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Open Access Publications from the University of California

Clinicopathological Cases from the University of Maryland

73-year-old Female with Syncope and Motor Vehicle Collision

Introduction: Patients with traumatic injuries can be difficult to assess, and their evaluation often evolves in the emergency department (ED). We describe how an ED attending physician member developed a differential diagnosis for this presentation, arrived at a suspected diagnosis, and what test he proposed to prove his hypothesis.

Case Presentation: This clinicopathological case presentation details the initial assessment and management of a 73-year-old female who presented to the ED following a motor vehicle collision precipitated by a syncopal episode.

Conclusion: The final surprising diagnosis is then revealed.

Case Series

Timely Diagnosis of Pneumoperitoneum by Point-of-care Ultrasound in the Emergency Department: A Case Series

Introduction: Pneumoperitoneum is a life-threatening diagnosis that requires timely diagnosis and action. We present a case series of patients with perforated hollow viscus who were accurately diagnosed by emergency physicians using point-of-care ultrasound (POCUS) while in the emergency department (ED).

Case Series: Three elderly patients presented to the ED with the complaints of syncope, abdominal pain with constipation, and unresponsiveness. The emergency physicians used POCUS to diagnose and then expedite the necessary treatment.

Conclusion: Point-of-care ultrasound can be used by emergency physicians to diagnose pneumoperitoneum in the ED.

Case Series of Three Patients with Disseminated Gonococcal Infection and Endocarditis

Introduction: The increasing incidence of Neisseria gonorrhoeae infections and emergence of cephalosporin-resistant strains means the threat of disseminated gonococcal infection and endocarditis needs to be reimagined into the differential diagnosis for patients treated in the emergency department (ED) for sexually transmitted infections and for endocarditis itself. Only 70 cases of disseminated gonococcal infection (DGI) with endocarditis had been reported through 2014.1-4 In 2019, however, an outbreak of DGI with one case of endocarditis was reported.5 This case series of three patients with DGI and endocarditis, in addition to the recent outbreak, may represent a warning sign for reemergence of this threat.

Case Report: We describe three cases within a recent three-year period of gonococcal endocarditis as seen and treated at our institution. These cases show divergent presentations of this insidious disease with both classical and atypical features. One case displayed a classic migratory rash with positive urine testing and a remote history of sexually transmitted infections, while another patient developed isolated culture-confirmed endocarditis with negative cervical testing and imaging, and the final case was a male patient who presented to the ED with fulminant endocarditis as the first ED presentation of infection.

Conclusion: Secondary to an overall rise in incidence and possibly due to increasing antibiotic- resistance patterns, gonococcal endocarditis should be included in the differential diagnosis of any case of endocarditis. Reciprocally, increased vigilance should surround the evaluation of any patient for sexually transmitted diseases while in the ED for both the development of DGI and endocarditis.

Kinetic Projectile Injuries Treated During Civil Protests in Los Angeles: A Case Series

Introduction: During protests following the death of George Floyd, kinetic impact projectiles (KIP) were used by law enforcement as a method of crowd control. We describe the injuries seen at a single Level 1 trauma center in Los Angeles over a two-day period of protests to add to the collective understanding of the public health ramifications of crowd-control weapons used in the setting of protests.

Case Series: We reviewed the emergency department visits of 14 patients who presented to our facility due to injuries sustained from KIPs over a 48-hour period during civil protests after the death of George Floyd.

Conclusion: Less lethal weapons can cause significant injuries and may not be appropriate for the purposes of crowd control, especially when used outside of established guidelines.

Push-Dose Pressors During Peri-intubation Hypotension in the Emergency Department: A Case Series

Introduction: Emergency physicians frequently encounter critically ill patients in circulatory shock requiring definitive airway procedures. Performing rapid sequence intubation in these patients without blood pressure correction has lethal complications. Questioning the efficacy and fearing side effects of push-dose pressors (PDP) has created an obstacle for their use in the emergency department (ED) setting. In this case series we describe the efficacy and side effects of PDP use during peri-intubation hypotension in the ED.

Case series: We included 11 patients receiving PDPs in this case series. The mean increase in systolic blood pressure was 41.3%, in diastolic blood pressure 44.3%, and in mean arterial pressure 35.1%. No adverse events were documented in this case series.

Conclusion: The use of push-dose pressors during peri-intubation hypotension may potentially improve hemodynamic status when used carefully in the ED.

Case Report

Pheochromocytoma Leading to Multiorgan Failure in a Pregnant Patient: A Case Report

Introduction: Pheochromocytoma, a neuroendocrine tumor that secretes catecholamines, can present with episodic sweating, diaphoresis, headaches, and hypertension, as well as cardiac and pulmonary involvement. In a pregnant patient, it must be differentiated from preeclampsia, a leading cause of maternal mortality in the developed world, which can similarly present with hypertension and multiorgan involvement. Both conditions require early diagnosis and treatment to reduce maternal and fetal morbidity and mortality.

