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Open Access Publications from the University of California

Clinicopathological Cases from the University of Maryland

55-year-old Male with Fatigue

This clinicopathological case presentation from the University of Maryland details the initial assessment and management of a 55-year-old, dialysis-dependent man with fatigue. We present how one of our emergency medicine faculty develops her differential when faced with this complaint. She describes how she arrives at the suspected diagnosis and the test she believes is needed to prove her hypothesis. The final surprising diagnosis is then revealed.

Medical Legal Case Report

Physician and Pharmacist Liability: Medicolegal Cases That are Tough Pills to Swallow

We present four medicolegal cases involving medication errors, which led to patient harm and subsequent settlements or jury awards to patients. These cases each involved scenarios in which a medication was inappropriately prescribed and/or inappropriately dispensed. In such cases, it is often not obvious whether the physician or pharmacist is at fault. These cases highlight the importance of understanding the roles and responsibilities of the physician and pharmacist in medication prescription and dispensation.

Case Series

A Pain in the Butt: A Case Series of Gluteal Compartment Syndrome

Introduction: Gluteal compartment syndrome is a rare and difficult-to-diagnose form of compartment syndrome.

Case Series: We present three patients with gluteal compartment syndrome and review the clinical presentation, imaging, and laboratory findings that assist in diagnosis. Suggestions for more readily diagnosing gluteal compartment syndrome are provided.

Conclusion: Emergency physicians must be familiar with the diagnosis and management of gluteal compartment syndrome to prevent the significant associated morbidity and mortality.

Case Report

Nebulized Tranexamic Acid for Pediatric Post-tonsillectomy Hemorrhage: A Report of Two Cases

Introduction: Tranexamic acid (TXA) use in pediatrics to control hemorrhage has gained interest in recent years, but there is limited literature on nebulized TXA especially regarding dosing and adverse effects. Tranexamic acid has anti-fibrinolytic properties via competitive inhibition of plasminogen activation making it a logical approach to promote hemostasis in cases of post-tonsillectomy hemorrhage.

Case Report: We describe two cases of post-tonsillectomy hemorrhage managed with nebulized TXA. In both cases, bleeding was stopped after TXA administration.

Conclusion: To our knowledge, this is the first case report to describe the use of nebulized TXA without an adjunct pharmacotherapy. Our two cases add additional reportable data on the safety of nebulized TXA and possible effectiveness on post-tonsillectomy hemorrhage.

The “Spiked Helmet” Sign Associated with ST-Elevation Myocardial Infarction: A Case Report

Introduction: The “spiked helmet” sign was first described in 2011 by Littmann and Monroe in a case series of eight patients. This sign is characterized by an ST-elevation atypically with the upward shift starting before the onset of the QRS complex. Nowadays the sign is associated with critical non-cardiac illness.

Case Report: An 84-year-old man with a history of three-vessel disease presented to the emergency department with intermittent pain in the upper abdomen. The electrocardiogram revealed the “spiked helmet” sign. After ruling out non-cardiac conditions the catherization lab was activated. The coronary angiography revealed an acute occlusion of the right coronary artery, which was balloon-dilated followed by angioplasty. The first 24 hours went uneventfully with resolution of the “spiked helmet” sign. On the second day, however, the patient died suddenly and unexpectedly.

Conclusion: Despite the association with non-cardiac illness, the “spiked helmet” sign can be seen by an acute coronary artery occlusion as an ST-elevation myocardial infarction (STEMI). Reciprocal ST-depression in these cases should raise the suspicion of STEMI.

Legionella Pneumonia on Point-of-care Ultrasound in the Emergency Department: A Case Report

Introduction:Legionella is an uncommon, atypical organism that can cause community-acquired pneumonia. Commonly associated with high fevers, gastrointestinal symptoms, and hyponatremia, it can be easily overlooked, especially during the coronavirus disease of 2019 (COVID-19) pandemic. Legionella has specific antibiotic treatment that will improve outcome; thus, its recognition is important.

Case Report: We present a case of Legionella pneumonia in a man presenting with shortness of breath and fever. The patient’s initial chest radiography was negative. With the use of point-of-care ultrasound (POCUS) the changes of atypical pneumonia could be seen. Ultimately Legionella was confirmed with urine antigen testing, and appropriate antibiotic treatment was started.

