Skip to main content
Open Access Publications from the University of California

Clinicopathological Cases from the University of Maryland

55-year-old Male with Exertional Dyspnea

Introduction: Dyspnea is a common presenting complaint for many patients in the emergency department.

Case Presentation: A 55-year-old man with type I diabetes presented to the emergency department with one month of intermittent palpitations and dyspnea. His lungs were clear to auscultation, and his chest radiograph was normal.

Discussion: This case takes the reader through the differential diagnosis and systematic work-up of dyspnea with discussion of the diagnostic study, which ultimately led to this patient’s diagnosis and successful treatment.

Clinicopathological Cases

55-year-old Woman with Headache, Vomiting, and Visual Disturbance

Case Presentation: A 55-year-old woman with a past medical history of hypertension, hyperlipidemia, and iron deficiency anemia presented to the emergency department with three days of headache, nausea, vomiting, and visual changes. Her vital signs were within normal limits. She was noted to have a left cranial nerve six palsy on exam.

Results: Her laboratory testing revealed leukocytosis, hyponatremia, and hypokalemia. A non-contrast computed tomography scan of the head revealed an enlarged sella turcica and pituitary gland with hemorrhage and deviation of the optic chiasm.

Conclusion: Her symptoms improved and she was discharged from the hospital in stable condition.

Case Series

Heroin Adulterated with the Novel Synthetic Cannabinoid, 5F-MDMB-PINACA: A Case Series

Introduction: Heroin can be adulterated with various substances that may or may not have pharmacological effects. Here we report a case series of 8 patients who presented to the emergency department after overdose with intravenous heroin preparation adulterated with the synthetic cannabinoid methyl 2-(1-(5-fluoropentyl)-1H-indazole-3-carboxamido)-3,3-dimethylbutanoate (5F-MDMB-PINACA).

Case Series: Except for one patient, all of them presented with a typical initial opioid toxidrome consisting of central nervous system and respiratory depression along with pinpoint pupils. Naloxone was given to them, triggering severe agitation and combative behavior along with overlapping features of anticholinergic and sympathomimetic toxidrome. All patients required multiple doses of benzodiazepines. Three were successfully treated with physostigmine.

Discussion: 5F-MDMB-PINACA is a synthetic cannabinoid that was added to heroin in samples obtained from patients reported in this case series. Patients demonstrated significant agitation after receiving naloxone for opioid toxidrome, presumably because of the removal of the depressant effect of opioids, which unmasked the excitatory effects of the synthetic cannabinoids. Three patients required physostigmine along with the benzodiazepines for control of their agitation, urine retention and abnormal vitals, suggesting the possibility of an anticholinergic toxidrome to have developed in these patients.

Conclusion: Heroin contaminated with 5F-MDMB-PINACA exhibits variable severities of anticholinergic effects, some on presentation and others only after opiate antagonism.

Case Report

Novel, Inexpensive Portable Respiratory Protection Unit (PRPU) for Healthcare Workers

Introduction: Given concern for increased aerosolization during intubation of patients with severe acute respiratory syndrome coronavirus, we sought to create a portable, inexpensive, and easily constructed device to help protect healthcare workers.

Methods: A respiratory protection unit can be constructed in approximately 30 minutes and for less than 50 United States dollars in materials, using polyvinylchloride pipe and automobile collision wrap.

Conclusion: This device provides possible increased protection during video laryngoscopy and can easily be replicated.

Early Multi-organ Point-of-Care Ultrasound Evaluation of Respiratory Distress During SARS-CoV-2 Outbreak: Case Report

Introduction: Coronavirus disease 2019 (COVID-19) is caused by the virus known as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).  Several case series from Italy and China have highlighted the lung ultrasound findings of this disease process and may demonstrate its clinical utility during the current pandemic.

Case Report: We present a case of a COVID-19 patient who presented to the emergency department twice within a 24-hour period with rapidly progressing illness. A multi-organ point-of-care ultrasound (POCUS) evaluation was used on the return visit and assisted clinical decision-making.

Discussion: A multi-organ POCUS exam allows for quick assessment of acute dyspnea in the emergency department. As the lung involvement of COVID-19 is primarily a peripheral process it is readily identifiable via lung ultrasound. We believe that when applied efficiently and safely a POCUS exam can reduce clinical uncertainty and potentially limit the use of other imaging modalities when treating patients with COVID-19.

Conclusion: This case highlights the utility of an early multiorgan point-of-care assessment for patients presenting with moderate respiratory distress during the severe SARS-CoV-2 pandemic.

