Volume 4, Issue 4, 2020
CPC-EM Full-Text Issue
Clinicopathological Cases from the University of Maryland
A 40-year-old man presents to the emergency department with headache, nausea and paresthesias, with subsequent fever and mental status change. Magnetic resonance imaging showed increased fluid-attenuation inversion recovery signal involving multiple areas of the brain, including the pons. This case takes the reader through the differential diagnosis of rhombencephalitis (inflammation of the hindbrain) with discussion of the unanticipated ultimate diagnosis and its treatment.
Medical Legal Case Report
We present three medicolegal cases of medical negligence settled out of court. These cases all involved patients who presented to the emergency department (ED) with a suspected diagnosis of kidney stone. Highlighted are the importance of patient communication, addressing incidental findings found during a patient’s ED visit, anticipating complications, and the need for thorough documentation.
Introduction: The literature on the clinical course of severe acute respiratory syndrome coronavirus 2 (SARS-COV-2) suggests patients continue shedding viral particles typically for an average of 20 days until the body builds immunity against the infection. However, a few cases have shown prolonged duration in viral shedding and highlight the significant increased mortality in these patients. It has also been suggested that multiple strains of SARS-COV-2 exist, keying the possibility to reinfection.
Case Report: We present a case of a 57-year-old male who presented twice over 37 days with symptoms related to SARS-COV-2, and only on his second visit was found to be in hypoxemic respiratory failure and cardiogenic shock. He also reportedly had a period of convalescence in between presentations.
Discussion: This case highlights the still unclear disease course of SARS-COV-2 and the need for diligence in providing strong follow-up instructions and evaluation for sequelae of the infection.
Introduction: Coronavirus disease 2019 (COVID-19) rarely manifests with severe complications in pediatric patients. An association between COVID-19 and a Kawasaki-like inflammatory syndrome has recently presented in pediatric patients.
Case Report: We report a unique case of multisystem inflammatory syndrome in children presenting with characteristic findings in a child who later developed cardiogenic shock requiring venoarterial extracorporeal membrane oxygenation.
Conclusion: Recognition of these early signs and symptoms facilitates screening and risk stratification of pediatric COVID-19 cases associated with increased morbidity.
Delirium Associated with Salicylate and Acetaminophen Overdose in a Patient with COVID-19: A Case Report
Introduction: The coronavirus disease 2019 (COVID-19) pandemic has created numerous clinical challenges for physicians, in part due to its wide range of clinical manifestations and associated complications.
Case Report: Here we present the case of a 69-year-old man who was admitted to the emergency department with fever, dyspnea, and altered mental status. We believe the patient’s condition was precipitated by a COVID-19 infection-induced delirium, a setting in which he ingested aspirin and acetaminophen in overdose that required lifesaving interventions.
Conclusion: This case illustrates the potential for neuropsychiatric effects in COVID-19 patients due to both direct viral central nervous system pathology and pandemic-related psychosocial stressors.
Introduction: Coronavirus disease 2019 (COVID-19) is caused by the severe acute respiratory syndrome coronavirus 2. It typically presents with respiratory symptoms such as fevers, cough, and shortness of breath. As the number of cases increases, however, COVID-19 is being increasingly recognized as being associated with a variety of other respiratory pathologies.
Case Report: We present the case of a 59-year-old man with COVID-19 pneumonia who acutely decompensated after having been on the medicine floor for two weeks. He was found to have a tension pneumothorax. This was treated with a needle decompression followed by a chest tube insertion. The patient subsequently recovered and was discharged.
Conclusion: This case highlights the importance of considering tension pneumothorax as a possible cause of shortness of breath in patients with COVID-19 pneumonia.
Introduction: Coronavirus disease 2019 (COVID-19) has spread around the world and caused hundreds of thousands of fatalities across a wide spectrum of patients with varying severity and presenting complaints. The discussion of the ability of this disease to cause significant illness in patients with various risk factors such as myasthenia gravis is important to help guide physicians on recognition and treatment options as the pandemic matures.
Case Report: Here we discuss a single case of isolated COVID-19 infection that precipitated a myasthenic crisis with no other clinical sequelae in a patient who presented to the emergency department (ED). This report highlights some of the initial difficulties and delay in diagnosis encountered earlier in the pandemic with limited testing supplies and processing labs; however, prompt ED recognition and treatment still led to a favorable outcome.
Conclusion: The patient recovered during this initial presentation and was successfully treated with plasma exchange and steroids only. It is important to recognize that myasthenia gravis patients may represent a uniquely vulnerable population that requires enhanced surveillance and screening to prevent significant morbidity and mortality. This case describes how even a mild infection with no significant clinical sequelae or significant signs on imaging studied can precipitate a crisis event.
The Evolution of Ultrasound in Medicine: A Case Report of Point-of-care Ultrasound in the Self-diagnosis of Acute Appendicitis
Introduction: Point-of-care ultrasound (POCUS) education during medical school develops physicians who are properly prepared for the next generation of medicine. The authors present the case of a first-year medical student who self-diagnosed appendicitis using POCUS.