Discussion: Given the increased awareness of COVID-19 it is important to consider a broad differential with respiratory illness. Legionella pneumonia on POCUS is consistent with atypical pneumonia descriptions on ultrasound. Point-of-care ultrasound can be used to diagnose atypical pneumonia, specifically caused by Legionella in our case.

Conclusion:Legionella is evident on POCUS but is difficult to distinguish from other infections with POCUS alone. One should consider Legionella if POCUS is positive for signs of atypical infection.

Angioedema Secondary to tPA Use in Acute Ischemic Stroke Patient with Hypertension: A Case Report

Introduction: A well-documented complication of administering tissue plasminogen activator (tPA) in stroke patients is acute intracranial bleeding. A lesser known but still significant complication is angioedema secondary to tPA administration, which can develop in certain individuals with risk factors such as angiotensin converting enzyme (ACE) inhibitor use and location of the stroke. Knowing the potential for this life-threatening complication and being prepared for its proper management is vital for emergency physicians.

Case Report: We report a 53-year-old Black female who presented to the emergency department with sudden onset of slurred speech and a facial droop. She was found to have an acute ischemic stroke and tPA was administered. She subsequently developed angioedema. Retrospectively, the patient was found to have risk factors that are thought to predispose patients to tPA-induced angioedema.

Conclusion: Risk factors associated with angioedema secondary to tPA administration have been documented in patients taking ACE inhibitors, as well as patients who develop strokes in the frontal lobe. While many cases may be mild, some patients may develop life-threatening angioedema. Although this complication does not necessarily contraindicate tPA use, it is prudent for the emergency physician to be vigilant for its development, prepared for its treatment, and to be diligent in assessing the need for control of the patient’s airway.

Transient Quadriplegia: A Case-Based Approach to Cervical Trauma

Introduction: Spinal cord injuries are a common reason for presentation to the emergency department (ED). Sports-related spinal injuries are one of the least common spinal injuries, falling behind vehicular accidents, acts of violence, and falls.

Case Report: This case report describes a case of transient quadriplegia in a 17-year-old male who presented to the ED after a helmet-to-helmet collision while participating in football.

Conclusion: Emergency physicians should be cognizant of potential spinal cord injury using clinical decision tools and radiologic imaging to properly disposition a patient presenting with cervical spine injury.

Spontaneous Ureteric Rupture and Its Implications in the Emergency Department: A Case Report

Introduction: Spontaneous ureteric rupture is uncommon and has a wide range of presentations. Accurate diagnosis and timely treatment is necessary to avoid potential serious complications.

Case Report: We present the case of a 55-year-old female who presented with severe right lower abdominal pain with rebound tenderness, vomiting, and a single episode of hematuria. A computed tomography with intravenous contrast of the abdomen and pelvis showed a 0.3-centimeter right upper ureteric calculus, with hydronephrosis and ureteric rupture. In view of the scan findings, a diagnosis of spontaneous ureteric rupture secondary to urolithiasis was made. The patient underwent a percutaneous nephrostomy and ureteric stenting.

Conclusion: Spontaneous rupture of the ureter is an uncommon diagnosis for which clinical and laboratory signs may not always be reliably present. A high index of suspicion is required for diagnosis, which is usually confirmed on advanced imaging. It may occur in serious complications of urinoma and abscess formation. As such, accurate diagnosis and timely treatment is crucial.

Acute Demyelinating Encephalomyelitis Following Measles Infection Due to Vaccine Failure: A Case Report

Introduction: Local outbreaks of measles infection are primarily mediated by international travel of persons from endemic areas, with subsequent spread of the virus via undervaccinated populations. Recent resurgences of measles in communities where vaccination rates are non-ideal secondary to philosophical objections require the emergency physician to more routinely consider the diagnosis. In cases of measles complicated by acute encephalitis or encephalopathy, the diagnosis can be especially difficult to make due to lack of a reliable primary historian.

Case report: Here we present a case of altered mental status and new-onset bilateral lower extremity weakness in a fully vaccinated young woman diagnosed with measles infection caused by acute disseminated encephalomyelitis in the setting of vaccine failure.

Conclusion: Despite a documented history of immunization, acute measles infection and its uncommon sequelae are possible. Recognizing vaccine failure and appropriately isolating patients are of paramount importance.