Urethral Calculi

Urolithiasis is a condition with calculi commonly found within the kidney, ureter, or bladder. The urethra is an uncommon location of urolithiasis, with limited case reports and literature reviews of its presentation and management. Here we discuss a 24-year-old female who presented with urinary urgency, flank pain, and urinary retention for 12 hours. Physical exam showed a calculus at the urethral meatus. This case discusses the manual removal of a urethral calculus in a female patient with use of forceps, resulting in complete resolution of symptoms and urinary retention.

An Early Holiday Surprise: Cholecystitis Wrapped in Takotsubo Cardiomyopathy

This is a novel case report of a 44-year-old woman who presented to the emergency department with epigastric pain wrapping around to her back. She had no risk factors for cardiac disease, but her initial electrocardiogram (ECG) showed a Wellens syndrome pattern and she was taken urgently to the catheterization lab. After a negative catheterization, she underwent cardiac magnetic resonance imaging, which was positive for Takotsubo cardiomyopathy (TC). Ultimately, abdominal computed tomography revealed that she had cholecystitis, which likely was the cause of her TC and ECG changes.

Acute Jaundice in a Six-year-old: An Unusual Presentation of Atypical Kawasaki Disease

Kawasaki disease (KD) is a rare vasculitis of childhood that is critical to recognize and treat due to associated morbidity and mortality. A six-year-old male presented to our emergency department (ED) afebrile but with reported recent fevers. Exam revealed jaundice and erythematous tongue with papules, and laboratory studies indicated a direct hyperbilirubinemia. Admitted for evaluation, he developed continuous fever, increasing maculopapular rash, and subsequent desquamation of hands and feet. He ultimately met criteria for incomplete KD, was treated with intravenous immunoglobulin, and avoided cardiac complications. This presentation of incomplete KD with hyperbilirubinemia is rare because the patient was afebrile at ED presentation.

Topical Tranexamic Acid for Hemostasis of an Oral Bleed in a Patient on a Direct Oral Anticoagulant

Introduction: Tranexamic acid (TXA) is an antifibrinolytic agent currently approved and utilized in the treatment of dysfunctional uterine bleeding, traumatic extracranial hemorrhage, anterior epistaxis, and dental procedures on patients with hemophilia. There is a paucity of literature evaluating the use of TXA for hemostasis in patients on direct oral anticoagulants (DOACs).

Case Report: Our patient, a 72 year-old male on rivaroxaban, presented with persistent bleeding following a punch biopsy of the buccal mucosa. Given the site of bleeding, inability to effectively tamponade, patient’s anticoagulated state, and risk of impending airway compromise, a dressing was soaked with 500 milligram (mg) of TXA and was held in place with pressure using a makeshift clamp until a thrombus formed. Hemostasis was achieved preventing the need for acute ENTotolaryngologic intervention and/or intubation. The patient was observed in the medical setting overnight and discharged home without any recurrence of bleeding or adverse events.

Discussion: This case report describes our experience achieving hemostasis for an otherwise uncontrollable oral bleed in an anticoagulated patient on a DOAC who could not be reversed. Intervention is simple to perform, cost-effective, and requires few resources which are readily available in most emergency departments.

Conclusion: We report a novel application of TXA to control an oral mucosal bleed in an anticoagulated patient which was on a DOAC refractory to traditional measures.

The Ultimate Poker Face: A Case Report of Facial Diplegia, a Guillain-Barré Variant

Introduction: Facial diplegia, a rare variant of Guillain-Barré syndrome (GBS), is a challenging diagnosis to make in the emergency department due to its resemblance to neurologic Lyme disease.

Case report: We present a case of a 27-year-old previously healthy man who presented with bilateral facial paralysis.

Discussion: Despite the variance in presentation, the recommended standard of practice for diagnostics (cerebrospinal fluid albumin-cytological dissociation) and disposition (admission for observation, intravenous immunoglobulin, and serial negative inspiratory force) of facial diplegia are the same as for other presentations of GBS.

Conclusion: When presented with bilateral facial palsy emergency providers should consider autoimmune, infectious, idiopathic, metabolic, neoplastic, neurologic, and traumatic etiologies in addition to the much more common neurologic Lyme disease.

Ruptured Coronary Sinus of Valsalva in the Setting of a Supracristal Ventricular Septal Defect

A sinus of Valsalva aneurysm (SOVA) is usually a silent entity until one of its complications arises, such as heart failure. SOVA itself is uncommon, but it is more frequently associated with a supracristal ventricular septal defect (SVSD). We present a 67-year-old man with a history of an asymptomatic SVSD who presented to the emergency department with signs and symptoms of heart failure. He was subsequently found to have a ruptured SOVA and underwent urgent surgical repair.

