Volume 6, Issue 1, 2022
CPC-EM Full-Text Issue
Clinicopathological Cases from the University of Maryland
Introduction: A 57-year-old, right-hand dominant female presented to the emergency department striking herself with her left hand.
Case Presentation: The astute medical staff looked beyond a behavioral health etiology. A detailed history, physical examination, and workup reveals the fascinating final diagnosis.
Discussion: This case takes the reader through the differential diagnosis and systematic workup of uncontrolled limb movements with discussion of the studies which ultimately led to this patient’s diagnosis.
Medical Legal Case Report
Introduction: This series reviews three cases of back pain where a highly morbid diagnosis was missed by an emergency physician and subsequently successfully litigated.
Case Report: We review the clinical entities of spinal epidural abscess and cauda equina syndrome, challenging diagnoses that can be easily missed and lead to patient harm if not treated promptly. Here we offer suggestions for recognizing these conditions quickly, performing an adequate history and exam, and using documentation to support decision-making.
Conclusion: When confronted with an unfortunate medical outcome, maintaining honesty is of paramount importance in medical-legal environments.
Point-of-care Ultrasound for the Evaluation of Acute Arterial Pathology in the Emergency Department: A Case Series
Introduction: The use of point-of care ultrasound (POCUS) in the evaluation of vascular emergencies including abdominal aortic aneurysm and deep vein thrombosis is well established. However, no current guidelines exist to outline the use of POCUS in the management of acute peripheral arterial pathology.
Case Series: Here, we present a case series that illustrates the utility of POCUS in the assessment of both traumatic and nontraumatic peripheral arterial disease. Direct visualization of the vasculature via B-mode, color Doppler, and pulsed-wave Doppler assisted in the diagnosis of the following: 1) an acute, post-catheterization thrombus of the proximal radial artery; 2) a complete, traumatic radial artery transection; 3) a forearm hematoma with active arterial extravasation; 4) a traumatic arteriovenous fistula; 5) an acute thrombosis of an artery bypass graft; and 6) an infected pseudoaneurysm.
Conclusion: The incorporation of POCUS into patient care allowed for rapid identification of significant peripheral arterial pathology and led to changes in clinical management, expedited patient care, and circumvented potentially harmful complications.
Introduction: Abdominal compartment syndrome (ACS) is a rare condition in which increased intra-abdominal pressure causes multiorgan dysfunction through decreased perfusion. Causes of this condition are variable, and early recognition is critical for favorable patient outcomes. Measurement of bladder pressure is recommended for diagnosis.
Case Report: A 64-year-old female on clozapine with a two-year history of chronic constipation presented to the emergency department in extremis with a protuberant abdomen. After resuscitative measures, computed tomography showed a dilated, stool-filled colon with a decompressed inferior vena cava and decreased perfusion. She died despite surgical decompression.
Conclusion: Severe constipation is a rare cause of ACS, and there is a lack of evidence-based guidelines. Options for bedside decompression are limited. To reduce morbidity and mortality in this population, early recognition of ACS is imperative. Initial interventions should support hemodynamics and respiration. Definitive management is surgical decompression.
Case Report: Differential Diagnosis of Lower Extremity Weakness in a Young Male - Consider Foix Alajouanine Syndrome
Introduction: There is a limited list of emergent spinal cord pathology that must be considered in patients with focal neurological deficits in the emergency department. Identification of these conditions requires a detailed history and neurological exam and may also require advanced testing and imaging.
Case Report: Here we present the case of a patient with a rare arteriovenous malformation of the spinal cord vessels causing congestive myelopathy (Foix-Alajouanine syndrome) that presented as a clinical mimic of spinal cord compression.
Conclusion: Emergency physicians should be aware of Foix-Alajouanine syndrome, as its workup and management differ from more common pathologies that may present similarly.
Introduction: This case report of renal vein thrombosis found on emergency bedside ultrasound illustrates the expanding role of point-of-care ultrasound (POCUS) in rapidly identifying rare renal pathologies.
Case Report: A 16-year-old female with a complex medical history presenting with right-sided abdominal pain and tenderness was found to have significant renal POCUS findings consistent with renal vein thrombosis.
Conclusion: In the medically complex patient with nonspecific chief complaints, it can be challenging to rapidly narrow a broad differential diagnosis. Point-of-care ultrasound has proven to be an extremely useful tool for this purpose. As emergency physicians become more proficient in the use of ultrasonography, it is likely that POCUS will be used with increasing frequency to identify additional pathology outside its traditional applications.