Case Report: A 25-year-old, first-year medical student presented to the emergency department with lower abdominal pain. What seemed like a straightforward appendicitis presentation came with a twist; the student brought self-performed ultrasound imaging of his appendix.
Conclusion: The student’s ultrasound skill set reflects favorably on the rapid evolution of ultrasound teaching in medical education.
Introduction: Patients with naturally occurring, impaired cell-mediated immunity secondary to age and pregnancy are known to be at risk of developing severe and invasive Listeria monocytogenes infections. Immunosuppressant medications, particularly infliximab, are also known to increase this risk.
Case Report: We present the case of a seven-year-old female on infliximab who was diagnosed with culture positive L. monocytogenes meningitis after a negative cerebral spinal fluid polymerase chain reaction (PCR).
Conclusion: Patients receiving infliximab who display signs of central nervous system infection should be suspected to have L. monocytogenes as an infecting agent, and empiric addition of ampicillin to their antibiotic regimen should be considered, with substitution of trimethoprim-sulfamethoxazole in cases of penicillin allergy, regardless of initial PCR results.
Cerebral Malaria in a Patient with Recent Travel to the Congo Presenting with Delirium: A Case Report
Introduction: Cerebral malaria, a syndrome of altered consciousness, is a rare and severe neurologic complication resulting from Plasmodium falciparum.1 Historically, cerebral malaria has been seen more frequently in children rather than adults. To complicate the diagnosis, cerebral malaria has few specific symptoms and neurologic findings can vary with each case.
Case Report: We describe a case of a 61-year-old male who returned from the Democratic Republic of Congo and presented to the emergency department with dehydration, fatigue, and intermittent confusion. He was ultimately diagnosed with cerebral malaria caused by P falciparum.
Conclusion: Even with close monitoring and appropriate treatment, cerebral malaria carries a severe risk of long-term neurocognitive deficits and a high mortality rate.
Introduction: Drug overdose represents a growing reason for emergency department visits and hospitalizations in the United States. Co-ingestion of multiple substances is also on the rise, and toxidromes can be seen from any of multiple drugs in a single patient.
Case Report: We present a case of diffuse alveolar hemorrhage secondary to cocaine abuse in a patient who was apneic and unresponsive after heroin overdose. The patient responded to supportive care and was discharged with complete return to physical and mental baseline.
Conclusion: Clinicians must be vigilant for any number of concomitant toxidromes when a patient is brought in with complications following drug overdose.
Introduction: Thyroid storm is a medical emergency associated with significant mortality. Hyperthyroid states have been associated with hypercoagulability as well as rhabdomyolysis. However, the pathophysiology of this association remains under investigation.
Case Report: A 62-year-old male patient presented to the emergency department with weakness and was found to have thyroid storm with concurrent submassive pulmonary embolisms and rhabdomyolysis. To our knowledge, this is the first reported presentation of this triad.
Conclusion: This case highlights the potentially difficult diagnosis and management of thyroid storm, as well as associated life-threatening complications, including venous thromboemboli and rhabdomyolysis.
Introduction: Giant urinary bladder calculus in an adult is an uncommon entity. The number of patients with giant bladder calculi has decreased over recent years owing to wider availability of healthcare and better diagnostic modalities.
Case Report: We present a case of a young adult without any history of recurrent urinary tract infections or bladder outlet obstruction with giant vesical calculus who presented to the emergency department with gross hematuria, abdominal pain, and dysuria. Investigations revealed a large calculus in the urinary bladder, and suprapubic cystolithotomy was performed. A large stone of 6.5×6×5.5 centimeters, weighing 125 grams, was removed. On follow-up, the patient was free of any symptoms and cystoscopy was normal.
Conclusion: Urinary outflow obstruction must be ruled out in all patients with giant vesical calculus. Patients without any predisposing condition should be treated as a separate entity and evaluated accordingly. Multiple surgical treatment modalities are available for bladder calculus patients. Treatment is personalised as per size of stone, number of stones, and associated comorbidities.
A Case Report of a Novel Harm Reduction Intervention Used to Detect Opioid Overdose in the Emergency Department
Introduction: As over 130 people die daily from opioid overdose in the United States, harm reduction strategies have become increasingly important. Because public restrooms are a common site for opioid overdose, emergency department waiting room restrooms (EDWRR) should be considered especially high-risk areas.
Case Report: We present the case of a patient found after a presumed opioid overdose in our EDWRR. Staff were alerted to his condition by a reverse motion detector (RMD), and rapidly treated him with naloxone.
Conclusion: The RMD is a novel intervention that can save lives and should be considered in EDs with a high incidence of opioid overdose.
Introduction: The clinical presentation of pulmonary embolism (PE) is often associated with classic vital instability such as tachycardia, hypoxia, and tachypnea. This critical diagnosis is often less likely if a patient is negative by Pulmonary Embolism Rule-Out Criteria (PERC) standards with a low pre-test probability of disease. Caution must be used when evaluating elite athletes with the PERC rule due to low resting heart rate and certain risk factors, which are inherent to athletics.