False Elevation of Volume Determined by Bladder Scanner Secondary to Bowel Obstruction

Bladder scanners allow for quick determination of bladder volumes (BV) with minimal training. BV measured by a machine is generally accurate; however, circumstances exist in which falsely elevated BVs are reported. This case details a patient with a significant small bowel obstruction (SBO) due to superior mesenteric artery syndrome causing a falsely elevated BV. We believe this is the first case report of a SBO causing an elevated BV by bladder scanner. Emergency physicians should be aware of the pitfalls of using bladder scanners, and use their point-of-care ultrasound skills when possible to expand their differential.

Open Dorsal Proximal Interphalangeal Dislocation

We report a case of a 44-year-old male with an uncommon case of an open dorsal proximal interphalangeal (PIP) dislocation. Although open PIP dislocations are often volar, dorsal dislocations are fraught with complications due to the potential for infection and damage to supportive structures. Features of this case are discussed together with its implications, including lack of standardized management in the literature, use of a closed reduction following copious irrigation, and requirement for antibiotic use.

An Atypical Presentation of Cystic Echinococcosis

Cystic echinococcosis (CE) is an infection caused by the Echinococcus granulosus tapeworm. CE generally manifests in the liver, but it may present in any organ. These patients often first present to the emergency department. Mortality over 10 years is significant for those who go undiagnosed. We report the case of a 34-year-old patient who immigrated from Yemen six years earlier. She presented with acute onset dysuria, suprapubic pain, and fever. Imaging revealed a primary multicystic mass on the right renal pole with a secondary lesion in the right hepatic lobe. On further investigation, the patient’s serum was positive for echinococcus antibodies.

Intracranial Hemorrhage Due to Secondary Hypertension from Intracranial Large Vessel Occlusion

Simultaneous hemorrhagic and ischemic strokes have been previously reported in the literature. Typically, these occur in patients secondary to dialysis, cerebral amyloid angiopathy, or thrombotic thrombocytopenic purpura.1,2,3 However, this is the unique case of a 62-year-old Asian female who presented with a hemorrhagic stroke suspected to be secondary to refractory hypertension from intracranial large vessel atherosclerotic flow limiting stenosis, with rapid subsequent large vessel occlusion and ischemic stroke. Questions arise such as ideal blood pressure parameters for dual management, timeliness of computed tomography angiography imaging in the emergency department for detection of large vessel occlusion during intracranial hemorrhage, and subsequent selection of treatment plan in the dual-lesion patient population.

Serotonin Syndrome versus Cannabis Toxicity in the Emergency Department

As more states legalize marijuana, the potential of marijuana abuse could lead to an increase in the number of emergency department (ED) visits. We describe two patients who presented to the ED with dilated pupils, rigidity in both lower extremities, and clonus in both feet after inhaling the vapor of a highly potent form of marijuana. Serotonin syndrome diagnosis was initially considered in the differential diagnosis. Ultimately, high-potency marijuana abuse was the final diagnosis. Therefore, marijuana toxicity should be considered in ED patients who present with signs and symptoms similar to that of serotonin syndrome.

Pyogenic Flexor Tenosynovitis as a Rare Complication of Dyshidrotic Eczema

Introduction: Pyogenic flexor tenosynovitis is an unusual complication of dyshidrotic eczema. The diagnosis has traditionally been made by Kanavel’s signs. Point-of-care ultrasound can be a useful adjunct in the diagnosis of this surgical emergency.

Case Report: We report the case of a 23-year-old male who presented with right middle finger pain and swelling and an overlying eczematous rash. The use of point-of-care ultrasound was performed to aid in the diagnosis of pyogenic flexor tenosynovitis. An incision and drainage was performed with deep wound cultures positive for Staphylococcus aureus.

Discussion: The presentation of pyogenic flexor tenosynovitis with underlying concomitant dermatological disease can complicate this challenging diagnosis. Point-of-care ultrasound can be an effective adjunct in revealing pyogenic flexor tenosynovitis rather than relying solely on the classical Kanavel’s signs, leading to earlier treatment. Conclusion: Our case demonstrates that point-of-care ultrasound can be a rapid and effective tool for the diagnosis of pyogenic flexor tenosynovitis in the setting of superimposed dermatological diseases.

Heterotopic Pregnancy Diagnosed with Point-of-care Ultrasound in the Emergency Department: A Case Report

Introduction: Heterotopic pregnancies are rare. However, they are occurring with increasing frequency. Unfortunately, diagnosis is frequently delayed, with patients presenting in extremis.