Case Report: We discuss the case of a pregnant patient at approximately 24 weeks’ gestation presenting with chest pain and shortness of breath who was found to have a left adrenal mass and hypertensive urgency. The patient acutely decompensated during the course of evaluation. She ultimately suffered pregnancy loss and multiorgan failure requiring percutaneous heart pump placement and extracorporeal membrane oxygenation therapy for support before fully recovering. The adrenal mass was confirmed to be a pheochromocytoma after excision and contributed to the development of hypertensive emergency with multiorgan failure.

Conclusion: Pheochromocytoma during pregnancy is a rare condition but must remain on the differential until ruled out to improve patient outcomes as much as possible. Obtaining blood pressure control is imperative to reducing maternal and fetal mortality. Preeclampsia is similarly serious, and early diagnosis is essential for adequate management of the condition until delivery can occur.

Thyroid Storm-induced Takotsubo Cardiomyopathy Presenting as Acute Chest Pain: A Case Report

Introduction: Stress-induced cardiomyopathy is a rare but serious cause of chest pain, which in recent studies has been shown to carry a similar in-hospital mortality to acute ST-elevation myocardial infarction. The pathophysiology of the disease is thought to be secondary to dysregulated catecholamine effects on myocardium.

Case Report: We present a case of a previously healthy female without known thyroid disease who presented to the emergency department for acute chest pain and was found to have thyroid storm- induced cardiomyopathy in a typical stress-induced cardiomyopathy pattern without evidence of coronary disease on catheterization.

Conclusion: Thyrotoxicosis can cause dysregulation of catecholamines and is a rare cause of stress-induced cardiomyopathy. It requires distinct therapies and should be considered by emergency physicians in the workup of acute chest pain with concern for stress-induced cardiomyopathy.

  • 1 supplemental video

Point-of-care Ultrasound Diagnosis of Pulmonary Hydatid Cyst Disease Causing Shock: A Case Report

Introduction: Point-of-care ultrasound (POCUS) is accepted as an important tool for evaluatingpatients presenting to the emergency department (ED) with dyspnea1 and undifferentiated shock.2Identifying the etiology and type of shock is time-critical since treatments vary based on thisinformation. Clinicians typically rely on the history, exam, and diagnostics tests to identify theetiology of shock. In resource-limited settings where there is reduced access to timely laboratory anddiagnostic studies. The use of POCUS enables rapid classification and directed treatment of shock.Additionally, POCUS can aid in the diagnosis of rarer tropical diseases that can be important causesof shock in resource-limited settings.

Case Report: We discuss a case of a pediatric patient who presented to an ED in Cusco, Peru, withacute dyspnea and shock. Point-of-care ultrasound was used to expedite the diagnosis of a rupturedpulmonary hydatid cyst, guide proper management of septic and anaphylactic shock, and expeditedefinitive surgical intervention.

Conclusion: In resource-limited settings where there is reduced access to timely laboratory anddiagnostic studies, the use of POCUS enables rapid classification and directed treatment of shock.

  • 2 supplemental videos

Rat-bite Fever–A Rare Diagnosis for a Common Pediatric Presentation: Case Report

Introduction: Fever and rash is a common pediatric presentation to the emergency department but can present a diagnostic challenge to the clinician. Here we report the successful identification and treatment of a rare zoonotic exanthem that was facilitated by a thorough history and physical exam.

Case Report: Rat-bite fever is a potentially fatal systemic illness characterized by relapsing fever, rash, and migratory polyarthralgias. Treatment includes antibiotics for Streptobacillus moniliformis, the most common pathogen, as well as appropriate hygiene education and prevention strategies. We report a case of S. moniliformis in the absence of an actual rodent bite.

Conclusion: Due to the generally non-specific presentation of the illness, as well as the growing trend of caring for domestic rodents, it is crucial that clinicians ask details related to zoonotic and other exposures while obtaining medical histories.

COVID-19 Associated Thyroid Storm: A Case Report

Introduction: The distinction between coronavirus disease 2019 (COVID-19) and thyroid storm can be extremely difficult to determine on clinical grounds alone as there is significant overlap between the signs and symptoms of each.

Case report: We present a case of a patient with thyroid storm triggered by underlying COVID-19 infection.

Conclusion: Infection with severe acute respiratory syndrome coronavirus 2 is linked to dysregulation of the thyroid gland through numerous mechanisms, although thyroid storm triggered by COVID-19 appears rare, with only a single case previously identified in the literature.

Nutcracker Syndrome Masquerading as Renal Colic in an Adolescent Athlete: A Case Report

Introduction: Abdominal pain and flank pain cause a significant proportion of emergencydepartment (ED) visits. The diagnosis often remains unclear and is frequently associated withrepeat visits to the ED for the same complaint. A rare cause of left upper abdominal and flank painis compression of the left renal vein between the aorta and the superior mesenteric artery known asnutcracker syndrome. Diagnostic findings on ultrasound include increased left renal vein diameterproximal and peak blood flow velocity increase distal to the superior mesenteric artery. We describesuch a patient presenting to an ED repeatedly with severe pain mimicking renal colic before the finaldiagnosis and intervention occurred.