Case Report: We report the case of a 20-year-old male Division 1 collegiate athlete with pleuritic chest pain diagnosed with PE despite being PERC negative. His presenting heart rate (HR) of 79 beats per minute was correctly determined to be tachycardic relative to his resting HR of 47-60 beats per minute. Despite his PERC negative status, PE was found after an elevated D-dimer and subsequent computed tomography angiography.
Conclusion: Special consideration should be used when evaluating elite athletes for PE, as their resting physiology may differ from the general population. Additionally, certain risk factors for thromboembolic disease are inherent in competitive athletics and should be considered during an initial risk assessment. The presented patient was successfully treated with oral anticoagulation for three months and was able to return to play.
Introduction: Abdominal pain is a common complaint in the emergency department. Point-of-care ultrasound (POCUS) is a rapid modality to evaluate for the etiology.
Case Report: A teenage male presented with symptoms concerning for appendicitis. POCUS revealed a non-peristalsing, non-compressible, tubular structure containing an echogenic stone. This was determined to be a ureteral stone within a dilated ureter, not appendicitis.
Conclusion: We propose a syndromic sonographic approach to right lower quadrant pain (RLQ) that includes the gallbladder, right kidney, bladder, and right adnexa, in addition to RLQ landmarks. This case emphasizes the value of such an approach to avoid diagnostic error.
- 1 supplemental video
Introduction: Ectopic pregnancy carries a high morbidity and mortality; patients are at risk for rupture and life-threatening hemorrhage.
Case Report: We present a rare case of ruptured abdominal ectopic pregnancy in a patient with a well-positioned intrauterine device (IUD) and discuss the diagnostic utility that transabdominal point-of-care ultrasound (POCUS) can have when performed at the bedside.
Conclusion: While pregnancy with an IUD in place is rare, when it is encountered the emergency provider should maintain a high degree of suspicion for extrauterine pregnancy and perform prompt evaluation for hemorrhagic shock using diagnostic POCUS.
Introduction: In patients with known malignancy and possible intracranial metastatic disease who are receiving treatment with therapeutic anticoagulation, limited data exist regarding risk of intracranial bleeding.
Case Report: We present a case of a 64-year-old female with known lung malignancy, evidence of possible metastatic disease, and bilateral deep vein thrombosis, who suffered severe intracranial hemorrhage following initiation of therapeutic anticoagulation. Current guidelines, available risk- stratification tools, and treatment options with their risks are discussed.
Conclusion: In patients with known or suspected intracranial metastatic disease, clinical decision tools can assist both the clinician and the patient in weighing risks and benefits of anticoagulation.
Introduction: Allergic fungal sinusitis (AFS) is a relatively uncommon cause of sinus pain and congestion. Extreme cases may require specialty evaluation and surgical treatment.
Case Report: In this case, an otherwise healthy young man presented to the emergency department with sinus pain and congestion for two weeks and was admitted to surgery for resection of his AFS.
Conclusion: This case demonstrates how a thorough history and physical exam can help catch potentially serious diseases, such as allergic fungal sinusitis, from the frequently benign chief complaint of sinus pain.
Inhaled Tranexamic Acid for Massive Hemoptysis in the Setting of Oral Anticoagulation: A Case Report
Introduction: We discuss a case of massive hemoptysis in the setting of a direct-acting oral anticoagulant (DOAC) successfully managed with nebulized tranexamic acid (TXA).
Case Report: Per the American College of Cardiology and the American Society of Hematology, it is recommended that significant bleeding associated with a DOAC be treated with either 4-factor prothrombin complex concentrate or andexanet alfa. However, our patient was at high risk for thrombotic complications given a recent pulmonary embolism.
Conclusion: We demonstrate that it is reasonable to trial nebulized TXA given its low cost, ease of administration, and safety profile. Additionally, this report discusses a unique dosing strategy and a previously unreported complication associated with nebulization of undiluted TXA.
Introduction: Silica gel packets are commonly used desiccants for medication products; these packets generally only pose a choking risk in young children. However, new cylindrical desiccant canisters have been developed, which may increase the risk for obstruction in adults.
Case Report: An elderly male presented to the emergency department complaining of difficulty swallowing after taking his morning medications. Through a diligent work-up a desiccant canister was found lodged in the lower esophageal sphincter. The patient was endotracheally intubated and a Roth Net retriever was used to remove the canister.
Conclusion: Cylindrical desiccant canisters pose an increased risk of esophageal obstruction.
Introduction: The nasopharyngeal airway (NPA) is used by emergency providers and first responders to assist with oxygenation in obtunded, critically ill patients. There are few recorded NPA complications.