Case Report: We present a case of a heterotopic pregnancy diagnosed by point-of-care ultrasound (POCUS) in a woman presenting with lower abdominal pain, who had a documented normal first trimester ultrasound the day prior to presentation.

Discussion: Given the increasing rates of heterotopic pregnancies, we can no longer be reassured by the presence of an intra-uterine pregnancy (IUP) in a patient with concerning signs and symptoms of a ruptured ectopic pregnancy. A thorough POCUS evaluation of the uterus and adnexa is essential for the diagnosis of heterotopic pregnancy in the emergency department.

Conclusion: This case highlights the value POCUS brings to the emergency department evaluation of patients in early pregnancy.

  • 1 supplemental video

Cardiac Memory-induced T-wave Inversions

Introduction: Cardiac memory refers to T-wave inversions that result when normal ventricular activation resumes following a period of abnormal ventricular activation.

Case Report: We present a case of a 29-year-old man with a pacemaker who presented with new, deep symmetric T-wave inversions caused by cardiac memory.

Discussion: Abnormal ventricular activation is most commonly induced by ventricular pacing but can also occur in the setting of transient left bundle branch blocks, ventricular tachycardia, and intermittent ventricular pre-excitation.

Conclusion: Recognition of this phenomenon may help to reduce unnecessary admissions, cardiac testing, and cardiac catheterizations.

Euglycemic Diabetic Ketoacidosis in Concurrent Very Low-carbohydrate Diet and Sodium-glucose Transporter-2 Inhibitor Use: A Case Report

Introduction: With the incredibly high incidence of Type 2 Diabetes in the current population of emergency department patients, it is critical for clinicians to understand the possible complications of the treatment of this disease. Medication like canagliflozin are more common to encounter on patient’s home medication lists and clinicians should be aware of how these medications, alone or combined with dietary modifications, can result in significant pathology and even mortality if not appropriately treated.

Case Report: We report a case of a patient with type II diabetes mellitus who presented with euglycemic diabetic ketoacidosis in the setting of concurrent use of canagliflozin, a sodium-glucose transporter-2 (SGLT-2) inhibitor, and strict adherence to a low-carbohydrate ketogenic diet for weight control.

Discussion: Euglycemic ketoacidosis has previously been observed in both diabetic and non-diabetic patients following strict ketogenic diets, as well as in diabetic patients being treated with SGLT-2 inhibitors.

Conclusion: As more patients choose ketogenic diets for weight control and diabetes management, clinicians should be aware of this potentially life-threatening complication in patients concurrently taking SGLT-2 inhibitors.

A Case Report of Angioedema and Anaphylactic Shock Induced by Ingestion of Polyethylene Glycol

Introduction: We report one of few documented cases of a severe anaphylactic reaction with angioedema to polyethylene glycol (PEG).

Case Report: The patient presented 30 minutes after onset of his symptoms and quickly developed hypoxia and hypotension refractory to intramuscular epinephrine, intravenous fluids, methylprednisolone, and supplemental oxygen via non-rebreather mask. He ultimately required intubation, an epinephrine infusion, and admission to the medical intensive care unit.

Discussion: This case depicts a clinical reaction to PEG, a medication rarely implicated in severe anaphylaxis or angioedema.

Conclusion: The allergenic potential of PEG-containing products should be raised, and providers should have a heightened awareness of these potential side effects.

A Case Report of Acute Heart Failure Due to Infective Aortic Endocarditis Diagnosed by Point-of-care Ultrasound

Introduction: Infective endocarditis (IE) is a life-threatening condition with significant morbidity and mortality, and can require surgical repair.

Case Report: A 36-year-old man presented to the emergency department for worsening dyspnea and chest pain. Point-of-care echocardiography demonstrated a mobile oscillating mass on the aortic valve with poor approximation of the valve leaflets, suggesting aortic valve insufficiency secondary to IE as the cause of acute heart failure. The patient underwent emergent aortic valve replacement within 24 hours.

Discussion: While point-of-care echocardiography has been well documented in identifying tricuspid vegetations, aorticvalve involvement and subsequent heart failure is less well described. Earlier recognition of aortic valve vegetations and insufficiency can expedite surgical intervention, with decreased complication rates linked to earlier antimicrobial therapy.

Conclusion: This case report highlights the ability of point-of-care ultrasound to identify aortic vegetations, allowing for the earlier diagnosis and therapy.