Case Report: A 16-year-old female, long-distance runner presented four times complaining ofintractable left upper quadrant abdominal pain radiating to the left flank after exercise. On each visiturinalysis revealed proteinuria and hematuria, and on two visits abdominal computed tomographyrevealed no kidney stone or dilatation of the collecting system. Ultimately, she was referred tovascular surgery where Doppler ultrasonography was used to diagnose left renal vein compression. Transposition of the left renal vein improved Doppler diameter and flow measurements andeliminated symptoms.

Conclusion: Emergency physicians must maintain a large list of possible diagnoses during theevaluation of abdominal and flank pain with a repetitive and uncertain etiology. Nutcracker syndromemay mimic other causes of abdominal and flank pain such as renal colic and requires appropriatereferral.

Gastric Pneumatosis After Accidental Ingestion of Concentrated Hydrogen Peroxide: A Case Report

Introduction: Hydrogen peroxide is a common oxidizing agent that if ingested may cause injury to the gastrointestinal tract or embolic events. Although therapy is primarily supportive, gastric perforation is a rare but serious complication of corrosive ingestion that may require surgical treatment.

Case Report: We report the case of a 77-year-old male who presented for nausea and vomiting after accidentally ingesting approximately 150 milliliters of 35% hydrogen peroxide. Computed tomography revealed gastric pneumatosis and extensive portal venous air. The patient was admitted for observation with plans for endoscopy; however, due to the limitations of our small community hospital, he was transferred to a tertiary care center due to concern for a potential gastric perforation.

Conclusion: The presence of portal venous air as a result of peroxide ingestion may be treated conservatively depending on presenting symptoms; however, severe injury such as gastrointestinal perforation may necessitate surgical intervention.

The Use of Point-of-care Ultrasound in the Diagnosis of Pott’s Puffy Tumor: A Case Report

Introduction: Pott’s puffy tumor (PPT) is a rare clinical disease characterized by forehead swelling from a subperiosteal abscess coupled with frontal bone osteomyelitis. It is often associated with severe complications and poor outcomes if left undiagnosed; thus, rapid recognition is crucial. Point-of-care ultrasound (POCUS) may provide an alternative pathway to diagnosis. It can be performed rapidly at the bedside and assist in early screening of patients, identifying those with high suspicion for PPT and prioritizing imaging and consultation.

Case Report: A 59-yghb ar-old-male presented to the emergency department for evaluation of a “lump” on his forehead. He recently had a bifrontal craniotomy to de-bulk a polyp burden in an effort to manage his recurrent sinusitis. To further characterize the mass, a POCUS examination was performed by the treating emergency physician. The examination found a subcutaneous, hypoechoic fluid collection extending superficially along the frontal bone. A discontinuity in the surface of the frontal bone was visualized through which the collection appeared to extend. Given the heightened concern for PPT based on the POCUS examination findings, otolaryngology service was consulted and the patient was admitted for further imaging and treatment.

Conclusion: Pott’s puffy tumor is a rare diagnosis that has the potential for life-threatening complications. Timely diagnosis is imperative. Point-of-care ultrasound can easily be used to help identify patients with suspicion for PPT in the acute care setting and influence patient management with regard to obtaining further imaging and plans for early consultation.

Early Extracorporeal Membrane Oxygenation in COVID-19 with Bullous Lung Disease on Mechanical Ventilation: A Case Report

Introduction: Extracorporeal membrane oxygenation (ECMO) has been well described as a viable option for patients in need of temporary supplemental oxygenation when ventilator capabilities have failed to augment a patient’s condition. Less described is the potential use of ECMO for lung protection in the setting of gigantic bullae despite initially adequate oxygenation.

Case Report: We describe how the early incorporation of ECMO in a patient with coronavirus disease 2019 and necrotizing pneumonia complicated by multiple large and gigantic bullae led to a favorable outcome.

Conclusion: The decision to start ECMO early, despite room for ventilator oxygenation adjustments, may have helped to prevent potential, significant complications such as tension pneumothorax while on positive pressure, thus potentially optimizing the outcome in this patient.

A Case Report of Opisthotonos Associated with Administration of Intramuscular Ketamine

Introduction: Ketamine, a commonly used medication to treat agitation, has known adverse effects such as emergence reactions, vomiting, and laryngospasm. Opisthotonos has not been a commonly reported adverse reaction.

Case Report: We report a case of opisthotonos brought on by administration of ketamine. A 24-year-old male with a history of schizophrenia was brought in by emergency medical services with opisthotonos shortly after treatment with 250 milligrams intramuscular ketamine by paramedics. He had become increasingly paranoid after being off his aripiprazole for a few weeks, and his family had become afraid for his and their safety. Paramedics administered ketamine to control his combative agitation, per protocol. The patient’s extreme neck and back extension rapidly resolved with the administration of midazolam. Further history and workup did not reveal another cause for opisthotonos.

Conclusion: This is the first reported case to our knowledge of ketamine-associated opisthotonos in the emergency setting. Emergency care providers should be aware of this potential side effect.