Case Report: We describe a unique case in which a patient went multiple days with recurrent symptoms of upper airway obstruction secondary to retained NPA. Discussion: Nasopharyngeal airways may be uniquely prone to being displaced and retained due to their use in emergent situations, their small size, and time of insertion in the field prior to emergency department (ED) contact where handoff is not often standardized.
Conclusion: The use of large-flanged NPAs might reduce incidences of displacement into the nasal cavity. This case highlights the need for improved handoff communication between emergency medical services and ED staff, especially to account for all inserted devices to prevent foreign body retention.
Introduction: Emergency providers should recognize that pneumothorax is a rare but serious complication of shoulder arthroscopy that may require a unique approach to decompression.
Case Report: We present a case of a 60-year-old female who presented to the emergency department with right-sided facial swelling, voice change, and shortness of breath three hours after an elective arthroscopic right rotator-cuff repair and was noted to have a right-sided pneumothorax. We also describe a potential novel approach to chest tube decompression that maintains shoulder adduction in patients with recently repaired rotator cuffs.
Conclusion: Although most cases of post-arthroscopy pneumothoraces are reported in patients who received regional anesthesia or have underlying lung pathology, it can occur in lower-risk patients as was demonstrated in our case. We also suggest considering an alternative anterior approach between the midclavicular and anterior axillary lines for chest decompression in select patients when a traditional approach is less ideal due to the need to maintain shoulder immobilization postoperatively.
Introduction: Persistent left-sided superior vena cava is a rare congenital venous malformation. While often clinically asymptomatic, these variations in normal anatomy may give rise to complications with central venous catheter placement.
Case Report: We present a case of a 71-year-old male who presented to the emergency department with sepsis of unknown etiology. A right-sided central venous catheter was placed, and due to a persistent left-sided superior vena cava the post-procedure chest radiograph showed a uniquely positioned catheter tip within the left atrium.
Conclusion: A persistent left-sided superior vena cava may lead to uniquely positioned catheter tip placement on post-procedural imaging. This case demonstrates the need to consider variants in normal venous anatomy, such as persistent left-sided superior vena cava, to aid with correct interpretation of post-procedure imaging findings.
Introduction: Priapism, a time-sensitive urologic emergency, is associated with hematologic disorders, malignancies, trauma, pharmaceuticals, and recreational drugs.
Case Report: A 51-year-old male presented with 36 hours of priapism after recreational use of nonprescribed pharmaceuticals including an oral phosphodiesterase inhibitor and intracorporally injected erectile medications, together with unspecified quantities of cocaine and alcohol. Venous blood gas confirmed ischemic priapism. Detumescence was achieved with intracavernosal phenylephrine injection, aspiration, and irrigation.
Conclusion: This case highlights the risk that recreational use of vasoactive medications by patients who seek to prolong sexual activity may lead to delayed presentation for ischemic priapism
Introduction: Silicone has been commonly used for both major and minor plastic and reconstructive surgery for decades. Due to the high costs associated with minor cosmetic procedures and plastic surgery, the unauthorized use of silicone injections by laypersons has become increasingly common. Improper or illegal subcutaneous injectable silicone has caused significant pulmonary complications and neurological complications, which can range from mild chest pain, hypoxia, and respiratory failure to coma and altered mental status.
Case Report: We present a patient who had a rare complication of respiratory failure secondary to silicone embolism syndrome (SES). SES is a rare, potentially deadly complication and has been associated with subcutaneous silicone injections. The diagnosis of SES can be challenging and requires a thorough patient history indicating recent cosmetic procedures.
Conclusion: This case describes the first case of SES of a male patient who presented to a community emergency department complaining of dyspnea after an episode of self-administered injectable silicone into his penis and scrotum and who developed SES-induced respiratory failure.
Introduction: Tetanus is an acute onset neurological disease that is often lethal. It has a high disease burden in low and middle-income countries. Tetanus is caused by a toxin made by spores of the bacterium Clostridium tetani, which are found in soil, dust, and animal feces. The toxin impairs the motor neurons leading to muscle stiffness. However, with the development of a toxoid vaccine, the incidence has sharply declined and is now categorized as a vaccine-preventable disease. The treatment of tetanus is primarily supportive and focuses on managing the complications until the effects of toxins resolve.
Case Report: We report the case of a 67-year-old farmer who previously sustained a laceration injury approximately 45 days prior to presenting to the emergency department with abdominal pain and rigidity. After a comprehensive evaluation to rule out other items in the differential diagnoses, he was diagnosed with tetanus based on clinical symptoms and ultimately required mechanical ventilation. The patient was then managed in the intensive care unit and later made an uneventful recovery.
Conclusion: This case illustrates an uncommon presentation of tetanus and the latency of the infectious process. Often when patients present with atypical symptoms, it poses a diagnostic dilemma to the clinicians. Thus, it is very important to carefully elicit a history of contaminated injury. This case also highlights the importance of prophylactic vaccine in low and middle-income countries, which can reduce disease-related mortality and morbidity.