  • 1 supplemental video

Eagle Syndrome: A Rare Case of Atraumatic, Painful Cervical Neck Swelling

Introduction: Painful neck swelling is a common emergency complaint but can present diagnostic challenges. Eagle syndrome is a rare clinical entity in which a pathologically elongated styloid process or ossified stylohyoid ligament produces a constellation of symptoms in the head and neck region.

Case Report: We present the case of a 50-year-old male with a spontaneous, atraumatic fracture of an elongated styloid process associated with hematoma formation and radiological findings of airway impingement.

Discussion: The classic triad for Eagle syndrome consists of unilateral cervicofacial pain, globus sensation, and dysphagia. Diagnosis of Eagle syndrome should be made based on a combination of physical examination and radiological findings. Treatment options vary based on severity of symptoms.

Conclusion: Although more likely to be an indolent and progressive complaint, providers in the acute care setting should be familiar with Eagle syndrome due to the potential for a spontaneous fracture of an elongated styloid process to cause acute, painful neck swelling and life-threatening airway compromise.

Gastric Adenocarcinoma Presenting as Chronic Back Pain: A Case Report

Introduction: Early stage gastric cancer is usually asymptomatic. It is not until later stages of the disease, usually with metastasis, that patients typically develop symptoms that would prompt further evaluation.

Case Report: We present a case of a patient with chronic back pain who was found to have a gastric antral mass as the etiology of her pain. The patient proceeded to have a partial gastrectomy with complete surgical excision of her early-stage gastric cancer, after which her chronic back pain resolved.

Conclusion: This case demonstrates the importance of considering significant pathology in patients presenting with chronic complaints to the emergency department.

Accidental Chlorine Gas Exposure in a Pediatric Patient: A Case Report

Introduction: Chlorine gas is a known irritant of the respiratory tract, which may cause damage to various systems depending on time of exposure and concentration of the gas. Current treatments are mainly supportive. While no definitive studies have been completed to date, it has been noted that treatment with a sodium bicarbonate solution via nebulizer may lead to improved outcomes for patients dealing with chlorine gas exposure.

Case Report: We present a case of a nine-year-old child arriving at the emergency department after exposure to chlorine gas. Complete recovery from his symptoms occurred rapidly with the administration of nebulized sodium bicarbonate.

Discussion: Inhaled chlorine gas acts as a mucous membrane irritant, with symptoms usually beginning within minutes of exposure. Inhaled nebulized sodium bicarbonate has been suggested as a therapy for chlorine exposure. Although its mechanism of action is not well understood, it is thought that inhaled sodium bicarbonate neutralizes the hydrochloric acid formed when the chlorine gas reacts with the water in the lungs.

Conclusion: Nebulized sodium bicarbonate solution at a low concentration appeared to rapidly and effectively reverse the symptoms due to chlorine gas inhalation in a young child.

A Case of Hyperkalemia Versus Pseudohyperkalemia in Chronic Lymphocytic Leukemia

Introduction: Both hyperkalemia and pseudohyperkalemia occur in the emergency department. True hyperkalemia necessitates emergent treatment while pseudohyperkalemia requires recognition to prevent inappropriate treatment. It is imperative that the emergency physician (EP) have an understanding of the causes and clinical presentations of both phenomena.

Case Report: We present a case of an 88-year-old male with chronic lymphocytic leukemia (CLL) and suspected blast crisis who was found to have elevated serum potassium levels without other manifestations of hyperkalemia and eventually was determined to have pseudohyperkalemia due to white cell fragility.

Discussion: Differentiation of hyperkalemia and pseudohyperkalemia is a critical skill for the EP. We discuss multiple causes of hyperkalemia and pseudohyperkalemia in an effort to broaden the knowledge base.

Conclusion: We present a case of CLL as an unusual cause of pseudohyperkalemia and review common causes of pseudohyperkalemia.

High-Pressure Injection Injury of the Face: A Case Report on Presentation and Management

Introduction: High-pressure injection injuries have been chronicled for decades.1 These injuries often affect distal extremities as they are most commonly involved in workplace accidents.1 However, we discuss a young male with a paint-gun injection injury to his face.

Case Report: We discuss the case of a young man presenting to the emergency department after high-pressure injection injury to the face. He eventually underwent extensive debridement of the face. We discuss differences in caring for an injection wound to an extremity versus the face, including time sensitivity of treatment, initial stabilizing measures, and critical steps.

Discussion: This case demonstrates a rare presentation of a high-pressure paint injection injury. This injury presented a unique surgical challenge where, despite compartment syndrome being less common, cosmetic outcome and infectious complication prevention remained critical priorities.

