Volume 3, Issue 2, 2019
CPC-EM Full-Text Issue
Clinicopathological Cases from the University of Maryland
Eight-year-old Boy with New-onset Seizure
An eight-year-old boy presented to the emergency department for a first-time seizure. The patient had only signs of mild dehydration on physical exam and had an uneventful postictal recovery. First-time seizures in pediatric patients are often benign and require only an outpatient workup; some are dangerous. This case takes the reader through the differential diagnosis and systematic work-up of new-onset pediatric seizures, leading to an unanticipated diagnosis.
Code Blue: Life-threatening Methemoglobinemia
Most cases of acquired methemoglobinemia result from exposure to certain drugs or toxins. One of the more common and well-described causes in the literature is exposure to topical benzocaine during medical procedures. We present a case series of acute acquired methemoglobinemia from a food source that has not been previously described in the literature: a dessert. Three patients, ages 5, 33, and 86 years, were brought to our emergency department by ambulance after becoming extremely ill from ingesting a dessert containing nitre powder at a family gathering. They all presented with hypotension, cyanosis, and hypoxia that was not responsive to oxygen administration. The adult patients had major improvement of symptoms after a single dose of methylene blue. In contrast, the 5-year-old child who had the worst symptoms minimally improved with administration of two doses of methylene blue requiring intensive care admission and transfer to a tertiary care center.
Anterior Loculated Pericardial Effusion Misinterpreted as Right Heart Dilation Suggesting Pulmonary Embolism
We report a case of anterior loculated pericardial effusion misinterpreted on point-of-care ultrasound as a dilated right ventricle, and suggesting diagnosis of pulmonary embolism (PE), in a patient with renal failure. The compressed right ventricle from tamponade physiology appeared to be a thickened intraventricular septum. Heparin was given empirically for presumed PE. Later the same day, computed tomography of the chest showed the effusion, as did formal echocardiogram. The patient had drainage of 630 milliliters of fluid and recovered from tamponade. Loculated effusions comprise 15% of all pericardial effusions, and misdiagnosis of PE with heparin therapy could be fatal.
- 1 supplemental video
Aortic Dissection with Subsequent Hemorrhagic Tamponade Diagnosed with Point-of-care Ultrasound in a Patient Presenting with STEMI
A 58-year-old male with no past medical history presented to the emergency department with sudden onset left lower extremity weakness and central chest pain with radiation to his back. Electrocardiogram revealed an acute inferior and posterior ST-segment elevation myocardial infarction(STEMI). Point-of-care ultrasound (POCUS) demonstrated right ventricular akinesis consistent with infarction, and an intimal defect consistent with an aortic dissection. We determined that cardiothoracic surgery was indicated rather than left-heart catheterization and anticoagulation. Using POCUS we were able to immediately diagnose a dissection of the aortic arch and considerably alter treatment in a patient presenting with STEMI.
Delayed Diagnosis of Spinal Tuberculosis in a 44-year-old Male with Acute on Chronic Low Back Pain
Spinal tuberculosis (STB), also known as tuberculous spondylitis, tuberculous vertebral osteomyelitis, or Pott’s disease is a rare subset of extrapulmonary tuberculosis. Although rare in developed countries, STB is an important diagnosis for the emergency physician to consider. We report a case of a 44-year-old African-American male with STB presenting as an acute exacerbation of chronic low back pain complicated by urinary retention and difficulty ambulating. Our patient had no known predisposing risk factors for tuberculosis. This patient’s STB was mistakenly diagnosed as nontuberculous vertebral osteomyelitis. This is not uncommon, as it is often difficult to distinguish the two clinically. This patient experienced advanced neurologic features at the time of initial presentation, which improved with surgical decompression. Ultimately, he re-presented to the emergency department 10 days after hospital discharge with recurrence of symptoms due to inaccurate antimicrobial selection. The diagnosis may hinge on the astute physician recognizing the characteristic, albeit subtle, imaging findings of STB.
A Desquamating Skin Rash in a Pediatric Patient
Prompt identification and treatment of true dermatologic emergencies is essential in emergency medicine, especially in vulnerable populations such as pediatric patients. This is a case of a three year-old female who presented with significant dehydration in the setting of a desquamating skin rash diagnosed in our emergency department as staphylococcal scalded skin syndrome.