A Case Report of B-cell Lymphoblastic Leukemia/Lymphoma Presenting as Isolated Torticollis in a 2-year-old Female
Introduction: Malignancy is a rare cause of acquired torticollis in children, and spinal cord involvement from hematolymphoid malignancies is similarly unusual. Neurologic abnormalities may not be present on initial evaluation, and delayed diagnosis and treatment is associated with increased risk of permanent paralysis.
Case Report: The author describes a case of isolated torticollis in a 2-year-old evaluated multiple times in the emergency department (ED) and outpatient settings. For her first three presentations, the patient had no associated neurologic abnormalities. She was discharged with return precautions and a presumptive diagnosis of viral infection/lymphadenitis. She later developed weakness of her left arm and was diagnosed with a B-cell lymphoblastic leukemia/lymphoma causing spinal cord compression.
Conclusion: This case highlights the importance of continued comprehensive and meticulous physical examination in patients with repeat ED visits, as well as the value of detailed discharge instructions in mitigating diagnostic delays in these patients.
Introduction: Spontaneous rupture of an inferior epigastric artery aneurysm is rare with very few cases reported in the medical literature. Although surgical options are available, this case was managed conservatively with outpatient management.
Case Report: A 29-year-old male presented with right groin pain and swelling that was initially felt to be consistent with an incarcerated inguinal hernia. Further evaluation revealed spontaneous rupture of an inferior epigastric artery aneurysm. The patient was treated conservatively and was ultimately discharged home from the emergency department.
Conclusion: Due to the similar clinical presentations, it was important to consider a broad differential to ultimately arrive at the correct diagnosis. In some reported cases of spontaneous epigastric artery aneurysm, surgical intervention was required for control of the bleeding. In our patient, however, conservative management was employed, and the patient was able to be safely discharged with close outpatient follow-up.
Gastric Diverticulum Presenting as Hematemesis: A Case Report Detailing an Uncommon Presentation of an Already Rare Entity
Introduction: Gastric diverticula (GD) are uncommon. Most are asymptomatic and diagnosed incidentally. Symptoms range from reflux and epigastric discomfort to life-threatening bleeding and perforation. We describe a case of symptomatic GD presenting as hematemesis requiring surgical treatment.
Case Report: A 57-year-old female presented to the emergency department (ED) with one day of epigastric pain and hematemesis. Hemoglobin was found to be stable, but blood urea nitrogen was elevated. Imaging revealed a fundal GD. Esophagogastroduodenoscopy did not show other etiology of hematemesis. The patient underwent partial gastric resection for GD removal and did well without further symptoms on follow-up.
Conclusion: Although rare, GD needs to be included on a differential diagnosis when evaluating gastrointestinal symptoms in the ED. Patients may present with an array of complaints but can potentially develop serious complications. Providers should be familiar with the diagnostic options and treatment regimens available to better care for patients presenting with GD.
Dysphagia Alone as a Unique Presentation of Wound Botulism in the Emergency Department: A Case Report
Introduction: Wound botulism is a rare and potentially fatal infectious disease, often seen in patients who abuse injection drugs. It classically presents with dysfunction of bilateral cranial nerves followed by proximal and distal motor weakness, which can progress to respiratory failure.
Case Report: We report a case of a 31-year-old female who presented to the emergency department for the fifth time with an eight-day history of isolated dysphagia without any other neurologic symptoms. She reported a history of injection drug abuse via “skin popping,” was admitted to the hospital, and ultimately diagnosed with wound botulism.
Conclusion: This case exemplifies the diagnostic pitfalls of rare diseases such as wound botulism and provides insight regarding the diagnosis and treatment of this entity. This case also highlights the unique medical and social challenges emergency physicians face while trying to reliably evaluate patients who abuse controlled substances.
Introduction: Supraventricular tachycardia (SVT) is a condition requiring emergency care in neonates.
Case Report: We describe a successfully treated case of neonatal SVT in a four-week-old neonate using the novel adenosine administration method. This technique is potentially easier to facilitate and does not require equipment such as a stopcock. Adenosine 0.2 milligrams per kilogram was drawn up into a syringe containing 0.9% sodium chloride to a total volume of 3 milliliters. Once administered, the patient had near-immediate return to normal sinus rhythm without sequelae.
Conclusion: This case demonstrates that the single-syringe method appears potentially safe and effective in neonates.
Introduction: Bowel obstruction is a rare but well reported complication of blunt abdominal trauma (BAT). Obstruction is most often seen acutely caused by bowel wall hematomas and chronically as a result of post-traumatic strictures. Here, we present a novel case of BAT causing a subacute obstructing bowel wall hematoma.
Case Report: A healthy, 32-year-old male presented to our emergency department with three days of nausea and vomiting. Chart review revealed he had been seen two weeks prior after a high-speed motor vehicle collision. During that initial visit, the patient had a benign abdominal exam and was discharged without imaging. On this return visit, the patient was found to have a large, obstructing colonic hematoma.
Conclusion: Because emergency physicians care for patients in both the acute and subacute phases of trauma, clinicians should recognize the more subtle sequelae of BAT.