Conclusion: While similarities exist in management of an injection injury to a limb, due to the rarity and deceptive appearance of this particular injury to the face, high suspicion along with urgent imaging and surgical consultation is warranted.

Rare External Jugular Vein Pseudoaneurysm

External jugular vein pseudoaneurysm is a very rare cause of a neck mass due to the low pressure venous system. This case demonstrates a 27-year-old female who presented to the emergency department with a non-tender, compressible, left-sided neck mass that enlarged with valsalva and talking, and intermittent paresthesias. Upon workup, she was diagnosed with an external jugular vein pseudoaneurysm. Complications of this diagnosis are mentioned in the literature; however, most patients with an external jugular vein pseudoaneurysm or aneurysm can be safely discharged with close follow-up with a vascular surgeon.

Images in Emergency Medicine

A Case of COVID-19 Pneumonia in a Young Male with Full Body Rash as a Presenting Symptom

Background: In December 2019 the coronavirus disease of 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2, was identified in Wuhan, China. In the ensuing months, the COVID-19 pandemic has spread globally and case load is exponentially increasing across the United States. Emergency departments  have adopted screening and triage procedures to identify potential cases and isolate them during evaluation.

Case Presentation: We describe a case of COVID-19 pneumonia requiring hospitalization that presented with fever and extensive rash as the primary presenting symptoms. Rash has only been rarely reported in COVID-19 patients, and has not been previously described.

Image to Fit the Clinical Picture: Point-of-care Ultrasound Assessment of Ebstein’s Anomaly in Peru

Ebstein’s anomaly is a congenital heart defect that when left untreated can lead to unique physical exam and ultrasound findings. This case describes a patient who presented with dyspnea and was found to have cyanosis, clubbing, and dilation of right-sided chambers on point-of-care ultrasound. The series of images highlights findings in late-stage Ebstein’s anomaly and serves as a springboard for the discussion of the pathophysiology, diagnosis, and treatment of this rare congenital heart disease.

  • 1 supplemental video

A Rare Case of Hip Pain Secondary to Pigmented Villonodular Synovitis

A 19-year-old Asian male presented to our emergency department with atraumatic right hip pain radiating to the right groin associated with pain on ambulation. Magnetic resonance imaging of the right hip with and without contrast revealed the diagnosis. Pigmented villonodular synovitis is a rare, monoarticular benign tumor originating from the synovium of the joint. The treatment is synovectomy of the pathological joint to prevent further disease progression.

Bowel Perforation in the Emergency Department Related to Bevacizumab Therapy and Recurrent Ovarian Cancer

Case Presentation: We describe the presentation to the emergency department of a patient with recurrent ovarian cancer treated with bevacizumab with the complication of bowel perforation. Discussion: We review the frequency and outcomes of bevacizumab-related bowel perforation. We also report the patient’s imaging findings, including the radiologic presentation of free intraperitoneal air and portal venous gas, both indicative of bowel perforation and the need for emergent surgical evaluation. Our case also illustrates the potentially catastrophic side effects of bevacizumab and other targeted oncologic therapies of which emergecny physicians may not be aware.

Ultrasonography of a Helical Left Common Carotid Artery

Case Presentation: An 83-year-old woman was admitted to the intensive care unit for septic shock at which point an internal jugular central venous line was placed. The patient’s common carotid artery was visualized in an atypical location, lateral to the internal jugular vein. Further inspection revealed the common carotid artery travelling in a rotational trajectory around the internal jugular vein.

Discussion: For at least two decades, point-of-care ultrasound has become the standard of care for placing central venous lines. This surprising anatomical orientation is rare and cautions physicians to fully explore a patient’s anatomy prior to placing central lines.

  • 1 supplemental video

55 year-old Female with Hematuria

Case Presentation: A 55 year-old female presented to the emergency department with left sided abdominal pain and hematuria. Computed tomography scan of her abdomen and pelvis demonstrated a large left renal mass with extension into the left ureter, left renal vein, and inferior vena cava. She was admitted and treated for presumed renal cell carcinoma (RCC).

Discussion: RCC may present with abdominal or flank pain and hematuria, but more commonly presents with vague symptoms. RCC should be suspected in a patient presenting with hematuria and abdominal or flank pain, especially if vague symptoms such as fatigue or anorexia are also present.