Perilymphatic Fistula After Penetrating Ear Trauma
Pneumolabyrinth, defined as air within the labyrinth on high-resolution computed tomography, suggests that a perilymphatic fistula (PLF) is present. PLF describes an abnormal communication between the middle and inner ear, and can result in deafness, vertigo, and imbalance. In the setting of a penetrating injury to the temporal bone or inner ear, pneumolabyrinth should trigger prompt otolaryngology consultation and urgent surgical exploration. We describe a case in which a 49-year-old male presented with a traumatic PLF secondary to penetrating ear injury. Imaging demonstrated extensive pneumolabyrinth. Despite delay in diagnosis, expeditious surgical intervention resulted in successful preservation of inner ear function.
De Garengeot Hernia Diagnosed with Point-of-care Ultrasound
De Garengeot hernias, defined as a femoral hernia containing the appendix, are rare. It is even uncommon to have an incarcerated de Garengeot hernia with associated acute appendicitis. We report a case of a 76-year-old female presenting to the emergency department for a right lower quadrant abdominal mass for four days. Physical exam was consistent with an incarcerated hernia. A point-of-care ultrasound revealed a non-compressible, blind-ended loop of bowel within the hernia sac, concerning for acute appendicitis within the mass. Computed tomography of the abdomen and pelvis confirmed the diagnosis of acute appendicitis within a femoral hernia.
Emergency Physician Reduction of Pediatric Hip Dislocation
Traumatic hip dislocation in children is relatively rare but presents a true emergency, as a delay in reduction can result in avascular necrosis of the femoral head and long-term morbidity. After sustaining a traumatic posterolateral hip dislocation, a seven-year-old boy presented to an outside facility where no attempt was made at reduction. The patient was transferred to our emergency department (ED) where he was promptly sedated and the dislocation was reduced in a timely manner. Emergency physicians have demonstrated high success rates with dislocation reduction. ED reduction should occur immediately to reduce the likelihood of long-term complications. While timely consultation with a pediatric orthopedist is recommended, that should not delay reduction. The reduction should ideally be performed before the patient leaves the department or is transferred to another facility.
A 22-year-old man presented to the emergency department with facial swelling, rash, and fatigue. Hehad a past medical history of pericarditis and pericardial effusion. His evaluation showed anemia and thrombocytopenia. He was admitted for intravenous administration of steroids, plasmapheresis, and workup of his anemia and thrombocytopenia. He was ultimately diagnosed with Evans syndrome as a presenting feature of systemic lupus erythematosus. Plasmapheresis was stopped but administration of steroids continued. His blood counts improved, and the facial swelling and rash subsided. Evans syndrome is an immunologic conundrum that requires early recognition and treatment.
Ruptured Visceral Artery Aneurysms: A Deadly Cause of Epigastric Pain
Visceral artery aneurysms (VAA) are rare, life-threatening disease processes that often affect the celiac, superior mesenteric, or inferior mesenteric arteries and their respective branches. The splenic, hepatic, superior mesenteric, and tripod celiac arteries are most commonly affected and have high rupture and mortality rates. This case describes splenic and celiac artery aneurysms ina patient that led to hemorrhagic shock and multisystem organ failure despite timely diagnosis and ligation. A brief review of the literature further elucidates the key risk factors in identifying patients with VAAs and their treatment course.
Acute Angle-Closure Glaucoma Secondary to a Phakic Intraocular Lens, an Ophthalmic Emergency
Implantable collamer lenses (ICL) are phakic (natural lens remains in place) lenses that were first developed in the 1990s for correction of high myopia. The effectiveness and safety of ICLs are making them an increasingly popular option for vision correction in the myopic patient, competing with traditional options like glasses, contacts, and procedures such as laser-assisted in situ keratomileusis. Although generally safe, due to the position of the phakic ICL in the eye, pupillary block remains a rare but vision-threatening complication of ICL implantation. Pupillary block caused by phakic ICL is a serious complication that requires urgent recognition and intervention and is poorly described in emergency medicine literature. We describe a case of pupillary block five years after ICL implantation that was refractory to standard medical therapy, highlighting the importance of early diagnosis and referral for more definitive therapy.
