Volume 1, Issue 1, 2017
Clinicopathological Cases from the University of Maryland
Sleep-Associated Torsades de Pointes: A Case Report
Torsades de Pointes (TdP) is a polymorphic ventricular tachycardia that occurs in the presence of anacquired or congenital long QT syndrome (LQTS). We present the case of a 57 year-old man withend-stage renal disease on methadone maintenance in which there occurred multiple episodes of TdPduring sleep. The patient was found to have a QTc interval of 548 milliseconds, and the dysrhythmiawas successfully treated with isoproterenol infusion and methadone substitution. It is surmised that thepatient had a multifactorial, acquired LQTS that during somnolence, reached a critical threshold of QTprolongation to lead to the development of TdP.
Weber B Distal Fibular Fracture Diagnosed by Point-of-care Ultrasound
We report the case of a 45-year-old woman who presented to the emergency department (ED)after an acute ankle inversion injury. After history and physical exam suggested a potential fracture,point- of-care ultrasound (POCUS) demonstrated a cortical defect of the distal fibula, consistentwith fracture. Plain radiography failed to demonstrate a fracture. Later, the fracture was identifiedas a Weber B distal fibular fracture by stress-view radiography. This case reviews the evaluation ofacute ankle injuries in the ED and the utility of POCUS as a supplemental imaging modality in theevaluation of ankle fracture.
The Neurocardiogenic Spectrum in Subarachnoid Hemorrhage: A Case Report and Review of the Literature
A 36-year-old man was brought to our emergency department after successful resuscitation ofout-of-hospital cardiac arrest with the whole spectrum of neurocardiogenic effects in subarachnoidhemorrhage: electrocardiographic changes, regional wall motion abnormalities, and elevationsof cardiac enzymes. Coronary angiography revealed normal coronary arteries but showed themidventricular type of Takotsubo cardiomyopathy in the left ventriculography. Subsequently, cerebralcomputed tomography revealed diffuse subarachnoid hemorrhage and generalized cerebraledema with brain herniation. Brain death was diagnosed. This case highlights the possibility of anacute cerebral illness (especially subarachnoid hemorrhage) as an underlying cause of cardiacabnormalities mimicking myocardial ischemia.
Pasteurella multocida Epiglottitis
Epiglottitis is an uncommon but life-threatening disease. While the most common infectious causesare the typical respiratory pathogens, Pasteurella multocida is a rare causative organism. Wepresent a case of P. multocida epiglottitis diagnosed by blood culture. The patient required intubationbut was successfully treated medically. P. multocida is a rare cause of epiglottitis; this is the ninthreported case in the literature. Most diagnoses are made from blood culture and patients usuallyhave an exposure to animals.
Spontaneous Bilateral Internal Carotid Artery Dissections in a Young Female with Headache
BACKGROUND: Spontaneous cervical artery dissection (sCAD) occurs when the intimal lining separates from the outer wall of the artery. Although rare, it is a common cause of stroke in young people. Presentations range from isolated headache to severe stroke symptoms.
CASE REPORT: A 41-year-old woman with minimal past medical history presented with left-sided headache and transient right leg weakness and numbness. The patient underwent CT angiography of the neck that showed bilateral internal carotid artery dissections with a relative stenosis from pseudoaneurysm formation on the left. She was placed on a heparin drip and transitioned to warfarin but subsequently required stent placement ten days later. If this patient had not undergone CT angiography at the time of presentation, she may have suffered significant morbidity and possible mortality.
Salmonella Urinary Tract Infection Heralding Thoracic Mycotic Aneurysm: Case Report as Medical Apology
We report a case as a patient apology as a means of teaching other physicians about a unique presentation of a rare disease. Salmonella species are unusually isolated organisms in urine. In the case described, appreciation for the rarity of Salmonella species in the urine facilitated recognition of a serious disseminated Salmonella infection. Physicians should consider disseminated Salmonella infection, as was found in a patient with an aortic mycotic aneurysm, after isolation of Salmonella in urine despite an initially benign clinical presentation.