A Chemist with a Strange Etiology of Rhabdomyolysis: A Case Report of a Rare Toxicological Emergency

Introduction: Chloroform, a halogenated hydrocarbon, causes central nervous depression, hepatotoxicity, nephrotoxicity, and rhabdomyolysis. Historically, chloroform had been used as a general anaesthetic and today is still used in chemical industries. Lack of proper personal protective equipment and adequate knowledge about its toxic effects can lead to serious harm.

Case report: A 33-year-old gentleman presented to the emergency department (ED) with altered mental status. Given his depressed mental status, the decision was made to intubate shortly after arrival for airway protection. Further history raised suspicion of occupational chloroform exposure. Brown-colored urine further strengthened suspicion of chloroform poisoning with resultant rhabdomyolysis. Forced alkaline diuresis and N-acetylcysteine were started in the ED. His mental status and respiratory efforts improved on hospital day two, and he was ultimately extubated. Creatine phosphokinase and myoglobin levels were initially high but gradually came down by hospital day six. On hospital day 10, the patient was deemed stable and safely discharged.

Conclusion: A patient with chloroform inhalation who suffered resultant rhabdomyolysis and hepatotoxicity was successfully treated with early initiation of forced alkaline diuresis, N-acetylysteine, and hemodialysis.

A Case Report of Acute Prostatitis Secondary to Use of P-valve Condom Catheter During Cave Diving

Introduction: Acute bacterial prostatitis is characterized by acute inflammation of the prostate gland accompanied by the presence of pain and other urinary tract or systemic symptoms. Prostatitis is a relatively common disease of the urinary tract in men, However, this case reports a man diagnosed with acute bacterial prostatitis with an unusual presentation, as well as an unusual pathogen and a unique mechanism of colonization.

Case Report: A 52-year-old male with no past medical history presented to our facility for right-sided buttock pain associated with dysuria, diarrhea, and perianal burning. The patient was diagnosed with sepsis secondary to acute bacterial prostatitis, and the pathogen identified in his urine was Aeromonas hydrophila/A. caviae. His disease process was later recognized as a complication of the use of a P-valve condom catheter while freshwater cave diving.

Conclusion: This is the first documented case of prostatitis as a result of the use of a P-valve condom catheter while diving. Furthermore, the pathogen identified is of particular interest as there are very few documented cases of urosepsis secondary to Aeromonas hydrophila or A. caviae.

Atypical Presentation of Aseptic Meningitis Due to Varicella Zoster: A Case Report

Introduction: Varicella zoster virus (VZV) meningitis is primarily an infection of the immuno-compromised. However, it can also affect immunocompetent individuals. Reactivation of VZV typically presents with a distinct dermatomal rash suggestive of varicella zoster, but there have also been reports of VZV meningitis presenting without a rash.

Case Report: We describe a case of VZV meningitis in a healthy, 30-year-old male presenting to the emergency department shortly after receiving his first coronavirus disease 2019 vaccination. He was treated with intravenous acyclovir and then discharged home on oral valacyclovir.

Conclusion: Emergency physicians should consider aseptic meningitis in immunocompetent patients presenting with atypical headaches in this population.

Bilateral Acute Angle-Closure Glaucoma: A Case Report of an Unusual Cause of Acute Headache in a Child

Introduction: Acute angle-closure glaucoma (AACG) is typically considered a disease of adulthood. However, AACG may occasionally be seen in children. The clinical presentation is similar to adults, including headache, vomiting, and eye pain. However, the etiology of angle closure in children is different and most often associated with congenital anterior segment abnormalities. A precipitating factor of AACG in children with previous established, anterior segment abnormalities is eye dilation, which may occur during routine ophthalmological examination with topical mydriasis, or physiologic mydriasis upon entering a dark room.

Case Report: We describe a 5-year-old child with a history of severe prematurity and retinopathy of prematurity (ROP) presenting with bilateral AACG following a routine outpatient, dilated ophthalmological examination. While angle-closure glaucoma has previously been reported in cases of ROP, a bilateral acute attack of AACG following pupil dilation in regressed ROP has hitherto been unreported.

Conclusion: Given the association of ROP and AACG, it can be expected that as the survival rate of premature infants improves, the incidence of ROP and AACG may also increase. It is therefore prudent for the emergency physician to have AACG on the differential for pediatric patients with headache and eye pain.

Didelphys Uterus in Pregnancy, an Uncommon Mullerian Duct Anomaly: A Case Report

Introduction: Didelphys uterus, or “double uterus,” is one of the rarest Müllerian duct anomalies (MDA). Due to its rarity, data are sparse on overall outcomes associated with this congenital defect, but it may be associated with several complications, both pregnancy and non-pregnancy related.

Case Report: In this case, a pregnant 35-year-old female with vaginal bleeding was subsequently diagnosed with uterus didelphys by transvaginal ultrasound imaging.

Conclusion: Despite its rarity, clinicians should be aware of MDAs and their associated compli-cations with pregnancy.