Empagliflozin-induced Diabetic Ketoacidosis Unmasking a Type 1 Diabetes Diagnosis
Empagliflozin is a sodium glucose cotransporter-2 inhibitor that inhibits renal glucose reabsorption through an insulin-independent mechanism. This class of drugs is used in the management of type 2 diabetes. A 49-year-old female with type 2 diabetes treated with empagliflozin presented to the emergency department in diabetic ketoacidosis (DKA). This case report details the series of events leading to the diagnosis of drug-induced DKA, which led to a change in the patient’s diagnosis from type 2 diabetes to type 1 diabetes.
Double Steal Phenomenon: Emergency Department Management of Recurrent Transient Ischemic Attack
Double steal phenomenon is a rare condition where occlusion of the innominate (brachiocephalic) artery leads to hemodynamic changes in which blood flow is shunted from the intracranial circulation down the right vertebral artery and subsequently up the right carotid and subclavian circulation. This is a case of a 67-year-old female presenting emergently with recurrent transient ischemic attacks due to double steal phenomenon. Emergency department recognition of the double steal phenomenon and large vessel occlusion by computed tomography angiogram of the head and neck allowed for early treatment, which was critical in avoiding irreversible cerebral infarction.
High Ascending Retrocecal Appendicitis in a Pediatric Patient Detected by Point-of-care Ultrasound
A 10-year-old male presented to our pediatric emergency department with progressive, colicky abdominal pain for one day, associated with fever and non-bilious vomiting. He had a guarded abdomen with sluggish bowel sounds. He was noted to have poor perfusion with tachycardia, which resolved with fluid resuscitation. Abdominal radiograph demonstrated the presence of a circular radiopaque structure at the right hypochondrial region. Point-of-care ultrasound revealed an ascending appendicitis with signs of perforation, which was unusually located just at the inferior edge of the liver, over the right hypochondrium. The patient was immediately admitted to the surgical intermediate care unit. Urgent laparoscopic appendectomy was successfully performed, and the child was discharged well.
Symptomatic Vaginal Infection by Neisseria meningitidis Resulting in Meningitis with Septic Shock
The most common infectious etiologies of vaginitis include Gardnerella bacterial vaginosis, candidiasis, and trichomoniasis. A few case reports describe symptomatic infection with Neisseria (N) meningitidis, an organism with potential for causing systemic disease with a high rate of morbidity and mortality. We describe a patient who presented with fulminant meningitis secondary to symptomatic vaginitis in which N. meningitidis was cultured. Due to the potential for significant morbidity and mortality as demonstrated by this case report, knowledge of this entity may prompt physicians to aggressively treat patients with vaginal cultures that are positive for N. meningitidis.
Images in Emergency Medicine
Point-of-care Ultrasound Diagnosis of Cholecystitis vs. Adenomyomatosis
- 1 supplemental video
Mucocutaneous Paraneoplastic Syndrome Secondary to Classical Hodgkin’s Lymphoma
Paraneoplastic syndromes may be the only presenting manifestation of an otherwise occult malignancy. This case report highlights a patient presenting to the emergency department with an atypical, multi-system disease, ultimately leading to a diagnosis of mucocutaneous paraneoplastic syndrome secondary to classical Hodgkin’s lymphoma. Emergency physicians should maintain a high clinical suspicion for paraneoplastic syndromes when patients present with multi-system manifestations.
Early Diagnosis of Heterotopic Pregnancy in a Primigravid Without Risk Factors in the Emergency Department
The Aquarium Sign: Another Opportunity for Detection of Perforated Viscus
- 1 supplemental video
Adding Insult to Injury: Asymptomatic Fat Embolism Identified on Computed Tomography
Fat embolism (FE) is a classically taught complication of long bone fractures, with the potential to cause high morbidity and mortality; however, it is rarely apparent on emergency department (ED) presentation or imaging. If recognized by the ED clinician, development of symptoms of FE may be avoided by early surgical fixation and potentially by corticosteroid administration.