patients who are young, female, have scoliosis or spinal abnormalities, or are at low risk for DVT yet who present with extensive lower extremity swelling and are found to have proximal thrombus burden. Often further imaging, anticoagulation, angioplasty, or thrombectomy are indicated to prevent morbidity and post-thrombotic syndrome in these patients.

ACOEP Clinicopathological Cases (Invitation Only)

48-year-old with Altered Mental Status and Respiratory Failure: A Case Report

Introduction: The differential diagnosis for altered mental status and respiratory failure is broad. Careful physical examination, appropriate use of diagnostic tools, and accurate interpretation and correlation of test results are important for piecing together the puzzle of a patient with altered mental status that emergency physicians commonly face. In certain cases, such as this one, rapid diagnosis and management is crucial for improving patient morbidity and mortality.

Case Presentation: A 48-year-old male with altered mental status and respiratory failure presented to the emergency department after being found unconscious on his porch. Vital signs were notable for temperature 105.5 °F, blood pressure 202/102 millimeters of mercury, pulse 126 beats per minute, respiratory rate 30 breaths per minute, and oxygen saturation 91% on room air. Physical examination revealed an obese male lying in bed awake in severe distress with labored breathing and unable to converse. His physical examination was significant for dry mucous membranes, tachycardia, and bilateral lower extremity 1+ pitting edema. He also appeared to have Kussmaul respirations with severe tachypnea, but his breath sounds were clear to auscultation bilaterally. On further examination, the patient appeared to have intravenous (IV) injection markings along his arms suggesting the possibility of IV drug use.

Discussion: With limited history, the only context clues initially available to assist in the diagnosis were abnormal vital signs and physical examination. The patient was tachycardic, hyperthermic, hypertensive, hypoxic, and tachypneic with altered mental status; he eventually required endotracheal intubation for hypoxic respiratory failure. The complexity of his condition prompted a large list for the differential diagnoses. Toxidromes, endocrine abnormalities, infectious process, cardiac and/or renal etiologies, and neurological pathology such as a cerebrovascular accident were considered. In the case of this patient, urgent diagnosis and management was crucial to prevent further decompensation and improve his outcome.

ACOEP Case Reports (Invitation Only)

Splenic Injury Following Colonoscopy: A Case Report

Introduction: Colonoscopy is a commonly performed outpatient procedure with a low risk of complications. The most common complications seen in the postoperative period include hemorrhage and perforation. Infrequently, splenic injury can occur.

Case Report: A 72-year-old male presented with a one-day history of left upper quadrant pain following colonoscopy. During the procedure he had two polyps removed along the transverse colon near the splenic flexure. There were no complications during the procedure or in the immediate post-operative period. On presentation to the emergency department, abdominal tenderness was present in the left upper quadrant without rebound, rigidity, or guarding. Point-of-care ultrasound of the abdomen demonstrated mixed hypoechoic densities confined to the splenic capsule, and computed tomography of the abdomen and pelvis with intravenous contrast noted a grade II/III splenic laceration without active extravasation. The patient was admitted for serial abdominal examination and labs.

Conclusion: Splenic injury following colonoscopy is a rare complication of colonoscopy. Emergency providers should be aware of this possible complication, and acute management should include basic trauma care and consultation for possible intervention, if warranted.