An Uncommon Presentation of Cryptococcal Meningitis in an Immunocompetent Patient: A Case Report

Introduction: Meningitis is a serious and potentially life-threatening infection of the central nervous system. Cryptococcus neoformans is a rare fungal cause of meningitis that commonly presents with atypical symptoms. Although this infection is most common in immunocompromised patients, it also occurs in immunocompetent patients. This case report describes an atypical presentation of cryptococcal meningitis in a seemingly immunocompetent patient.

Case Report: A 40-year-old immunocompetent patient with no significant past medical history had visited the emergency department (ED) five times within a span of 30 days reporting dental pain and headache. Throughout each of the visits, no clear symptoms signaling the need for a meningitis workup were observed, as the patient had been afebrile, displayed no nuchal rigidity, and his presenting symptoms subsided within the ED after treatment. A lumbar puncture was performed after emergency medical services brought the patient in for his sixth ED visit, initially for stroke-like symptoms and altered mental status. Spinal fluid was indicative of cryptococcal meningitis.

Conclusion: This case highlights the challenge of identifying cryptococcal meningitis in the ED, particularly in immunocompetent patients who do not display classic meningitis symptoms. It also highlights the importance of keeping a broad differential and carefully ruling out diagnoses when patients return to the ED multiple times for the same complaint.

Small Bowel Volvulus as Delayed Presentation of Undiagnosed Crohn’s Disease: A Case Report

Introduction: Emergency department (ED) visits related to flare-ups of inflammatory bowel disease (IBD) are becoming more prevalent. There are many potentially dangerous complications and sequelae of uncontrolled IBD.

Case Report: We report a case of a middle-aged woman who presented with a few hours of severe abdominal pain, nausea, and vomiting. Given her hemodynamic instability, she was sent urgently for computed tomography, which showed an incomplete small bowel malrotation, mesenteric volvulus, and high-grade small bowel obstruction with evolving ischemia. The patient underwent exploratory laparotomy to resect most of her small intestines. Biopsies later revealed active Crohn’s disease.

Conclusion: Patients with flare-ups of IBD are common in the ED, but very few present with a midgut volvulus later in life. Our case is unique and adds to the literature due to the dramatic consequences of undiagnosed Crohn’s disease in a patient with intermittent symptoms and extensive workup spanning over two decades.

Atypical Presentation of Haemophilus influenzae Septic Arthritis: A Case Report

Introduction: Septic arthritis is a destructive form of acute arthritis that requires expeditious recognition. as delayed treatment yields significant morbidity and mortality.

Case Report: A 40-year-old male presented to the emergency department with right elbow pain. Examination revealed tachycardia, swelling, redness, tenderness, and decreased range of motion of the right humeroulnar joint. Synovial fluid analysis was consistent with an inflammatory etiology, but blood and joint cultures ultimately revealed Haemophilus influenzae.

Discussion: This case highlights the importance of trusting clinical findings over laboratory evidence in patients with suspected septic arthritis.

Whirlpool No More: A Case of Misdiagnosed Malrotation with Midgut Volvulus

Introduction: Adult intestinal malrotation with midgut volvulus is rare and most often diagnosed on abdominal imaging. Once the diagnosis is made, prompt surgical intervention is necessary. A finding suggestive of malrotation with midgut volvulus on abdominal imaging is the “whirlpool” sign where the superior mesenteric vein and superior mesenteric artery twist at the root of the abdominal mesentery. This sign was once thought to be pathognomonic, but recent studies have shown that it can be seen in asymptomatic patients.

Case Report: A 20-year-old female presented to our emergency department with diffuse abdominal pain. Computed tomography demonstrated the “whirlpool” sign with a concern for malrotation with midgut volvulus. Surgical consultation was obtained and the patient was rushed to the operating room for an exploratory laparotomy. Normal mesenteric attachments were seen and no significant pathology was identified during the laparotomy. The patient was eventually diagnosed with gastritis and discharged in stable condition.

Conclusion: Emergency physicians and surgeons alike should be cautious in confirming malrotation with midgut volvulus solely due to the “whirlpool” sign on abdominal imaging. Premature diagnostic closure can lead to unnecessary procedures and interventions for patients as in the case we report here.

Images in Emergency Medicine

Diagnosis of Bladder Diverticula with Point-of-Care Ultrasound

Case Presentation: A 65-year-old male presented to the emergency department with symptoms including fever, abnormal urinalysis, and elevated post-void residual. Point-of-care ultrasound was used to rapidly diagnose a bladder diverticulum. The patient was subsequently seen by urology for outpatient bladder repair.

Discussion: Bladder diverticula, an out-pouching of the bladder, may occur congenitally or as a result of various bladder conditions and/or surgery. Although bladder diverticula are rare and often asymptomatic, severe complications including frequent recurring urinary tract infections may arise depending on the patient.