Traumatic Pneumothorax Following Acupuncture: A Case Series
Acupuncture and dry needling are used by a range of health professionals to treat conditions such as musculoskeletal pain. Treatment occurs both in an outpatient setting and in emergency departments (EDs). Acupuncture and dry needling are considered to be relatively safe techniques with a low risk of serious adverse events. We report three cases of traumatic pneumothorax following acupuncture/dry needling that presented to our ED between 2014 and 2016.
A Case of Severe Accidental Hypothermia Successfully Treated with Cardiopulmonary Bypass
After missing for 7 days a 34 year-old female was found with a rectal temperature of 19.8oC. Instead of attempting aggressive rewarming in the emergency department she was directly transferred to the operating room for extracorporeal rewarming. She received cardiopulmonary bypass (CPB) for 66 minutes at an initial warming rate of 12oC/ hour and warmed to 36.2oC. Her post-op course was complicated by sepsis, which eventually led to bilateral below-knee amputations after refusing antibiotics. She was discharged 22 days after admission, with full neurologic recovery. This remarkable case highlights the emerging role of CPB as the definitive therapy for severe accidental hypothermia.
Cervical Ectopic Pregnancy in a 23 Year Old with Uterus Didelphys
Ectopic pregnancy remains an important diagnosis for the emergency physician to recognize, accounting for up to 2% of all pregnancies and associated with significant morbidity and mortality. Ectopic pregnancies can implant in various sites outside of the uterus, one of the rarest of which is in the cervix. Cervical ectopics account for less than 1% of ectopic pregnancies, but are associated with higher rates of significant bleeding than others1-2.Uterine anomalies are a predisposing factor for ectopic pregnancies. This case highlights the emergency room management of cervical ectopic pregnancy in a 23 year old with a history of uterine didelphys.
Methadone-induced Torsades de Pointes Masquerading as Seizures
The authors herein present the case of a 53-year-old female who was being treated, as an outpatient, for seizure disorder but was also receiving high dose Methadone therapy. She presented to the Emergency Department for what appeared to be a seizure and was found to have a prolonged QTc interval as well as runs of paroxysmal polymorphic ventricular tachycardia with seizure-like activity occurring during the arrhythmia. The markedly prolonged QTc interval corrected after treatment with intravenous magnesium, and subsequent EEG, neurologyand cardiology consultations revealed the cause of the recurrent seizure-like episodes to be secondary to the cardiotoxic effects of methadone.
Valentino’s Syndrome: A Life-Threatening Mimic of Acute Appendicitis
Perforated ulcers are a rare cause of abdominal pain, and may not be considered when pain is localized to the right lower quadrant (RLQ). This case highlights an unusual presentation of a perforated duodenal ulcer that presented with RLQ pain, which has been described as Valentino’s Syndrome. Valentino’s Syndrome occurs when gastric or duodenal fluids collect in the right paracolic gutter causing focal peritonitis and RLQ pain. This case highlights that perforated ulcers, while an uncommon cause of RLQ pain, must remain on the differential of any patient that has an abdominal examination consistent with peritonitis.
Remote South American Snakebite with Extensive Myonecrosis
This report describes a patient envenomated by a Brothrops atrox, common fer-de-lance viper, in the remote rainforest of eastern Ecuador and without access to definitive care for 7 days. Antivenom was not administered; by the time of presentation to a hospital, he had suffered myonecrosis of his lower leg, which was treated with debridement and eventual skin graft. The ramifications of this long evacuation demonstrate the need for more accessible health services and educational outreach.
Acute Portal Vein Thrombosis Diagnosed with Point-of-care Ultrasonography
Abdominal pain is the most common presenting complaint to the Emergency Department, however acute portal vein thrombosis is an uncommon cause of abdominal pian in the Emergency Department. In the following case report, we present a patient who presented to the Emergency Department with symptoms of gastroenteritis but was ultimately diagnosed with acute portal vein thrombosis by bedside emergency ultrasound.