Arterial-embolic Strokes and Painless Vision Loss Due to Phase II Aortitis and Giant Cell Arteritis: A Case Report

Introduction: Aortitis refers to abnormal inflammation of the aorta, most commonly caused by giant cell arteritis (GCA). Herein, we present a 57-year-old female with aortitis and arterial-embolic strokes secondary to GCA.

Case Report: Our patient presented to the emergency department following an episode of transient, monocular, painless vision loss. Computed tomography angiogram head and neck demonstrated phase II aortitis, and magnetic resonance imaging revealed evidence of arterial-embolic strokes.

Conclusion: Cerebrovascular accident is a rare complication of large-vessel vasculitis and can occur due to multiple underlying etiologies including intracranial vasculitis, aortic branch proximal occlusion, or arterial-embolic stroke.

Pneumopericardium after Laparoscopic Hernia Repair Presents with ST-segment Changes: A Case Report

Introduction: Although rare, iatrogenic cases of pneumopericardium have been documented following laparoscopic surgery and mechanical ventilation. Electrocardiogram (ECG) changes, including ST-segment depressions and T-wave inversions, have been documented in cases of pneumopericardium, and can mimic more concerning causes of chest pain including myocardial ischemia or pulmonary embolism.

Case Report: This unique case describes a patient who presented with chest pain and ST-segment changes on ECG hours after a laparoscopic inguinal hernia repair and who was found to have pneumopericardium.

Conclusion: While iatrogenic pneumopericardium is often self-limiting and rarely requires intervention, it is critical to differentiate pneumopericardium from other etiologies of chest pain, including myocardial ischemia and pulmonary embolism, to prevent unnecessary intervention.

A Report of Two Cases: Unlearning Lactic Acidosis

Introduction: The term “lactic acidosis” reinforces the misconception that lactate contributes to acidemia. Although it is common to discover an anion gap acidosis with a concomitant elevated lactate concentration, the two are not mutually dependent.

Case Report: Here we describe two patients exhibiting high lactate concentrations in the setting of metabolic alkalemia.

Conclusion: Lactate is not necessarily the direct cause of acid-base disturbances, and there is no fixed relationship between lactate and the anion gap or between lactate and pH. The term “metabolic acidosis with hyperlactatemia” is more specific than “lactic acidosis” and thus more appropriate.

Point-of-care Ultrasound in Early Diagnosis of Cardiomyopathy in a Child with Viral Myocarditis: A Case Report

Introduction: Pediatric myocarditis is a commonly missed diagnosis in the pediatric emergency department (ED) with high morbidity and mortality. The presentation of cardiogenic shock secondary to myocarditis and septic shock can be difficult to differentiate during initial resuscitation, and incorrect treatment can lead to poor prognosis. Early diagnosis may provide a better prognosis for this life-threatening condition.

Case Report: We report a case of a five-year-old female who presented to the ED with non-specific symptoms of myocarditis. Rapid point-of-care ultrasound led to early diagnosis, correct management, and great prognosis for the patient.

Conclusion: Providers must maintain a high index of suspicion for cardiogenic shock in patients with nonspecific symptoms and fluid unresponsiveness. Point-of-care ultrasound can help in the identification of cardiac disorders and guide practitioners in their management plans.

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Atezolizumab-induced Autoimmune Diabetes in a Patient with Metastatic Breast Cancer: A Case Report

Introduction: Immune checkpoint inhibitors (ICI) are a class of immunotherapy drugs used increasingly in the treatment of multiple types of cancer. Major side effects include immune-related adverse effects, potentially resulting in damage to normal tissue across multiple different organ systems.

Case Report: A 74-year-old woman with a history of triple negative metastatic breast cancer treated with the ICI atezolizumab presented with new-onset autoimmune diabetes in diabetic ketoacidosis.  She required fluid resuscitation, insulin infusion, vasopressors, and initial hospitalization in the intensive care unit. The patient was subsequently discharged on bolus dose insulin and remained an insulin-dependent diabetic at three-month follow-up.

Conclusion: Autoimmune diabetes is a rare, but life-threatening, adverse event associated with ICIs such as atezolizumab. To our knowledge this is the only case report of atezolizumab causing autoimmune diabetes in the setting of metastatic breast cancer. As ICIs become more common in the treatment of cancer, emergency physicians should remain vigilant for the various immune-mediated complications associated with this class of immunotherapy drugs.