- 1 supplemental video
Introduction: As the medical community and world have combatted the coronavirus disease 2019 (COVID-19) pandemic, a significant advance was the development of a vaccine against the virus that has already claimed over 4.5 million lives worldwide. Vaccines manufactured by Pfizer-BioNTech and Moderna were the first two COVID-19 vaccines given emergency use authorization by the United States Food and Drug Administration. Preliminary data demonstrated not only the vaccines’ efficacy rates of greater than 95% after a second dose, but also marked safety. Initial data showed only 21 cases of anaphylaxis of greater than 1.8 million doses administered. The majority of those patients had a history of anaphylaxis and presented within the first 15 minutes after administration of the vaccine
Case Report: We describe a patient who had an anaphylactic reaction to her second dose of the Pfizer BioNTech severe acute respiratory syndrome coronavirus 2 (SARS CoV-2) vaccine with no prior history of allergic reactions or anaphylaxis. This reaction required multiple doses of epinephrine and a four-day hospitalization. We review both the available reports of anaphylaxis to the SAR CoV-2 vaccine and information on other prolonged cases of anaphylaxis.
Conclusion: Our case report is unique in that the patient, despite no prior history of anaphylaxis, had a prolonged course requiring a four-day hospitalization. To our knowledge this is one of the first case reports of prolonged anaphylaxis after the second dose of Pfizer BioNTech COVID-19 vaccine in a patient with no history of prior anaphylaxis.
Managing Subarachnoid Hemorrhage Precipitated by Anesthesia-assisted Rapid Opioid Detoxification: A Case Report
Introduction: Anesthesia-assisted rapid opioid detoxification (AAROD) is a controversial method of treating opioid dependence that involves sedating patients during a period of provoked withdrawal. Reported adverse outcomes of the procedure demonstrate the importance of recognizing the potential complications of AAROD.
Case Presentation: We present a case of a 41-year-old male presenting with a subarachnoid hemorrhage following an AAROD procedure.
Conclusion: This case report and discussion reviews the pathophysiology of opioid withdrawal syndrome, potential complications following AAROD, and important management considerations.
Introduction: Conducted electrical weapons, commonly known by their proprietary eponym, TASER, are frequently used by law enforcement. A review of the literature yielded descriptions of taser barb removal from soft tissue and surgical intervention for barbs lodged in sensitive areas such as the eye and head, but not from other osseous sites.
Case Report: We report the case of a 30-year-old male transferred from another hospital with a taser dart embedded in his clavicle. Prior attempts at bedside removal had been unsuccessful. We describe bedside removal of the taser barb from bone using local anesthesia and simple fulcrum technique.
Conclusion: We describe a novel fulcrum technique for removal of a taser dart embedded in bone. This is a reasonable technique to attempt in patients with involvement of superficial osseous structures to avoid operative intervention.
Introduction: Aripiprazole is an atypical antipsychotic with unique receptor-binding properties that has a favorable safety profile in therapeutic doses compared to other antipsychotics. Massive aripiprazole overdose in children, however, presents with profound lethargy and may have neurologic, hemodynamic, and cardiac effects, often requiring admission to a high level of care.
Case Report: We describe a case of a 21-month-old male with a reported 52-milligram aripiprazole ingestion. Initial vital signs were remarkable for tachycardia and hypertension, which rapidly resolved. The patient did not develop hypotension throughout hospitalization. He experienced 60 hours of lethargy. Irritability associated with upper extremity spasms and tremors occurred from 36-72 hours post ingestion, which resolved without intervention. The initial electrocardiogram demonstrated ST-segment depressions in the anteroseptal leads; further cardiac workup was normal. Concurrent medical workup was unrevealing. Aripiprazole and dehydro-aripiprazole serum concentrations sent 46 hours after reported exposure were 266.5 nanograms per milliliter (ng/mL) and 138.6 ng/mL, respectively. He returned to neurologic baseline and was discharged 72 hours after ingestion.
Conclusion: Antipsychotics, including aripiprazole, should be considered as a potential toxicological cause of persistent central nervous system depression; ingestion of a single dose has the potential to cause significant toxicity.
Introduction: Endophthalmitis is a rare intraocular infection caused by numerous organisms from several possible sources. Fungal endophthalmitis is a rare subset of this pathology with limited diagnostics available. One of the few options to make this diagnosis is vitreous sampling, which is invasive, and results are not immediately available.
Case Report: This case report describes the successful use of point-of-care ultrasound to visualize an intraocular fungal mass in a 60-year-old male who presented to the emergency department (ED) with two weeks of left eye pain and erythema approximately two months postoperative from a cataract extraction surgery.
Conclusion: Fungal endophthalmitis is a rare and challenging diagnosis. Methods of diagnosing this pathology are not readily available in the ED. Point-of-care ultrasound may be a useful adjunct for the prompt diagnosis of fungal endophthalmitis.
- 1 supplemental video
Introduction: A cornual pregnancy describes a rare ectopic location positioned within the myometrium next to the fallopian tube, which can be difficult to find on traditional ultrasound imaging. Given its location and the stretch within the uterine wall, cornual pregnancies can progress for weeks prior to diagnosis. Ruptures can, therefore, be catastrophic with disproportionally high maternal mortality rates compared to other ectopic pregnancies.