  • 1 supplemental video

Computed Tomography Appearance of the “Whirlpool Sign” in Ovarian Torsion

Case Presentation: A 28-year-old female presented to the emergency department complaining of right lower abdominal pain. A contrast-enhanced computed tomography (CT) was done, which showed a 15-centimeter right adnexal cyst with adjacent “whirlpool sign” concerning for right ovarian torsion. Transvaginal pelvic ultrasound (US) revealed a hemorrhagic cyst in the right adnexa, with duplex Doppler identifying arterial and venous flow in both ovaries. Laparoscopic surgery confirmed right ovarian torsion with an attached cystic mass, and a right salpingo-oophorectomy was performed given the mass was suspicious for malignancy.

Discussion: Ultrasound is the test of choice for diagnosis of torsion due to its ability to evaluate anatomy and perfusion. When ovarian pathology is on the patient’s right, appendicitis is high in the differential diagnosis, and CT may be obtained first. Here we describe a case where CT first accurately diagnosed ovarian torsion by demonstrating the whirlpool sign, despite an US that showed arterial flow to the ovary. Future studies should determine whether CT alone is sufficient to diagnose or exclude ovarian torsion.

Enterocutaneous Fistula and Abscess Diagnosed with Point-of-care Ultrasound

Case Presentation: A 64-year-old female with history of umbilical hernia repair with mesh 18 years prior, cystocele, and diabetes mellitus presented with 10 days of abdominal and flank pain.  The patient was tachycardic, normotensive, afebrile, and had an erythematous, tender, protuberant abdominal wall mass. Point-of-care ultrasound (POCUS) revealed an irregular, heterogeneous extraperitoneal fluid collection with intraperitoneal communication; these findings were consistent with an abscess and infected mesh with evidence for intraperitoneal extension.  The diagnosis of enterocutaneous fistula (ECF) with infected mesh and abdominal wall abscess was confirmed with computed tomography and the patient was admitted for antibiotics and source control.

Discussion: A rare complication of hernia repair with mesh, ECF typically occurs later than more common complications including cellulitis, hernia recurrence, and bowel obstruction. In the emergency department, POCUS is commonly used to evaluate for abscess; in other settings, comprehensive ultrasound is used to evaluate for complications after hernia repair with mesh. However, to date there is no literature reporting POCUS diagnosis of ECF or mesh infection. This case suggests that distant surgery should not preclude consideration of mesh infection and ECF, and that POCUS may be useful in evaluating for these complications.

  • 1 supplemental video

Gastric Pneumatosis: An Atypical Presentation of Desmoid Tumor

Case presentation: A middle-aged woman presented to the emergency department with a chiefcomplaint of abdominal pain, fever, vomiting, and diarrhea. Abdominal computed tomographyrevealed gastric pneumatosis and air in the portal system. The patient had an unfavorable clinicalcourse with pneumoperitoneum and septic shock due to secondary peritonitis. She underwentemergency laparotomy where neoformation of the mesentery root was found with infiltration of thesmall intestine and jejunal perforation. The anatomopathological study of the tumor revealed that itwas a desmoid tumor.

Discussion: To our knowledge this is the first report in the literature of gastric pneumatosis as theinitial presentation of a mesenteric desmoid tumor. Although it usually has a benign clinical course,its locally invasive characteristics can lead to critical illness. Physicians shouldn’t overlook thesetypes of complications, as early identification and surgical intervention can modify the prognosis andshorten hospital stay.

SAPHO Syndrome: An Unusual Cause of Dysphagia

Case Presentation: This case describes a 51-year-old male who presented to the emergency department with a complaint of two weeks of progressively worsening dysphagia as well as the emergence of superficial fluid collections on the anterior chest and leg during the same period. Computed tomography showed retropharyngeal and paratracheal fluid collections with adjacent vertebral osteitis; however, biopsies were negative for any infectious or mycobacterial source, and instead showed chronic inflammatory changes.

Discussion: Synovitis, acne, pustulosis, hyperostosis, osteitis (SAPHO) syndrome is a rare rheumatic disorder that presents with multifocal osteitis and sterile neutrophilia. SAPHO syndrome may be easily mistaken for a diffuse infectious process on initial evaluation and imaging; however, it is treated with anti-inflammatory medications, including non-steroidal anti-inflammatory drugs and corticosteroids. Although most patients achieve remission of symptoms with treatment, the location of the fluid collections and resultant bony destruction may be life-threatening if undiagnosed.

Pacemaker Lead Migration and Ventricular Perforation in a Patient Presenting with Chest Pain

Case Presentation: We describe a middle-age male with a past medical history of second-degree atrioventricular block type II status post permanent pacemaker placement the day prior who presented to the emergency department complaining of chest pain. Electrocardiography showed a non-paced ventricular rhythm. Chest radiograph showed the ventricular pacemaker lead located distally overlying the right ventricle apical area. On further investigation, chest computed tomography showed a perforation of the ventricular wall by the pacemaker lead prompting urgent intervention by the cardiothoracic surgery team for lead replacement and right ventricular repair.

Discussion: Our case illustrates the importance of timely recognition of a perforated pacemaker lead in a patient presenting with chest pain after device implantation. We additionally describe the risk factors for ventricular perforation, initial clinical presentation, and management approach.