Rhabdomyolysis: A Case Report of an Extrapulmonary Presentation of Mycoplasma pneumoniae

Introduction: We present an unusual case of rhabdomyolysis secondary to Mycoplasma pneumoniae in a healthy 27-year-old female. M. pneumoniae is associated with numerous extrapulmonary manifestations, including acute hepatitis, Stevens-Johnson syndrome, and rhabdomyolysis. Most documented cases affect the pediatric population, with only five cases in adults reported in the literature.

Case Report: The patient presented with complaints of myalgia and intractable cough. In this case the initial presentation demonstrated hypoxia requiring supplemental oxygen, and a creatine kinase of 7,646 units per liter (U/L) (reference range 26-192 U/L) with a peak of 29,427. During her hospitalization, she also remained persistently hypoxic for several days but ultimately was successfully weaned off all supplemental oxygen. She was discharged home after a seven-day hospitalization.

Conclusion: This patient’s presentation of an insidious, upper respiratory infection along with the subsequent development of rhabdomyolysis with reactive antibodies to M. pneumoniae demonstrates a link between these two clinically important conditions.

Point-of-care Ultrasound to Distinguish Subgaleal and Cephalohematoma: Case Report

Introduction: Cephalohematomas generally do not pose a significant risk to the patient and resolve spontaneously. Conversely, a subgaleal hematoma is a rare but more serious condition. While it may be challenging to make this diagnostic distinction based on a physical examination alone, the findings that differentiate these two conditions can be appreciated on point-of-care ultrasound (POCUS). We describe two pediatric patient cases where POCUS was used to distinguish between a subgaleal hematoma and a cephalohematoma.

Case Reports: We describe one case of a 14-month-old male brought to the pediatric emergency department (PED) with concern for head injury. A POCUS examination revealed a large fluid collection that did not cross the sagittal suture. Thus, the hematoma was more consistent with a cephalohematoma and less compatible with a subgaleal hematoma. Given these findings, further emergent imaging was deferred in the PED and the patient was kept for observation. In the second case an 8-week-old male presented with suspected swelling over the right parietal region. A POCUS examination was performed, which demonstrated an extensive, simple fluid collection that extended across the suture line, making it more concerning for a subgaleal hematoma. Given the heightened suspicion for a subgaleal hematoma, the patient was admitted for further imaging and evaluation.

Conclusion: Point-of-care ultrasound can be used to help differentiate between a subgaleal hematoma and a cephalohematoma to risk-stratify patients and determine the need for further imaging.

Can’t Dissolve Me Now: A COVID-19 Provoked Venous Thromboembolism Breaks Through Apixaban: Case Report

Introduction: Coronavirus disease 2019 (COVID-19) is a multisystem process with a growing evidence of its endotheliopathy effects, with subsequent hypercoagulability states.

Case Report: WWe present an emergency department case of a COVID-19-provoked deep venous thrombosis and pulmonary embolism without a history of venous thromboembolism (VTE), with extension of the VTE despite adherence to apixaban.

Conclusion: This case demonstrates the importance of further research and protocols for optimal dosage and treatment to prevent worsening VTE in COVID-19 patients.

Reversible Total Vision Loss Caused by Severe Metformin-associated Lactic Acidosis: A Case Report

Introduction: Metformin is a biguanide used to treat diabetes mellitus (DM). Metformin-associated lactic acidosis (MALA) carries a high mortality and can occur in patients with renal failure from drug bioaccumulation. Reversible vision loss is a highly unusual, rarely reported complication of MALA. We present a case of a patient whose serum metformin concentration was unusually high and associated with vision loss.

Case Report: A 60-year-old woman presented to an outside hospital emergency department with acute vision loss after being found at home confused, somnolent, and hypoglycemic, having last being seen normal two days prior. She reported vomiting and diarrhea during that time and a recently treated urinary tract infection. The visual loss resolved with continuous renal replacement therapy.

Conclusion: This novel case of a patient with Type II DM prescribed metformin and insulin who developed reversible vision loss while suffering from MALA highlights the potential for vision loss in association with MALA.

A Traumatic Tick Bite: A Case Report

Introduction: Human granulocytic anaplasmosis is a tick-borne disease with an increasing incidence associated with morbidity and mortality. Uncertainty remains whether a prophylactic dose of doxycycline is effective in prevention.

Case Report: We present a case of an 80-year-old female with syncope, resultant facial trauma, and fever two weeks after a tick bite for which she received prophylaxis. Workup revealed anaplasmosis, and treatment led to symptomatic improvement.

