Volume 3, Issue 4, 2019
CPC-EM Full-Text Issue
Clinicopathological Cases from the University of Maryland
A 50-year-old male presented to the emergency department with four days of intermittent chest pain and shortness of breath, which progressively worsened in severity. Testing revealed a troponin I greater than 100 times the upper limit of normal and an electrocardiogram with non-specific findings. This case takes the reader through the differential diagnosis and systematic work-up of the deadly causes of chest pain, ultimately leading to this patient’s diagnosis.
Astonishing Cases and Images in Emergency Medicine
A 33-year-old male was brought to the emergency department after a penetrating arrow injury to the chest. Initial evaluation revealed the arrow was penetrating the sternum, lung, and aortic arch. Because the patient was in a remote area, timely transfer to a specialized center for definitive operative repair was delayed approximately 24 hours. Treatment was focused on minimizing risk of hemorrhage with tight blood pressure control, while tube thoracostomy was deferred to avoid a change in intrathoracic pressure. The left-sided hemothorax was monitored with serial point-of-care ultrasounds. Ultimately he was successfully transferred and underwent successful surgical intervention.
Medical Legal Case Report
Malpractice liability systems exist, in part, to provide compensation for medical malpractice, corrective justice for those injured by it, and to incentivize quality care by punishing substandard care. Defensive medicine is loosely defined as practice based primarily on the fear of litigation rather than on expected patient outcomes. It is largely motivated by a physician’s belief that the malpractice system is unfair, slow, and ineffective; these perceptions make malpractice concerns one of the largest physician stressors. A physician’s perception of malpractice rarely correlates with the stringency of their state’s tort system, overestimates their own risk, and overestimates the cost of defensive practices. While estimates are difficult to make, defensive medicine likely only accounts for 2.8% of total healthcare expenses. The phrase “tort reform” has been frequently used to suggest fixes to the malpractice system and to defensive practices. Safe harbors, clinical practice guidelines, comparative fault reform, reducing plaintiff attorney fees, and apology laws have each been evaluated as potential remedies to defensive practice, although most are unproven and all must be deployed in a state-by-state approach.
Importance of Multiple-window Assessment for the Diagnosis of Ascending Aortic Dissection Using Point-of-care Ultrasound: Report of Three Cases
Acute ascending aortic dissection has a high mortality rate and requires rapid diagnosis and treatment. Point-of-care ultrasound (POCUS) can aid in the diagnosis. The aortic root is usually evaluated in the parasternal long-axis view; however, a dissection flap is not always visible in this projection. We present three cases of acute, type A aortic dissection in which the dissection flap was only evident in the apical five-chamber and subxyphoid views. These cases suggest that POCUS may play a pivotal role in the initial diagnosis of acute ascending aortic dissection and highlight the importance of viewing multiple windows to fully evaluate this possibility.
- 3 supplemental videos
We present six cases of central retinal artery occlusion (CRAO) and central retinal vein occlusion (CRVO) that we recently treated with hyperbaric oxygen (HBO2). Patients in three of the six cases, including the CRVO case, experienced near to complete restoration of their vision. Another case had marked improvement. Our findings are similar to other case studies with approximately 65-70% improvement in patients treated for CRAO. Physicians should be aware that rapid referral of CRAO and CRVO patients to HBO2 is efficacious. Such patients should be placed on 100% oxygen by non-rebreather mask as soon as the diagnosis is suspected, pending transportation to HBO2.
Pennies for Your Thoughts: A Case Series of Pancytopenia Due to Zinc-Induced Copper Deficiency in the Same Patient
A 47-year-old schizophrenic male presented on three separate occasions with pancytopenia and sideroblastic anemia due to copper deficiency from massive zinc penny ingestion. The poisoning was treated differently on each visit: intravenous (IV) copper plus surgical decontamination and chelation with calcium disodium versenate (CaNa2EDTA); IV copper plus whole bowel irrigation; and IV copper with surgical decontamination only. Serum zinc half-lives were 80.0 hours, 233.2 hours, and 83.9 hours, respectively. Importantly, chelation with CaNa2EDTA did not significantly alter the elimination half-life. This is the first reported case of the same patient being treated on three different occasions with three different regimens for this condition.
Altered mental status is a common symptom in emergency department evaluations and may be present in as many as four to ten percent of patients. The etiology can be difficult to determine without significant evidence from laboratory, radiographic and physical examination. The diagnostic approach is largely driven by the provider’s clinical judgment based on the available history. Consequently, less-common diagnoses can be easily missed or delayed if a reasonable suspicion does not exist when considering possible causes. Cerebral venous sinus thrombosis (CVST) is one such uncommon, seldom-considered disease that carries a significant morbidity and mortality. Its clinical presentations vary and it disproportionally affects young to middle-aged individuals. Knowledge of the disease, particularly the risk factors, is key to making the diagnosis. We will discuss the case of a patient who presented with CVST and intraparenchymal hemorrhage in a resource-limited environment.