Adrenocortical Carcinoma Discovered with Point-of-care Ultrasound

Case Presentation: A 34-year-old woman presented to the emergency department with bilateral lower extremity edema and shortness of breath. She had been seen by her primary care provider. Lab work and a follow-up with endocrinology had been unrevealing. Using point-of-care ultrasound we identified a cystic mass in the right upper quadrant prompting further imaging.

Discussion: Abdominal and pelvic computed tomography confirmed a mass in the right posterior liver, which was later identified as an adrenocortical carcinoma. Ultrasound is an important diagnostic tool in the setting of lower extremity edema and can be used to assess for heart failure, liver failure, obstructive nephropathy, venous thrombosis, and soft tissue infection. In this case, ultrasound helped expedite the diagnosis and treatment of a rare malignancy.

  • 1 supplemental video

Traumatic Anterior Dislocation of Ocular Cataract Lens

Case presentation: A 33-year-old male presented to the emergency department following a motor vehicle collision with complaints of right eye pain after hitting his head on the steering wheel. Point-of-care ultrasound (POCUS) revealed retinal detachment and an anterior lens dislocation.

Discussion: Lens dislocations following blunt head trauma can often be diagnosed using POCUS. Anterior ocular lens dislocation is a rare but vision-threatening result of head trauma. This case highlights how POCUS can facilitate early detection of ocular pathology, such as lens dislocation, and improves patient outcomes.

Carpometacarpal Dislocation with Third Metacarpal Fracture

Case Presentation: A 17-year-old male presented to the emergency department (ED) due to trauma to the right hand and wrist after punching a locker at school. He had significant soft tissue swelling. Radiographs demonstrated intra-articular metacarpal fractures with associated carpometacarpal dislocations. The dislocation was reduced bedside in the ED and ultimately underwent closed reduction surgical management with orthopedic surgery.

Discussion: Metacarpal fractures result from high-force impact injuries and account for 30-40% of all hand injuries. The most common sites of second through fifth metacarpal fractures are at the neck and the shaft, with the majority involving the fifth metacarpal neck (commonly coined “boxer’s fractures”). Carpometacarpal (CMC) dislocations are a rare injury associated with high-force impact trauma to the wrist. These injuries account for as little as 1% of all acute hand and wrist injuries. Carpometacarpal dislocations are often difficult to diagnose on physical examination due to significant soft tissue swelling, and they can easily be missed on anterior-posterior views of the hand. Lateral and oblique plain radiograph views are essential in the diagnosis as they are more likely to show dislocations. Despite appropriate plain radiographic views, subtle CMC dislocations may be difficult to discern dependent on the level of dislocation or subluxation and overlapping of joints. These injuries are rare due to otherwise highly stable ligamentous and muscular attachments within the wrist. Because of these attachments, dislocations are often associated with concomitant metacarpal fractures.

Disseminated Kaposi Sarcoma

Case Presentation: A 28-year-old male with a recent diagnosis of human immunodeficiency virus presented to the emergency department with odynophagia and dysphagia for a month. Physical exam revealed Kaposi sarcoma partially occluding the airway. Point-of-care ultrasound was used to assist with the diagnosis of reactive lymphadenopathy, and computed tomography revealed systemic disease. Otolaryngology was urgently consulted, and the patient was admitted for prompt tracheostomy the following day.

Discussion: Kaposi sarcoma is a violaceous vascular neoplasm that is an acquired immuno-deficiency syndrome (AIDS)-defining illness. Mucocutaneous membranes should be thoroughly evaluated with patients suspected of AIDS. This case demonstrates the vital evaluation of the patient’s airway to assess patency. Highly active antiretroviral therapy should be initiated promptly, as well as chemotherapy in severe systemic cases.

ACOEP Clinicopathological Cases (Invitation Only)

The Tired Pregnant Woman

Introduction: Many pregnant women develop hyperemesis gravidarum. There are numerous gastrointestinal, genitourinary, neurologic, and metabolic causes to consider in this patient population.

Case Presentation: This clinicopathological case presentation details the initial assessment and management of an 18-year-old pregnant patient who presented to the emergency department with a complaint of nausea, vomiting, fatigue, and intermittent bleeding.

Discussion: This case takes the reader through the differential diagnosis and evaluation of the patient and the signs and symptoms, including her agitation and tachycardia, that led us to the correct diagnosis.

ACOEP Case Reports (Invitation Only)

Splenic Injury Following Colonoscopy: A Case Report

Introduction: Colonoscopy is a commonly performed outpatient procedure with a low risk of complications. The most common complications seen in the postoperative period include hemorrhage and perforation. Infrequently, splenic injury can occur.

Case Report: A 72-year-old male presented with a one-day history of left upper quadrant pain following colonoscopy. During the procedure he had two polyps removed along the transverse colon near the splenic flexure. There were no complications during the procedure or in the immediate post-operative period. On presentation to the emergency department, abdominal tenderness was present in the left upper quadrant without rebound, rigidity, or guarding. Point-of-care ultrasound of the abdomen demonstrated mixed hypoechoic densities confined to the splenic capsule, and computed tomography of the abdomen and pelvis with intravenous contrast noted a grade II/III splenic laceration without active extravasation. The patient was admitted for serial abdominal examination and labs.