Progressive Disordered Movements in an Infant Leads to Rare Diagnosis
Infantile desmoplastic ganglioglioma is a supratentorial superficially located cystic neuroepithelial tumor. It is an exceedingly rare tumor with an incidence of <0.1% of central nervous tumor and approximately 60 cases reported in the literature. We present a case of a 3-month-old infant with progressive disordered movements described as intermittent upper body stiffening with associated eye blinking, drooling, and change in level of alertness. A seizure was witnessed in the emergency department after which, the child was sent for imaging studies. Magnetic resonance imaging revealed a large solid and cystic mass in the temporal region measuring 8.6cm x 7.9cm x 5.1cm. The infant underwent complete surgical resection and post-surgical pathology revealed a diagnosis of infantile desmoplastic ganglioglioma. The patient had an excellent post-operative course in the months following discharge. At his last well child visit, no neurological deficits were appreciated and the infant was meeting expected milestones for his age.
Fecal Impaction with Multisystem Organ Involvement
Fecal impactions are a common complaint in the emergency department population. The potential for significant derangement in physiologic processes of other organ systems is often underappreciated.
A 19 year-old male, previously healthy, presented to the emergency department at our institution with complaint of abdominal pain which was found to be secondary to severe fecal impaction. In the search for alternative diagnoses, imaging was performed which revealed effects on multiple other organ systems.
This case illustrates the secondary effects of a severe fecal impaction. The emergency physician must be aware of these consequences, as the opportunity to review labs and imaging is not often provided in the standard workup of these patients.
Images in Emergency Medicine
Massive Emphysematous Pyelonephritis
Our case presents an image of a condition that is rare and particularly severe, as shown by free air not only in the right renal parenchyma, but also extending outside the capsule, around the renal vasculature, and into the left perirenal space.
Traumatic Right Ventricular Rupture after Blunt Cardiac Injury: CT Diagnosis after False Negative Pericardial Window on FAST Due to Concomitant Pericardial Rupture
Blunt cardiac injury encompasses multiple injuries, including contusion, acute valvular disorders, and chamber rupture.Blunt traumatic cardiac rupture is a very rare occurrence accounting for 0.5% of blunt trauma cases with a very high mortality rate.Coexisting pericardial rupture in patients with cardiac rupture obscures the diagnosis and contributes to mortality.False negative pericardial ultrasound secondary to a concomitant pericardial laceration and subsequent decompression of the cardiac hemorrhage into the ipsilateral pleural space is extremely rare and has only been recently described in the literature.This image depicts a case of traumatic right ventrictular rupture from blunt cardiac injury and highlights the importance of considering an underlying cardiac injury in the presence of a negative FAST pericardial window in patients with a traumatic hemothorax.
Orbital Trapdoor Fracture: An Open-and-shut Case?
The authors present a case of orbital trapdoor fracture with entrapment in an adult patient along with brief summary of the literature.
The Daughter Cyst
The daughter cyst is a benign simple cyst within a cyst that is radiographically difficult to distinguish from ectopic pregnancy and must be differentiated in any woman with the potential to become pregnant. The following case report details how the clinicians discovered, diagnosed, and managed this finding. This structure is of particular clinical importance in the field of emergency medicine, as it can be easily misdiagnosed as a potential surgical emergency.
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Point-of-care Ultrasound in Pregnancy: Think Congenital Zika Virus
Starting in 2015, microcephaly associated with Zika virus emerged as a public health emergency of international concern. Initial cases in the United States were travel-associated, however, there are increasing reports of local transmission in pockets of the country and therefore public concerns may escalate.1 Emergency physicians commonly perform point-of-care ultrasound on pregnant patients, a population of special concern. This paper describes ultrasound findings typical of Zika-related congenital malformations that may be incidental findings or detected when examining exposed or concerned patients. These discoveries should alert emergency physicians to provide urgent referral for confirmatory studies and counseling.
CPC-EM Full-Text Issue
Erratum (Staff Only)
A Case of COVID-19 Causing Croup
Introduction: Viral laryngotracheobronchitis, or croup, is a common respiratory illness in children that presents with a fever, barking cough, and stridor. The most common viral origin of croup are the parainfluenza viruses.
Case Presentation: Here, we present a case of croup in which the viral panel was negative for all commonly tested viral causes of croup, but positive for coronavirus disease 2019 (COVID-19). Conclusion: This case represents a new report of COVID-19 as the viral origin of croup.