Case Report of Traumatic Uterine Rupture in a Multigravida Woman with Emergency Department Cesarean Section
Introduction: Uterine ruptures in blunt trauma are an extremely rare complication. Furthermore, while perimortem cesarean sections in cardiac arrest patients are a well-established practice in emergency medicine, cesarean sections in the emergency department are rarely performed on non-arresting patients.
Case Report: A multigravida woman at approximately 24 weeks gestation presented as a transfer from an outside hospital after a motor vehicle collision. Upon arriving to our facility, she underwent an emergency cesarean section in the trauma bay and was found to have a uterine rupture with the fetus free floating in the right upper quadrant of the abdomen.
Conclusion: Uterine rupture is a rare but important complication of blunt abdominal trauma in pregnant patients. Resuscitative cesarean sections may be necessary for favorable outcomes. A well prepared and diversified team was essential to maternal survival.
Images in Emergency Medicine
Case Presentation: A 53-year-old male presented to the emergency department with acute onset of bilateral hearing loss as well as vertigo and severe vomiting. The Head Impulse– Nystagmus–Test of Skew exam was indicative of a central neurologic process. Computed tomography angiogram of the head and neck revealed near-total bilateral vertebral artery occlusions in the second and third segments. The patient was admitted for further evaluation; subsequent magnetic resonance imaging revealed multiple areas of infarction in the cerebellar hemispheres, medulla, and occipital lobes.
Discussion: This case describes a unique presentation of a posterior stroke. Common symptoms include vertigo, loss of balance, and vomiting. However, bilateral hearing loss as a prominent symptom is uncommon. Imaging revealed a rare finding of bilateral vertebral artery occlusion.
Point-of-care Ultrasound in the Evaluation of Mitral Valve Regurgitation and Mitral Annular Calcification
Case Presentation: A 77-year-old female presented to the emergency department (ED) with chest pain. Cardiac point-of-care ultrasound (POCUS) was performed and demonstrated a hyperechoic structure on the posterior leaflet of the mitral valve. Admission to cardiology and echocardiogram revealed moderately decreased mobility of the posterior leaflet, mitral annular calcification, and severe mitral regurgitation.
Discussion: These findings highlight the role of POCUS in identifying mitral valve pathology in the ED, ultimately leading to appropriate disposition and management. Mitral annular calcification can lead to significant manifestations including mitral stenosis or regurgitation, and advanced cases have been associated with an increased risk of infective endocarditis, thrombosis, and arrhythmia.
- 1 supplemental video
Case Presentation: A 61-year-old female presented to the emergency department with right upper quadrant abdominal pain following a cholecystectomy 18 days prior. Computed tomography (CT) of her abdomen demonstrated a large abscess in her post-hepatic fossa. She was admitted to the general surgery service and received an image-guided percutaneous drain placement with interventional radiology with immediate return of purulent material. She was discharged home after a three-day hospital course with outpatient antibiotics and follow-up.
Discussion: Patients may have multiple complications following cholecystectomy, including infection, bleeding, biliary injury, bowel injury, or dropped stone. The emergency clinician must consider cholecystectomy complications including gallbladder fossa abscess in patients presenting with abdominal pain in the days to weeks following cholecystectomy, especially if they present with signs of sepsis. Critical actions include obtaining CT and/or ultrasonography, initiating broad spectrum antibiotics, and obtaining definitive source control by either surgery or interventional radiology.
Case Presentation: A 48-year-old-female presented to the emergency department with dislodgement of her percutaneous endoscopic gastrostomy (PEG) tube, necessitating bedside replacement. Replacement was done without difficulty and gastrografin radiography was obtained to confirm positioning. Radiography revealed contrast filling the colon at the splenic flexure and proximal descending colon suggestive of colocutaneous fistula formation.
Discussion: The patient required hospitalization with surgical consultation, initiation of parenteral nutrition, and conservative management of the fistula with surgical replacement of the PEG tube. Although rare, it is paramount for the emergency physician to be aware of this complication when undertaking bedside replacement of PEG tubes.
Case Presentation: A 63-year-old female presented to the emergency department complaining of cough, neck swelling, dysphagia, and dysphonia for two days, with a past medical history of atrial fibrillation managed with warfarin. Investigations revealed a supratherapeutic international normalised ratio (greater than 10). Imaging and endoscopic examination showed an extensive retropharyngeal hematoma with significant mass effect on the airway.
Discussion: A rare but potentially fatal complication of warfarin anticoagulation is upper airway hematoma, with violent coughing described as an inciting cause. Signs of airway compromise necessitate specialist consultation and definitive airway management, while mild cases without airway concerns can be managed conservatively with medical anticoagulation reversal.
Case Presentation: A 24-year-old pregnant female presented to the emergency department with lower abdominal cramping and vaginal bleeding. A point-of-care ultrasound demonstrated a calcified yolk sac.