Conclusion: We review the presenting symptoms, laboratory findings, and treatment of anaplasmosis, as well as give caution about the limitations in prescribing a prophylactic dose of doxycycline following a tick bite.

A Case Report of Cardiogenic Syncope Due to Loperamide Abuse: Acute Presentation and Novel Use of Buprenorphine

Introduction: Loperamide is a non-prescription anti-diarrheal agent targeting µ-opioid receptors in the intestinal tract. At high doses it crosses the blood-brain barrier, where µ-opioid agonism can cause euphoric effects. Misuse has been increasing for both the euphoric effects and as an alternative treatment for opioid dependence and withdrawal.

Case Report: Here we report the case of a 30-year-old woman presenting with syncope, who was found to have severe myocardial conduction delays in the setting of chronic loperamide abuse.

Conclusion: Treatment with sodium bicarbonate and hypertonic sodium resulted in improvement of her conduction abnormalities. Prior to discharge she was initiated on buprenorphine for her opioid use disorder.

Neonatal Parotitis: A Case Report

Introduction: Acute suppurative parotitis is a rare finding in the neonate. It is commonly caused by Staphylococcus aureus, but other bacterial isolates may be emerging. It is a novel disease for this age group and requires unique management. Only 32 cases of neonatal suppurative parotitis have been described in the English-language literature over the last 35 years. 

Case Report: We describe a case of a 14-day-old male who presented to the pediatric emergency department with a 24-hour history of swelling and redness of the right cheek. On examining him, purulent material was seen inside his oral cavity. He was subsequently hospitalized with a diagnosis of neonatal suppurative parotitis and received five days of parenteral antibiotics with improvement in swelling and redness. He was discharged home with oral antibiotics. 

Conclusion: Although neonatal suppurative parotitis is rare, it should be suspected in newborns presenting with an erythematous pre-auricular mass with or without any predisposing factors. We describe a rare case of acute suppurative parotitis in a neonate and review the published literature.

When the Red Tide Rolls In: A Red Tide Associated Angioedema Case Report

Introduction: Histamine-mediated angioedema is a potentially life-threatening reaction following exposures that incite mast cell activation. In Florida, red tides are a frequent phenomenon caused by overgrowth of the harmful algae species Karenia brevis, which contain environmentally detrimental brevetoxins. Even in low concentrations, brevetoxins can cause disease in humans through inducing histamine release. We report the first documented case of angioedema associated with red tide exposure.

Case Report: A 52-year-old-male presented with severe angioedema encompassing both lips within a few hours after exposure to red tide algae. Other symptoms included voice changes and difficulty swallowing. Laboratory findings revealed complement factors that were within reference range, which ruled out a bradykinin-mediated pathology and supported the diagnosis of histaminergic angioedema. Symptoms resolved after 24 hours in the intensive care unit under management with epinephrine, diphenhydramine, methylprednisolone, and famotidine.

Conclusion: In coastal regions, red tide algae should be recognized as a rare cause of acute angioedema. Emergency management of histamine-mediated angioedema should focus on preventing respiratory compromise with frequent airway monitoring and treatment with steroids, antihistamines, and epinephrine.

Pediatric Innominate Artery Pseudoaneurysm Rupture in Vascular Ehlers-Danlos Syndrome: A Case Report

Introduction: Ehlers-Danlos syndrome is a well classified connective tissue disorder recognized by its features of hyperextensibility of joints and hyperelasticity of the skin. However, the rare vascular type (Ehlers-Danlos type IV) is more difficult to identify in the absence, rarity, or subtlety of the classical physical features. Patients presenting to the emergency department (ED) with acute complications of vascular Ehlers-Danlos syndrome may be critically ill, requiring accurate diagnosis and tailored management.

Case Report: This report details a case of spontaneous innominate artery pseudoaneurysm rupture in a pediatric patient with previously undiagnosed Ehlers-Danlos syndrome. Initial ED evaluation was followed by urgent operative intervention and subsequent genetic testing to confirm final diagnosis.

Conclusion: Due to its high morbidity and mortality, vascular type Ehlers-Danlos syndrome should be considered in the differential for otherwise unexplained spontaneous vascular injury.

Profound Weakness and Blurry Vision in a Pandemic: A Case Report

Introduction: Neuro-Behçet’s disease (NBD) is a manifestation of Behçet’s disease, a relapsing inflammatory multisystem disease. Data on patients with autoimmune disease in the setting of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) is limited.