Perineal and rectal pain are common presentations in the emergency department (ED). In the majority of cases, clinical examination is sufficient to detect local anorectal pathologies. However, perianal and rectal abscesses and fistulas are often the primary concerns prompting diagnostic imaging in the ED. Currently, computed tomography is the preferred imaging modality. Recently, transperineal ultrasound has emerged as an optimal imaging modality for the diagnosis of perineal and perianal abscesses. We present a case in which point-of-care ultrasound accurately detected an intersphincteric abscess, and review the appropriate ultrasound technique to evaluate patients with suspected perianal and rectal abscesses.
- 1 supplemental video
Sudden unexplained death in epilepsy (SUDEP) refers to a death in a patient with epilepsy that is not due to trauma, drowning, status epilepticus, or another apparent cause. Although the pathophysiology of SUDEP is incompletely understood, growing evidence supports the role of seizure-associated arrhythmias as a potential etiology. We present a unique case of a patient presenting with ventricular tachycardia shortly following a seizure, along with corresponding laboratory data. Awareness of high risk arrhythmias in seizure patients could lead to advances in understanding pathophysiology and treatment of this complication of seizure disorder and ultimately prevention of SUDEP.
Rhabdomyolysis is a condition in which skeletal muscle breakdown causes the release of intracellular components into the bloodstream – defined as elevations in serum creatine kinase levels. The etiology of rhabdomyolysis is varied and may be the result of toxin-mediated mechanisms or metabolic derangements, or they may develop secondary to other conditions such as seizures, trauma and prolonged immobilization. In this case, we present a patient with suspected acute toxin-mediated rhabdomyolysis in the setting of trimethoprim-sulfamethoxazole (TMP-SMX) therapy for urinary tract infection. To our knowledge, this marks the fifth case report of an otherwise healthy patient diagnosed with rhabdomyolysis thought to be secondary to TMP-SMX.
Prior exposure to poison ivy and poison oak, which are plants in the Anacardiacea family and contain high levels of urushiol, appear to be a risk factor for delayed hypersensitivity reactions to mango fruits. Cross-sensitization between these plants and mangos is believed to be secondary to an overlap in the urushiol antigen and 5-resorcinol, found predominately in mango peels. This unique combination of sensitization and reaction constitutes a type IV hypersensitivity response, mediated and driven by T cells reacting to similar antigens. We present a case of an otherwise healthy man, with a remote history of poison ivy exposure, who presented with a delayed but significant reaction to mango fruit. Obtaining the patient’s history of prior plant exposures and reactions was key to isolating the likely underlying causation of his presentation.
Neurofibromatosis (NF) is a common autosomal dominant disorder that can be subdivided into type 1, type 2, and schwannomatosis. Patients with NF1 typically develop café-au-lait spots, scoliosis, and benign neurofibromas. In addition, NF1 predisposes to vascular complications including stenosis, arterial ectasia, and aneurysms. Here, we report the case of an otherwise healthy 32-year-old man who developed a fatal tension hemothorax due to vertebral artery aneurysm rupture. Based on the available literature, we discuss the presentation, workup, and available therapeutic approaches to this complication of neurofibromatosis.
Cervical epidural injections are commonly used to treat patients with radicular neck pain. The following is a description of a case of subarachnoid hemorrhage, subdural hemorrhage, and pneumocephaly following cervical epidural injection.
Occult Vascular Transection Identified by Point-of-care Ultrasound Demonstrating Evidence of Retrograde Flow
Acute vascular injury can be a cause of significant disability and morbidity. High clinical suspicion and a thorough physical examination are key components to facilitate a timely diagnosis. We present a case of acute vascular injury after isolated penetrating trauma. Physical examination demonstrated a strong distal radial pulse; however, point-of-care ultrasound facilitated an evaluation of the directionality of arterial flow, demonstrating that flow was retrograde via the palmar arch. We subsequently identified a proximal and complete arterial laceration.
- 1 supplemental video
Iatrogenic aortic dissection (IAD) status-post-cardiac catheterization is a rare complication often isolated to the proximal aorta. This is a case of IAD isolated to the distal aorta in a 41-year-old female who presented to the emergency department with right leg pain after undergoing three cardiac catheterizations. The diagnosis of IAD was made upon discovery of an intimal flap in the distal aorta and femoral artery while performing a point-of-care ultrasound to evaluate for deep vein thrombosis.