Discussion: When identified, calcification of the yolk sac in the first trimester is a sign of fetal demise. It is important for an emergency physician to be aware of the various signs and findings on point-of-care ultrasound and be familiar with the management of these pathologies.
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ACOEP Clinicopathological Cases (Invitation Only)
A 54-year-old female with facial swelling for one month who had repeatedly been treated for allergic reaction during multiple emergency department (ED) visits, presented to the ED for the same complaint of facial swelling. Maintaining a broad differential diagnosis was of critical importance to appropriately evaluating the patient and arriving at the correct conclusion for the etiology of the patient’s symptoms. Upon establishing the correct diagnosis, a multidisciplinary approach was used to intervene to provide early treatment without delay.
ACOEP Case Reports (Invitation Only)
Introduction: Soft tissue injuries are a common presenting complaint seen in the emergency department following trauma. However, internal degloving injuries are not commonly seen by the emergency provider.
Case Report: A 57-year-old male presented with right lower extremity pain, bruising, and swelling after a low-speed bicycle accident five days prior. Physical examination revealed an edematous and ecchymotic right lower extremity extending from the mid-thigh distally. Computed tomography of the thigh demonstrated a hyperdense foci within the fluid collection suggesting internal hemorrhage and internal de-gloving suggestive of a Morel-Lavallée lesion.
Discussion: The Morel-Lavallée lesion is a post-traumatic soft tissue injury that occurs as a result of shearing forces that create a potential space for the collection of blood, lymph, and fat. First described in 1853 by French physician Maurice Morel-Lavallée, this internal degloving injury can serve as a nidus of infection if not treated appropriately. Magnetic resonance imaging has become the diagnostic modality of choice due to its high resolution of soft tissue injuries. Treatment has been focused on either conservative management or surgical debridement after consultation with a surgeon.
Conclusion: The emergency physician should consider Morel-Lavallée lesions in patients with a traumatic hematoma formation to avoid complications that come from delayed diagnosis.
Introduction: Chest pain is one of the most common causes of emergency department visits on an annual basis and carries a high degree of morbidity and mortality if managed inappropriately.
Case Report: A 36-year-old male presented with four months of left-sided chest pain with dyspnea on exertion. Physical examination and laboratory values were within normal limits. Chest radiograph depicted diffuse interstitial nodular opacities throughout the lungs bilaterally with bilateral perihilar consolidations. Computed tomography of the chest demonstrated mid and upper lung nodularity with a perilymphatic distribution involving the central peribronchial vascular regions as well as subpleural and fissural surfaces causing conglomerate in the upper lobes centrally with associated hilar and mediastinal lymphadenopathy. The next day the patient underwent bronchoscopy with endotracheal ultrasound and transbronchial biopsies and pathology revealed non-necrotizing, well-formed granulomas embedded in dense hyaline sclerosis consistent with sarcoidosis.
Discussion: Sarcoidosis is a multi-system granulomatous disease characterized by noncaseating granulomas on pathology. The worldwide epidemiology of sarcoidosis is currently unknown due to many patients being asymptomatic. However, patients may present with a persistent cough, dyspnea, or chest pain. Emergency department management should be aimed at minimizing long-term sequelae of the disease through obtaining labs and imaging after specialist consultation and arranging urgent follow-up.
Conclusion: Although not one of the six high-risk causes of chest pain, sarcoidosis should be included in the differential to minimize the risk of long-term morbidity associated with advanced forms of the disease.
Introduction: The number of nontraumatic dental pain emergency department (ED) visits continues to substantially rise in frequency every year. While there are several methods for treating dental pain, an inferior alveolar nerve block (IANB) is a non-narcotic alternative that provides instantaneous relief of severe pain.
Case Report: A 59-year-old male presented to the ED from a dentist’s office for evaluation of a right-sided headache with an associated episode of palpitations and near syncope that developed while receiving an inferior alveolar nerve block. Computed tomography of the patient’s head revealed multiple small foci of air in the right temporalis muscle and in the intracranial venous drainage system. Given the patient’s history of dental procedure, the intravascular introduction of air and local anesthetic was suspected.
Conclusion: Inferior alveolar nerve block procedures can have complications, including hematoma formation, trismus, facial palsy, needle breakage, and in this case, intravascular injection and cerebral air embolism. To perform a successful IANB, it is critical for providers to be familiar with anatomical landmarks and to consistently perform aspiration to confirm that needle placement is not intravascular.
Introduction: Neurological complaints are a common presenting symptom seen by the emergency physician. However, the Miller-Fisher variant of Guillain-Barré syndrome is a rare cause of neurological complaints seen in the emergency department.
Case Report: A 26-year-old male presented with dysphonia and bilateral hand and feet paresthesia after a recent diarrheal illness. Examination revealed the absence of tricep, brachioradialis, patellar and Achilles tendon reflexes bilaterally, and difficulty with phonation. Lumbar puncture revealed the presence of anti-GQ1b antibodies, and the patient was diagnosed with Miller-Fisher variant of Guillain-Barré.