Case Report: We discuss the case of a 22-year-old male with SARS-CoV-2 who presented to the emergency department with weakness and vision changes. Brain imaging showed enhancing lesions. History revealed possible autoimmune disease. A diagnosis of NBD exacerbated by SARS-CoV-2 was made.

Conclusion: Patients with SARS-CoV-2 are presenting with exacerbations of systemic illnesses. Although NBD is uncommon, medical professionals need to consider this in the differential of central nervous system disorders, as it is a potentially treatable condition.

Chloroquine Ingestion to Prevent SARS-CoV-2 Infection: A Report of Two Cases

Introduction: Amid the global pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), chloroquine and hydroxychloroquine were being studied as agents to prevent and treat coronavirus disease 2019. Information about these agents and their effects circulated throughout the general public media, raising the concern for self-directed consumption of both pharmaceutical and non-pharmaceutical products.

Case Report: We present two cases of chloroquine toxicity that occurred after ingestion of an aquarium disinfectant that contained chloroquine phosphate in a misguided attempt to prevent infection by SARS-CoV-2. One patient had repeated emesis and survived, while the other was unable to vomit, despite attempts, and suffered fatal cardiac dysrhythmias.

Conclusion: These cases illustrate the spectrum of toxicity, varied presentations, and importance of early recognition and management of chloroquine poisoning. In addition, we can see the importance of sound medical guidance in an era of social confusion compounded by the extremes of public and social media.

Metronidazole, an Uncommon Cause of Dizziness and Ataxia in the Emergency Department: A Case Report

Introduction: Metronidazole, a nitroimidazole antibiotic, is a well-known antibacterial and antiprotozoal agent that is generally well tolerated without many serious side effects. Most adverse reactions affect the gastrointestinal or genitourinary system, but the central nervous system may also be afflicted. In addition to headache and dizziness, cerebellar dysfunction can occur with metronidazole use.

Case Report: We discuss the clinical presentation and imaging findings of metronidazole-induced encephalopathy in a 12-year-old male. The patient had a history of Crohn’s disease and chronic Clostridium difficile infection for which he had received metronidazole for approximately 75 days prior to arrival to a local emergency department (ED). He presented with five days of progressive vertigo, nausea, vomiting, and ataxia. Subsequent magnetic resonance imaging showed symmetric hyperintense dentate nuclei lesions, characteristic of metronidazole-induced encephalopathy. The patient’s symptoms improved rapidly after cessation of metronidazole, and his symptoms had completely resolved by discharge on hospital day two.

Conclusion: Metronidazole-induced encephalopathy is a rare cause of vertigo and ataxia that can lead to permanent sequela if not identified and treated promptly. Thus, it is important for physicians to keep this diagnosis in mind when evaluating patients on metronidazole who present to the ED with new neurologic complaints.

Salmonella Aortitis in an Elderly Male, a Rare but Deadly Cause of Abdominal Pain: A Case Report

Introduction: Infectious aortitis is a rare condition with mortality rates approaching 100% without surgical intervention. Symptoms and findings may be vague. Computed tomography (CT) with intravenous (IV) contrast, once the gold standard of diagnosis, may only show subtle findings. More recently, CT angiography (CTA) and magnetic resonance angiography have become the diagnostic modalities of choice.

Case Report: A 58-year-old diabetic male presented to our emergency department with nausea, vomiting, diarrhea, fevers, and abdominal pain of two weeks duration. The patient had been seen just days before at another facility with the same complaints. He received an abdominal CT with IV contrast that was reported as negative and discharged with the diagnosis of gastroenteritis. He failed to improve and presented to our facility. On presentation, the patient was diaphoretic and uncomfortable. A repeat abdominal CT with IV contrast revealed a mantle of low density around the aorta. The patient was started on IV antibiotics, and a follow-up CTA of the abdomen and pelvis showed an irregular saccular aneurysm. Vascular surgery was consulted, and the patient underwent vascular reconstruction.

Conclusion: Because of the high level of mortality seen in infectious aortitis and improvement in patient outcomes with surgical intervention, a high index of suspicion needs to be maintained in patients presenting with fever and chest, abdominal, and back pain, especially in the setting of risk factors and bacteremia. The clinician should be aware that the usual modality for the evaluation of abdominal pain, CT with IV contrast, may not be adequate to make the diagnosis.