- 1 supplemental video
Varicella zoster virus in the adult patient most commonly presents as shingles. Shingles is a painful vesicular eruption localized to a specific dermatome of the body. One of the potential complications of this infection is involvement of the central nervous system causing encephalitis. An increased risk of this complication is associated with the immunocompromised patient. In this case report, we review the history and physical exam findings that should raise clinical suspicion for varicella zoster encephalitis, as well as the epidemiology, risk factors, treatment, and prognosis of this type of infection.
Acute acalculous cholecystitis (AAC) is a rare, potentially serious disease that has been associated with Kawasaki disease (KD) in children. Studies suggest that patients presenting with severe abdominal symptoms secondary to KD have increased resistance to intravenous immunoglobulin (IVIG), and a higher rate of coronary artery aneurysms. We describe an eight-year-old boy who presented to the emergency department with severe abdominal pain and was diagnosed with AAC and KD. He was treated with IVIG and high-dose aspirin, achieving good response with complete symptom resolution. He had no coronary artery aneurysms or further complications and was discharged after three days.
Delusional parasitosis is an uncommon psychiatric disorder that manifests as having parasitic delusions. Due to its rarity, delusional parasitosis is a challenging and costly diagnosis of exclusion and proves difficult to manage for many providers. Although this syndrome is frequently discussed in psychiatric and dermatology reports, it is not commonly described in emergency medicine (EM) literature. As a result, best practices for workup and treatment remain unclear from an EM perspective. Patients typically return multiple times for medical evaluation and exhaust numerous resources. In this case report we review the appropriate steps for initial evaluation of patients with suspected delusional parasitosis, differential diagnoses, and increase awareness for prudent treatment strategies.
Direct oral anticoagulants are now commonplace, and reversal agents are recently becoming available. Andexanet alfa (AnXa), approved by the United States Food and Drug Administration in 2018, is a novel decoy molecule that reverses factor Xa inhibitors in patients with major hemorrhage. We present a case of a 70-year-old man taking rivaroxaban with hemodynamic instability from a ruptured abdominal aortic aneurysm. He received AnXa prior to endovascular surgery, and intraoperatively he could not be heparinized for graft placement. Consideration should be given to the risks and benefits of AnXa administration in patients who require anticoagulation after hemorrhage has been controlled.
Ventricular Fibrillation Cardiac Arrest in Young Female from Diffuse Left Anterior Descending Coronary Vasospasm
This is a case of the most severe and potentially fatal complication of coronary artery vasospasm. We report a case of a 40-year-old female presenting to the emergency department (ED) via emergency medical services with chest pain. The patient experienced a ventricular fibrillation cardiac arrest while in the ED. Post-defibrillation electrocardiogram showed changes suggestive of an ST-elevation myocardial infarction (STEMI). Cardiac catheterization showed severe left anterior descending spasm with no evidence of disease. Coronary vasospasm is a consideration in the differential causes of ventricular fibrillation and STEMI seen in the ED.
Tumor lysis syndrome is an oncologic emergency that can present with variable symptoms and is truly a laboratory-based diagnosis without pathognomonic clinical findings. The classical teaching is to consider this diagnosis in cancer patients undergoing chemotherapy. We present the case of a 66-year-old female with newly diagnosed metastatic liver adenocarcinoma, not on chemotherapy, who was diagnosed with spontaneous tumor lysis syndrome. Cognizance of this syndrome and associated laboratory findings are paramount to diagnosis and rapid intervention.
Ketamine is used widely in emergency departments for a variety of purposes, including procedural sedation and pain management. A major benefit of using ketamine is the rapid onset and lack of respiratory depression. The known side effects include emergence reactions, hallucinations, hypertension, dizziness, nausea, and vomiting. Recent studies have shown the benefit of ketamine for refractory status epilepticus; however, this application of the drug is still being studied. We present a case where ketamine likely induced a seizure in a patient on whom it was used as a single agent in procedural sedation. Seizure is not a known side effect of ketamine in patients without a seizure history. Given the eagerness over additional uses for ketamine, this novel case of a seizure following procedural sedation with ketamine should be of interest to emergency providers.
Postmortem Sperm Retrieval in the Emergency Department: A Case Report and Review of Available Guidelines
Postmortem sperm retrieval (PMSR) requests and retrievals are increasing in the emergency department (ED) setting. Few EDs have protocols in place, and many emergency physicians (EP) lack the knowledge of how to proceed when such situations arise. We report the case of a 31-year-old male cardiac-arrest victim who expired in the ED, after which his wife requested PMSR. We review the guidelines, procedures, and issues of consent that arise with PMSR. EPs must be aware of their institution’s policies and consultant availability should a request for PMSR arise.