Discussion: Miller-Fisher syndrome is an acute, autoimmune response that typically follows either an upper respiratory or diarrheal illness. Typically associated with dysfunction of cranial nerves three, four, and six, Miller-Fisher syndrome may present with facial paralysis, opthalmoplegia, arefexia, or ataxia. Lumbar puncture with the presence of anti-GQ1b antibodies is indicative. Treatment could include supportive respiratory care, intravenous immunoglobulin therapy, or plasmapheresis.
Conclusion: Miller-Fisher syndrome is a rare form of Guillain-Barré syndrome that the emergency provider should include in the differential when faced with a patient with cranial nerve dysfunction.
Appropriate Evaluation of Psychiatric Patients Highlighted by Creutzfeldt-Jakob Disease: A Case Report
Introduction: Determination of medical stability for patients presenting with psychiatric complaints is common for emergency clinicians. A thorough history and physical examination is important.
Case Report: A 53-year-old male presented to the emergency department (ED) with depression, suicidal ideation, and decline in activities of daily living over six months. While his initial neurologic examination was non-focal, subsequent re-evaluations demonstrated significant changes, and he was ultimately diagnosed with Creutzfeldt-Jakob disease.
Conclusion: This case demonstrates how a detailed history of the present illness could have led to a more accurate and timely medical disposition from the ED.
Introduction: While the electrocardiogram (ECG) for pulmonary embolism typically shows tachycardia or evidence of right heart strain, it can demonstrate ischemic changes similar to acute coronary syndrome.
Case Report: The patient in this case presented with syncope, chest pain, and an ECG showing an anterior acute myocardial infarction (AMI) without evidence of right heart strain. His cardiac catheterization showed no coronary artery occlusions, but some signs of pulmonary embolism (PE), which was confirmed on computed tomography angiography of the chest.
Conclusion: This case demonstrates that PE should be high on the differential for AMI and describes an uncommonly encountered mimic for classic ST-elevation myocardial infarction ECG changes. Further diagnostics to confirm the diagnosis should be obtained when indicated.
Introduction: Dermatology complaints account for 3.3% of emergency department (ED) visits per year. Most rashes are benign, but there are a select few that emergency physicians must be familiar with as delay in treatment could be life threatening.
Case Report: A well-appearing, 76-year-old male presented to the ED with multiple coalescing pustules to his palms and soles and was transferred to the nearest tertiary care hospital for dermatology consult. He was diagnosed with palmoplantar pustulosis and discharged home with a five-day course of clobetasol propionate 0.05% cream twice daily and outpatient dermatology follow-up.
Conclusion: Palmoplantar pustulosis is an uncommon skin condition characterized by recurrent eruptions of sterile pustules localized to the palms and soles. Emergency physician awareness of this rare diagnosis may help prevent hospital admissions and lead to earlier initiation of treatment with outpatient dermatology follow-up.
Introduction: Sepsis commonly brings patients to the emergency department (ED). Patient outcomes can vary widely. In some cases, rare complications of sepsis such as autoimmune hemolytic anemia can occur.
Case Report: A 68-year-old female presented with sepsis secondary to infected nephrolithiasis. The patient had signs and symptoms consistent with hemolysis upon arrival to the ED. Her hemolysis progressively worsened over a two-day period leading to a diagnosis of warm autoimmune hemolytic anemia. She responded well to treatment; however, her condition began to worsen due to a new infection caused by perforated colonic diverticula. The patient ultimately expired from complications of her perforated colonic diverticula.
Conclusion: It is crucial that emergency physicians understand the risk factors, symptoms, pathophysiology, and treatment of this rare complication of sepsis so that favorable patient outcomes can be achieved.
Introduction: Lyme disease typically presents with viral-like symptoms and a pathognomonic rash. With disease progression, symptoms of nervous system involvement usually include facial nerve palsy and meningitis, but other atypical neurologic manifestations have less commonly been documented.
Case Report: A six-year-old male presented with prolonged fevers, rash, headache, and non-specific neurologic symptoms. The diagnosis of neuroborreliosis with meningitis and polyradiculitis was confirmed with laboratory evaluation and lumbar puncture.
Conclusion: Neuroborreliosis is a disseminated form of Lyme disease. While meningitis is a common sign, the presentation of polyradiculitis in children is rare and can lead to misdiagnosis and delay in treatment.
ACOEP Images in Emergency Medicine
Case Presentation: A 40-year-old male presented the the emergency department (ED) due to a diffuse body rash after a sexual encounter. Examination revealed a maculopapular rash that included the palms and soles of the feet bilaterally. A rapid plasma reagin was positive, and the patient was treated with 2.4 million units of benzathine benzylpenicillin intramuscularly.
Diagnosis: Secondary syphilis can mimic many disease processes but classically presents as a painless macular rash on the palms of the hands and soles of the feet. Diagnosis is based upon clinical examination coupled with serological testing. Emergency department management should include 2.4 million units of benzathine benzylpenicillin intramuscularly and mitigation strategies.