Accidental Arthrotomy Causing Aseptic Monoarthritis Due to Agave Sap: A Case Report

Introduction: Aseptic inflammatory arthritis has been reported from thorns or cactus needles after inadvertent arthrotomy. Agave sap irritants may cause an aseptic inflammatory arthritis mimicking a septic joint. 

Case Report: A 27-year-old male presented with left knee pain and swelling two hours after suffering an accidental stab wound to his left lateral knee by an agave plant spine. Synovial fluid white blood cell count was 92,730 mm3 with 75% neutrophils and no crystals. Surgical washout was remarkable for turbid fluid and no foreign body. Synovial fluid and blood cultures remained without growth. At two-week follow-up, the patient had recovered.

Conclusion: Penetrating injuries from agave thorns can cause an inflammatory arthritis that mimics septic arthritis.

Images in Emergency Medicine

Bilateral Luxatio Erecta Humeri

Case Presentation: We describe a middle-aged male presenting to the emergency department with bilateral shoulder pain, holding both arms in abduction after trauma. Radiographs demonstrated a bilateral inferior dislocation of the glenohumeral joints consistent with luxatio erecta humeri.

Discussion: We review the clinical presentation of luxatio erecta and its complications. We also describe the characteristic presentation on radiographs. Our case illustrates the hallmark findings of luxatio erecta of an abducted humeral shaft parallel to the scapular spine.

Adolescent Male with Severe Groin Pain Due to Traumatic Injury

Case Presentation: A 14-year-old boy presented to the emergency department complaining of severe groin pain on the right side following a minor fall. Computed tomography and magnetic resonance imaging revealed a hematoma in his right iliacus muscle. He was diagnosed with a traumatic iliacus hematoma, and he recovered spontaneously with short-term oral analgesics.

Discussion: Traumatic iliacus hematomas are rare entities and subside with conservative management in most cases. However, this condition may be associated with femoral nerve palsy, and surgery is indicated in severe cases. Traumatic iliacus hematoma should be considered in the differential diagnosis of severe groin pain.

A Young Boy with Neck Pain

Case Presentation: A five-year-old boy presented to our emergency department with severe posterior neck pain that was exacerbated upon neck movement. Cervical spine radiography revealed calcification in the cervical intervertebral disk 3-4.

Discussion: Pediatric idiopathic intervertebral disk calcification is a benign, rare condition that might be complicated by associated severe neurological symptoms. In this case, the symptoms gradually subsided with conservative management alone.

Rare but Foreseeable: Rapidly Expanding Retropharyngeal Hematoma After Fall from Height

Case Presentation: An elderly man presented to the emergency department after a fall from a 15-foot height. Initial examination revealed signs of head and neck trauma without airway compromise. Computed tomography imaging identified cervical fractures at the first and second level with a retropharyngeal hematoma. In discussion with the trauma service, the patient was admitted to the hospital for airway monitoring. After 10 hours he clinically deteriorated, resulting in acute respiratory failure, and ultimately required intubation. The patient was intubated with a hyperangulated video laryngoscopy, and a surgical set-up was also prepared. The intubation was uncomplicated and resulted in clinical improvement. The patient was extubated after three days without difficulty and was ultimately discharged following an uncomplicated hospital course.

Discussion: Retropharyngeal hematoma is a rare but significant clinical condition. Rapid decline and airway compromise have been described. Patients often require intubation and mechanical ventilation to avoid airway obstruction and respiratory failure. Coagulopathies should be reversed, if present. Prompt recognition and treatment of this condition is crucial to successful management.

Case of Displaced Glenoid Fracture After Fall: Subtle Findings with Significant Implications for Trauma Patients

Case Presentation: A 64-year-old man presented to the emergency department with a chief complaint of left shoulder pain after a mechanical fall from standing. Plain radiography revealed a displaced fracture of the inferior glenoid rim. A computed tomography further characterized the fracture and the patient was taken emergently by an orthopedic surgeon for open reduction and internal fixation.

Discussion: Scapula fractures, especially isolated glenoid rim fractures, are rare and most typical of high-energy mechanism traumas. A missed or delayed diagnosis can result in long-term suffering and disability. Awareness of radiographic as well as physical findings and the subsequent classification system described below can optimize outcomes for trauma patients with glenoid fractures.