In the United States, gestational trophoblastic diseases (GTD), including molar pregnancies, occur in 121 out of 100,000 pregnancies.1 Many patients with GTD may develop hyperthyroidism. GTD-induced thyroid storm is a rare but life-threatening complication of GTD.2 Once patients are hemodynamically stable, the mainstay of definitive treatment is evacuation of the mole.3 We present a case of molar pregnancy-induced thyroid storm presenting as vaginal bleeding, fever, and tachycardia.
Celiac artery compression syndrome, also called median arcuate ligament syndrome (MALS), is a rare condition in which the diaphragmatic crura compresses the celiac axis. This results in a constellation of primarily gastrointestinal (GI) symptoms including nausea, vomiting, postprandial abdominal pain, and weight loss. It is typically a diagnosis of exclusion and may be detected via several imaging techniques including ultrasound and computed tomography angiography. We present an atypical case of MALS detected in the emergency department (ED). We review the symptomatology, diagnostic workup, and treatment options here, as well as discuss implications concerning revisits to the ED for recurrent GI symptoms.
Hemorrhage is a major cause of death among trauma patients. Controlling the bleeding is essential but can be difficult when the source of bleeding remains unidentified. We present a 67-year-old healthy male with a hypovolemic shock after a suicide attempt by jumping from a height. Apart from a bilateral pneumothorax with multiple rib fractures, a femur fracture and spine fractures, computer tomography (CT) revealed a closed, degloving injury of the back, also known as a Morel-Lavallée lesion. Hemodynamic instability due to hemorrhage caused by a Morel-Lavallée lesion in the lumbar region is very rare and easily overlooked. This case demonstrates the importance of clinical signs of Morel-Lavallée, and illustrates the need for total body CTs to exclude other locations of bleeding and to detect contrast extravasation. This report also discusses the possible treatment options for Morel-Lavallée lesions.
Colpocephaly is a form of congenital ventriculomegaly characterized by enlarged occipital horns of the lateral ventricles with associated neurologic abnormalities. The diagnosis of colpocephaly is typically made in infancy. Its diagnosis in adulthood without associated clinical symptoms is exceptionally rare. We report a case of colpocephaly diagnosed incidentally in an adult without neurologic abnormalities in the emergency department. To our knowledge, this is only the ninth reported case in an asymptomatic adult and the first to be described in the emergency medicine literature.
Images in Emergency Medicine
A 71-year-old male presented to the emergency department (ED) for worsening right knee pain for the prior 3-4 weeks. Point-of-care ultrasound (POCUS) of the right knee showed a pseudo-double contour sign. Subsequent ultrasound-guided arthrocentesis of the knee joint was performed, and fluid studies showed the presence of calcium pyrophosphate crystals, which was consistent with pseudogout. Ultrasound for detection of calcium pyrophosphate crystals in pseudogout and chondrocalcinosis has sensitivity of 86.7% and specificity of 96.4% making POCUS a valuable tool for diagnosing crystalline-induced arthropathy in the ED.
Acquired Pediatric Right Diaphragmatic Hernia Following Automatic Implantable Cardioverter-Defibrillator Placement
Diaphragmatic hernias are an uncommon occurrence in the pediatric population; however, they can cause significant morbidity and mortality if the diagnosis is missed or delayed. This case discusses the radiographic and clinical exam findings of a one-year-old patient with this pathology.
This case describes and depicts cardiac standstill with thrombosed blood within the chambers of the heart. This was likely due to stasis of blood from a prolonged no-flow state. After viewing this ultrasound finding, the decision was made to halt resuscitative efforts in this case of a patient in cardiac arrest.
- 1 supplemental video
Physiological shock requires prompt diagnosis and treatment in the emergency department. We present a case of physiological shock in a 91-year-old woman resulting from obstruction of the left atrium and inferior vena cava by a giant esophageal hiatal hernia, identified using computed tomography imaging. The patient’s age and history, including diet and eating behavior (namely needing to lie down immediately after a meal), and kyphotic posture were important factors to consider in establishing the differential diagnosis. While rare, a giant esophageal hiatal hernia should be considered in the differential diagnosis of obstructive shock.
Due to the recent increase in endovascular procedures, retained foreign bodies such as stents and catheters in vasculature have become a common and serious complication. Treatments for these complications vary depending on the acuity and stability of the foreign body in the vessel. We discuss a rare case of an adult found to have an incidental retained umbilical artery catheter in the aorta.