Conclusion: Splenic injury following colonoscopy is a rare complication of colonoscopy. Emergency providers should be aware of this possible complication, and acute management should include basic trauma care and consultation for possible intervention, if warranted.

48-year-old with Altered Mental Status and Respiratory Failure: A Case Report

Introduction: The differential diagnosis for altered mental status and respiratory failure is broad. Careful physical examination, appropriate use of diagnostic tools, and accurate interpretation and correlation of test results are important for piecing together the puzzle of a patient with altered mental status that emergency physicians commonly face. In certain cases, such as this one, rapid diagnosis and management is crucial for improving patient morbidity and mortality.

Case Presentation: A 48-year-old male with altered mental status and respiratory failure presented to the emergency department after being found unconscious on his porch. Vital signs were notable for temperature 105.5 °F, blood pressure 202/102 millimeters of mercury, pulse 126 beats per minute, respiratory rate 30 breaths per minute, and oxygen saturation 91% on room air. Physical examination revealed an obese male lying in bed awake in severe distress with labored breathing and unable to converse. His physical examination was significant for dry mucous membranes, tachycardia, and bilateral lower extremity 1+ pitting edema. He also appeared to have Kussmaul respirations with severe tachypnea, but his breath sounds were clear to auscultation bilaterally. On further examination, the patient appeared to have intravenous (IV) injection markings along his arms suggesting the possibility of IV drug use.

Discussion: With limited history, the only context clues initially available to assist in the diagnosis were abnormal vital signs and physical examination. The patient was tachycardic, hyperthermic, hypertensive, hypoxic, and tachypneic with altered mental status; he eventually required endotracheal intubation for hypoxic respiratory failure. The complexity of his condition prompted a large list for the differential diagnoses. Toxidromes, endocrine abnormalities, infectious process, cardiac and/or renal etiologies, and neurological pathology such as a cerebrovascular accident were considered. In the case of this patient, urgent diagnosis and management was crucial to prevent further decompensation and improve his outcome.

Acute Myocardial Infarction in a Patient with Twin Pregnancy: A Case Report

Introduction: Acute myocardial infarction (AMI) rarely occurs during pregnancy and presents unique challenges in diagnosis and management. Traditionally, pregnancy has not readily been considered a risk factor for AMI in the emergency department despite the potential for adverse impacts on maternal and fetal health. As cardiovascular risk factors and advanced maternal age become more prevalent in society over time, the incidence will continue to increase. Prior cases with singular gestation have been reported; however, only one previous case during a twin pregnancy was identified in the medical literature.

Case Report: We describe a rare case of acute ST-segment elevation myocardial infarction in a 37-year-old woman at 24 weeks gestation with a dichorionic diamniotic twin pregnancy.

Conclusion: It is important for the emergency physician to recognize acute coronary syndrome as a part of the differential diagnosis of chest pain in pregnant patients and be familiar with the diagnostic and management options available for this special population.

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Needle Decompression of Tension Pneumoperitoneum: A Case Report

Introduction: Tension pneumoperitoneum is rarely encountered in the emergency department but can have disastrous effects on the body when it is. However, an emergency physician has skills that can be readily applied to needle decompress the abdomen for rapid stabilization.

Case Report: A 42-year-old male arrived via ambulance after a likely overdose with mental status improvement following naloxone administration. He was found to be in respiratory distress due to a rigid, distended abdomen that required intubation for stabilization. Computed tomography imaging showed significant pneumoperitoneum with tension physiology. Surgery consultation was unable to intervene immediately, and needle decompression with an angiocatheter was performed at the bedside with immediate ventilatory improvement.

Conclusion: Tension pneumoperitoneum is a rare but potentially disastrous consequence of overdose secondary to emesis and rupture of the gastric wall. Needle decompression is a skillset already in the emergency physician’s toolbox and can be applied for emergency stabilization of a tension pneumoperitoneum with proper forethought and technique.

Bilateral Cranial Nerve VI Palsies in Cryptococcal Meningitis, HIV, and Syphilis: A Case Report

Introduction: Cranial nerve (CN) VI palsy is a common complaint seen in the emergency department (ED) and has a wide range of causes. Bilateral CN VI palsies are uncommon and appear to be associated with more severe complications.

Case Report: A 29-year-old male presented to the ED from an ophthalmology office for diplopia, headache, and strabismus. He was found to have bilateral CN VI palsies and new-onset seizure in the ED. A lumbar puncture revealed cryptococcal meningitis. Additional tests revealed a new diagnosis of human immunodeficiency virus (HIV), acquired immunodeficiency syndrome (AIDS), and syphilis.

Conclusion: Cryptococcal meningitis remains a life-threatening complication of HIV/AIDS. Coinfections with HIV, particularly syphilis, further complicate a patient’s prognosis as both can lead to devastating neurological sequelae. In cryptococcal meningitis, elevated intracranial pressure is a complication that can manifest as seizures, altered mental status, and cranial nerve palsies.