ACOEP Clinicopathological Cases (Invitation Only)

A 45-year-old Female with an Atypical Presentation of Pharyngitis

Introduction: Emergency physicians are trained to treat a variety of ailments in the emergency department (ED), some of which are emergent, while others are not. A common complaint seen in the ED is a sore throat. While most sore throats are easily diagnosed and treated, less common causes are often not considered in the differential diagnoses. Therefore, the purpose of this case study was to present an atypical case of sore throat and discuss differential diagnoses.

Case Presentation: The patient was a 45-year-old female who presented to the ED with a three-day history of sore throat that was exacerbated by eating and drinking. The patient was not on any prescription medications, but tried over-the-counter medications for the sore throat without any improvement in symptoms. Review of systems was positive for sore throat, fevers, and chills. Physical examination of her oropharynx revealed mildly dry mucous membranes with confluent plaques and white patchy ulcerative appearance involving the tongue, tonsils, hard palate, and soft palate. Rapid streptococcal antigen, mononucleosis spot test, and KOH test were performed and found to be negative.

Discussion: After initial testing was negative, a follow-up complete blood count with differential and complete metabolic profile were ordered. The patient was found to have decreased lymphocytes and platelets. Based upon those results, a diagnosis was made in the ED, the patient was started on medication, and further laboratory workup was ordered to confirm the diagnosis. ED providers should consider non-infectious as well as infectious causes for a sore throat, as this might lead to a diagnosis of an underlying condition.

ACOEP Case Reports (Invitation Only)

Low Back Pain and Swelling as an Atypical Presentation of IgA Vasculitis

Introduction: Immunoglobulin A vasculitis (IgA vasculitis), formerly Henoch-Schonlein purpura, is the most common vasculitis in children.

Case Report: A 6-year-old female presented with low back pain and swelling, difficulty ambulating, and rash two weeks after a respiratory infection. She was approached with a broad differential and ultimately diagnosed with IgA vasculitis.

Discussion: Cutaneous manifestations, arthralgias, renal and gastrointestinal involvement are the most common presenting signs of IgA vasculitis. Only two cases of IgA vasculitis associated with lumbar pain and swelling were identified in the literature.

Conclusion: While rash and joint pain are common presenting signs of IgA vasculitis, practitioners should be aware it can present atypically.

Fever Unmasked Brugada Syndrome in Pediatric Patient: A Case Report

Introduction: Brugada syndrome is an arrhythmogenic disorder that is a known cause of sudden cardiac death. It is characterized by a pattern of ST segment elevation in the precordial leads on an electrocardiogram (EKG) due to a sodium channelopathy.

Case Report: This case report highlights the case of a five-year-old female who presented to the emergency department with a febrile viral illness and had an EKG consistent with Brugada syndrome.

Discussion: Fever is known to accentuate or unmask EKG changes associated with Brugada due to temperature sensitivity of the sodium channels.

Conclusion: Febrile patients with Brugada are at particular risk for fatal ventricular arrhythmias and fevers should be treated aggressively by the emergency medicine provider. Emergency medicine providers should also consider admitting febrile patients with Brugada syndrome who do not have an automatic implantable cardioverter-defibrillator for cardiac monitoring.

Unsuspecting Dietary Factors in Hyperkalemia: A Case Report on Why History Matters

Introduction: We present a case of hyperkalemia secondary to excessive dietary intake of hard caramel candies.

Case Report: An 88-year-old male who presented with acute abdominal pain and vomiting was found to have hyperkalemia of 6.9 milliequivalents per liter. He was stabilized, treated, and discharged the following day after resolution. The cause was identified as his daily consumption of 200 hard caramel candies.

Discussion: The patient had been consuming sugar-free candies, which induced a chronic diarrhea. This led to potassium wasting and augmentation of his home medications. When he transitioned to eating regular caramel candies, he retained too much potassium leading to his presentation.

Conclusion: While often overlooked, dietary history is a crucial part of history-taking to ensure that the underlying cause for illness is discovered and addressed.

Brugada Syndrome: Presentation and Management of the Atypical Patient in the Emergent Setting

Introduction: Brugada syndrome is a genetic disorder of the heart’s electrical system that increases a patient’s risk of sudden cardiac death. It is a syndrome most prevalent in Southeast Asians and is found 36 times more commonly in Asians than in Hispanics.

Case Report: We report and discuss a case of a 68-year-old Hispanic male who presented with clinical and electrocardiogram abnormalities consistent with Brugada syndrome.

Discussion: The patient’s age and ethnicity represents an atypical presentation of this rare syndrome and the lack of reported studies in the literature pertaining to these demographics reflect this.

Conclusion: Further studies and characterizations are necessary as manifestations continue to be unearthed. As such, Brugada Syndrome should be considered in the differential diagnosis for a myriad of patient populations.