Hemithorax Westermark Sign Secondary to Complete Pulmonary Artery Occlusion from Pulmonary Embolus

Case Presentation: We describe a complete right hemithorax Westermark sign found in a patient with a near-complete, right pulmonary artery trunk occlusion secondary to a pulmonary embolus.

Discussion: We review the sensitivity and specificity of a Westermark sign in the identification of a pulmonary embolism, and how this aided us in managing our patient in the emergency department.

Ultrasonographic Findings in Fat Embolism Syndrome

Case Presentation: A 93-year-old man living in a nursing home presented to our emergency department with altered mental status. Examination revealed hypotension and severe hypoxia. Chest radiograph showed infiltrates in the right upper lobe, and computed tomography of the abdomen and pelvis demonstrated a left femoral neck fracture. A point-of-care transthoracic echocardiogram (TTE) revealed an enlarged right ventricle, severe tricuspid regurgitation, and numerous white floating dots moving toward the right atrium from the inferior vena cava (IVC), leading to the diagnosis of fat embolism syndrome (FES).

Discussion: Although imaging studies can facilitate diagnosis, the diagnosis of FES is typically made by clinical history and presentation, making a swift diagnosis often difficult in those who are critically ill. Recent case reports have described that TTE can detect fat emboli, seen as flowing hyperechoic particles in IVC. This image demonstrates the utility of TTE to diagnose FES.

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Young Woman with Leg Lesions

Case Presentation: The patient was a 33-year-old woman with inflammatory bowel disease presenting for worsening lower leg lesions with significant pain recalcitrant to oral doxycycline.

Discussion: Pyoderma gangrenosum is a rare ulcerative skin condition with significant pain that is often associated with other systemic diseases typically treated with immunosuppressive medications aimed at the underlying cause.

An Unusual ECG Artifact Caused by Faulty Cardiac Monitor Leads

Case Presentation: We present the case of a 74-year-old female patient who presented to the emergency department with lower extremity weakness found to have a fixed frequency square wave artifact in all leads of her electrocardiogram (ECG). After troubleshooting, faulty external cardiac monitor leads were identified as the cause of this unique artifact.

Discussion: The ECG is an important diagnostic tool for medical providers. Electrocardiogram artifacts are extremely common, and knowledge of artifacts is necessary to prevent inappropriate interpretation, diagnostic error, and unnecessary workup. Medical providers should have a low threshold for suspicion when ECG findings do not correlate with the patient’s chief complaint or history of present illness. They must also be familiar with the most frequent ECG artifact variants and be prepared to follow a stepwise approach to troubleshoot less frequent variants.

“One Note Higher”: A Unique Pediatric Hand Fracture

Case Presentation: An otherwise healthy, 12-year-old male presented to the emergency department after a fall down the stairs in which he landed on his right hand. Radiographs demonstrated a Salter-Harris II fracture at the base of the proximal phalanx of the fifth digit with ulnar deviation, also known as an “extra-octave“ fracture. Orthopedic surgery was consulted and the fracture was reduced and placed in a short-arm cast. The patient was discharged and scheduled for orthopedic follow-up.

Discussion: A Salter-Harris II fracture at the base of the proximal phalanx of the fifth digit with ulnar deviation is referred to as an “extra-octave” fracture due to the advantage a pianist would gain in reach of their fifth phalanx if not reduced. However, reduction is needed if the fracture is displaced and can be achieved by several described methods including the “90-90” or “pencil” methods followed by cast or splint application. Percutaneous pinning is rarely needed. Complications include flexor tendon entrapment, collateral ligament disruption, and malunion leading to a “pseudo-claw” deformity. We recommend that all extra-octave fractures receive orthopedic follow-up in one to two weeks or sooner if severely displaced.

A Rare Case of Cranial Nerve VII Neuropraxia Associated with Alveolar Nerve Blocks

Case Presentation: A 26-year-old male presented to our emergency department for six days of right-sided facial myasthenia and parasthesias following a dental procedure using anesthetic nerve blocks.

Discussion: Iatrogenic cranial nerve VII neuropraxia, a peripheral nerve injury, is an uncommon complication of alveolar nerve blocks with few documented cases specifically due to dental anesthesia. Treatment usually involves use of oral corticosteroid and/or antiviral medications along with close follow-up in clinic with a neurologist and/or otolaryngologist.

Erratum (Staff Only)

This Article Corrects: "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.