A 62-year-old woman with a history of metastatic breast cancer and known meningioma presented with unilateral vision loss associated with anisocoria and an afferent pupillary defect. On magnetic resonance imaging we found the cause to be optic nerve compression by a right frontal meningioma. Monocular vision-loss etiologies are anatomically localized to structures anterior to the optic chiasm. This case serves as a reminder that cerebral structures in this location must not be forgotten in the differential.
Cutaneous maggots are occasionally encountered in the emergency department. We present a case in which maggots were visually identified and ultrasound was used to detect additional maggots below the skin crevices in a patient with elephantiasis nostras verrucosa.
- 1 supplemental video
A 54-year-old man presented to the emergency department with confusion and Parkinsonian features after suspected heroin snorting. He had magnetic resonance imaging of the brain demonstrating isolated symmetric bilateral globus pallidus (GP) restricted diffusion and edema consistent with hypoxic ischemic encephalopathy. In contrast to other anoxic/ischemic insults, where the GP is preferentially spared, autopsy reports on intravenous heroin users have found the GP to be specifically affected, often demonstrating symmetric bilateral lesions. Opioid toxicity should be considered in patients presenting with Parkinsonian features on examination or pallidal lesions on imaging, especially in younger adults where infarction is less common.
A 78-year old male presented to the emergency department after accidental dislodgement of his chronic gastrostomy tube. A replacement gastrostomy tube was passed easily through the existing stoma and flushed without difficulty. Confirmatory abdominal radiography demonstrated contrast in the proximal small bowel, but the patient subsequently developed epigastric pain and refractory vomiting. Computed tomography revealed the tip of the gastrostomy tube terminating in the pylorus or proximal duodenum. This case highlights gastric outlet obstruction complicating the replacement of a gastrostomy tube and the associated radiographic findings.
Neuroretinitis from neurosyphilis is an uncommon finding in previously healthy young individuals. A 37-year-old presented with three days of painless, unilateral vision loss with an associated diffuse erythematous non-pruritic truncal rash. Physical exam demonstrated vision loss in the left eye. Fundoscopic exam showed unilateral peripapillary hemorrhage, papilledema and venous engorgement. Labs showed positive syphilis antibody qualitative. Magnetic resonance imaging demonstrated 12 millimeters of high right frontal lobe cerebrospinal fluid density. The patient was treated with benzylpenicillin and within 18 hours had improvement of his vision.
Disseminated Intravascular Coagulation with Purpura Fulminans Presentation of Acute Promyelocytic Leukemia
A 47-year-old male presented to the emergency department with 12 hours of nausea, vomiting, abdominal pain, and a widespread skin eruption with mottled, irregular, purpuric lesions with subsequent rapid decompensation. Laboratory analysis revealed thrombocytopenia, bandemia, elevated metamyelocytes, abnormal coagulation panel, decreased fibrinogen, elevated fibrin split products, renal dysfunction, bacterial rods, dohle bodies, and toxic granulation. Acute promyelocytic leukemia (APML) was confirmed via bone marrow biopsy, flow cytometry, and fluorescence in situ hybridization analysis. Disseminated intravascular coagulation (DIC) may be the initial presentation of APML. When treated promptly, APML can achieve high remission rates; however, conditions such as DIC continue to increase mortality requiring early recognition to improve survival rates.
As United States emergency departments (ED) and hospitals continue to contend with increasing numbers of patients presenting with complications of substance abuse, emergency physicians should also be aware of patients who may be smuggling illicit drugs. We report the case of a 26-year-old man who was transported to the ED for suspected drug smuggling. Abdominal computed tomography was notable for the presence of multiple tubular foreign bodies throughout the colon that were later identified as packets containing heroin. Body-packing patients present a high-risk clinical scenario that may result in massive, inadvertent drug exposure.
A 52-year-old man without known medical history presented with painful, progressive, bilateral lower extremity edema over a two-week period. An abdominal exam noted a firm left upper quadrant mass. Emergency department (ED) point-of-care ultrasound (POCUS) revealed a hyperechoic, heterogeneous structure in the inferior vena cava that was determined to represent a tumor thrombus extending from a primary renal cell carcinoma. This case demonstrates how POCUS was valuable in rapidly diagnosing this rare cause of lower extremity edema and its usefulness in directing the initial ED management of this patient.
- 1 supplemental video
A 62-year-old man presented to the emergency department with acute, atraumatic, swelling of his left ear. Incision and drainage revealed serous fluid without blood or purulence. He was diagnosed with acute perichondritis with an effusion and managed with oral antibiotics. Perichondritis must be recognized and treated promptly to avoid necrosis of the underlying avascular cartilage and auricular deformity.