Spontaneous Carotid Artery Dissection Presenting as Trigeminal Neuralgia in the Emergency Department

Introduction: Carotid artery dissection (CAD) is a critical diagnosis in the emergency department (ED). Trigeminal neuralgia, while not uncommon, may cause the patient significant discomfort but generally is not attributed to severe morbidity and mortality.

Case Report: We present a case of spontaneous CAD presenting with the classic intermittent “lightning-like” jaw and head pain suggestive of trigeminal neuralgia that was ultimately diagnosed utilizing computed tomography angiogram after multiple visits to the ED.

Discussion: Coincidentally the patient had been started on anticoagulation a few days prior and no additional intervention was required.

Conclusion: This case report discusses current recommendations for diagnosis, treatment, and long-term prognosis of CAD.

Diet-induced Ketoacidosis in a Non-diabetic: A Case Report

Introduction: Anion gap metabolic acidosis is a common disorder seen in the emergency department. The differential can include toxicological, renal, endocrine, infectious, and cardiogenic disorders. Ketosis, however, is one of the rarer causes of metabolic acidosis seen by the emergency physician in developed nations.

Case Report: A 53-year-old female presented after starting a low-carbohydrate ketogenic diet for weight loss. She reported xerostomia, nausea with abdominal pain and a 17-pound weight loss over the previous 22 days. Labs revealed an anion-gap metabolic acidosis with ketosis. She was treated with 5% dextrose in normal saline and a sliding scale insulin coverage. Her anion gap corrected during her hospital course and was discharged on hospital day three.

Discussion: The ketogenic diet typically consists of a high-fat, adequate protein and low carbohydrate diet that has previously been thought to be relatively safe for weight loss. However, when carbohydrates are completely removed from the diet an overproduction of ketones bodies results in ketoacidosis. Treatment should be aimed at halting the ketogenic process and patient education.

Conclusion: Although rarely included in the differential for metabolic acidosis, diet-induced ketosis should be included by the emergency physician when faced with a patient who recently changed their eating patterns.

Portal Venous Thrombosis Associated with Use of Etonogestrel/ethinyl Estradiol Vaginal Ring

Introduction: Portal venous thrombosis is a life-threatening cause of abdominal pain. In younger patients, heritable thrombophilias, pregnancy, tobacco use, and oral contraceptives are associated.

Case Report: A 26-year-old woman prescribed contraceptive vaginal ring presented with abdominal pain and was diagnosed with an extensive portal venous thrombosis. Management included heparin and later an oral anticoagulant with good short-term outcome.

Discussion: Women using hormonal contraception are approximately four times more likely to develop thromboembolism. Risk of thromboembolism is similar between users of intravaginal and oral contraceptives.

Conclusion: Portal venous thrombosis must be considered in women presenting with abdominal pain who are prescribed hormonal contraceptives, including intravaginal forms.

Subacute Presentation of Central Cord Syndrome Resulting from Vertebral Osteomyelitis and Discitis: A Case Report

Introduction: Central cord syndrome (CCS) is a clinical syndrome of motor weakness and sensory changes. While CCS is most often associated with traumatic events. There have been few documented cases being caused by abscesses resulting from osteomyelitis.

Case Report: A 56-year-old male presented to a regional trauma center complaining of excruciating neck and bilateral upper extremity pain. Computed tomography of the cervical and thoracic regions revealed severe discitis and osteomyelitis of the fourth and fifth cervical (C4-C5) with near-complete destruction of the C4 vertebral body, as well as anterolisthesis of C4 on C5 causing compression of the central canal. Empiric intravenous (IV) antibiotic therapy with ampicillin/sulbactam and vancomycin was initiated, and drainage of the abscess was scheduled. After the patient refused surgery, he was planned to be transferred to a skilled nursing facility to receive a six-week course of IV vancomycin therapy. A month later, patient returned to emergency department with the same complaint due to non-compliance with antibiotic therapy.

Discussion: Delayed diagnosis and treatment of osteomyelitis can result in devastating neurological sequelae, and literature supports immediate surgical debridement. Although past evidence has suggested surgical intervention in similar patients with presence of abscesses, this case may suggest that antibiotic treatment may be an alternative approach to the management of CCS due to an infectious etiology. However, the patient had been non-compliant with medication, so it is unknown whether there was definite resolution of the condition.

Conclusion: In patients presenting with non-traumatic central cord syndrome, it is vital to identify risk factors for infection in a thoroughly obtained patient history, as well as to maintain a low threshold for diagnostic imaging.