Case Report: A 34-year-old female recently treated with methotrexate for ectopic pregnancy presented to the emergency department (ED) for acute onset of lower abdominal cramping without vaginal bleeding. She arrived clinically stable and quickly decompensated with witnessed syncope in the ED, prompting point-of-care ultrasound showing free fluid in the abdomen. The patient was taken for emergent surgery by obstetrics while receiving transfusion of blood products for suspected ruptured ectopic pregnancy. A fetus estimated to be 10 weeks of age was discovered in the left cornual region. Approximately two liters of intraperitoneal blood were drained without complication.
Conclusion: Cornual pregnancy is a difficult to diagnose but potentially disastrous type of ectopic pregnancy due to massive hemorrhage. Emergency clinicians should be aware of this condition given its rare occurrence but potentially catastrophic outcomes.
Introduction: Necrotizing mediastinitis is a rare complication following a dental procedure. It is frequently lethal and requires prompt diagnosis with advanced imaging, administration of broad-spectrum antimicrobials, and early surgical consultation.
Case Report: A 19-year-old, otherwise healthy male presented to the emergency department with chest pain, muffled voice, and facial and neck swelling six days following dental extraction. He was found to have a retropharyngeal abscess causing necrotizing mediastinitis and septic shock. The patient was started on broad-spectrum antimicrobials, required 10 surgical procedures, and experienced a prolonged hospitalization.
Conclusion: Consider necrotizing mediastinitis in patients presenting with chest pain and signs of retropharyngeal infection after dental procedures. Prompt imaging, antimicrobial therapy, and surgical consultation is critical in treating this frequently fatal disease.
Introduction: Patients commonly present with neck masses to the Emergency Department. The acute presentation of such a mass can be alarming to patients and their families. In this report we discuss a rare etiology of an acutely presenting neck mass in an adult.
Case Report: We present a 19-year-old patient with an acute neck mass. The mass developed abruptly soon after initiation of a new upper body strength-training regimen. The patient’s history was unremarkable for any trauma or constitutional symptoms. Physical examination revealed the mass, which was diagnosed as a lymphatic malformation by imaging. Surgical removal was successful with pathology confirming the diagnosis.
Conclusion: Lymphatic malformations, although rare, may present in adulthood. The acute presentation of a new mass, coupled with a lack of concerning constitutional symptoms, should increase the diagnostic suspicion of a lymphatic malformation.
Introduction: Congenital bowel malrotation resulting in midgut volvulus is traditionally regarded as a diagnosis of infancy. Rarely, congenital bowel malrotation is diagnosed in adolescents or adults and requires a high index of suspicion. Presentations can be acute or chronic, and physical examination findings are nonspecific. Diagnosis is primarily achieved through abdominal computed tomography (CT) or during exploratory laparotomy. The pathophysiology in late-onset malrotation is similar to neonatal malrotation, with a division of Ladd’s bands – peritoneal fibrous bands that connect the cecum to the right lower quadrant retroperitoneum – as the definitive treatment. We present a case of congenital bowel malrotation in an adolescent with persistent and worsening migratory abdominal pain.
Case Report: An 18-year-old female presented to the emergency department with two days of poorly localized abdominal pain and nausea. Initial evaluation was unremarkable and she was discharged home with a diagnosis of constipation. She returned two days later with worsening abdominal pain and new onset emesis. Given her persistent and worsening symptoms an abdominal CT was performed, which revealed malrotation of the bowel. Taken together, her CT findings and abdominal symptoms were concerning for symptomatic congenital bowel malrotation and she underwent a Ladd procedure. She remained asymptomatic both at discharge and at two-week postoperative follow-up.
Conclusion: Symptomatic congenital bowel malrotation is more common in older children and adults than has traditionally been thought. Physicians must consider this diagnosis in their differential when working up a patient for acute or chronic intermittent abdominal pain to prevent potentially severe sequelae.
Introduction: Fournier’s gangrene is a severe, necrotizing, and potentially fatal, soft tissue infection of the perineum that can be difficult to diagnose clinically. Point-of-care ultrasound (POCUS) has established a critical role in emergency medicine as a quick diagnostic tool due to its safety, accuracy, and cost effectiveness.
Case Report: We present a case in which POCUS was used to rapidly confirm diagnosis in an unstable, severely septic patient presenting to the emergency department with Fournier’s gangrene.
Conclusion: Point-of-care ultrasound can be used to make the diagnosis of Fournier’s gangrene in critical patients when other diagnostic modalities are not feasible due to a patient’s clinical state.
Introduction: The perforation of a cecal diverticulum is a rare and challenging condition for the emergency physician.
Case Report: A 47-year-old man with a past surgical history of bilateral inguinal hernia repair presented to the emergency department (ED) with acute abdominal pain of three days’ duration. Pain was localized to the right lower quadrant (RLQ), with anorexia as the only associated symptom. Upon arrival to the ED, his exam demonstrated focal RLQ tenderness to palpation, rebound tenderness, and guarding. Labs did not show any elevation in inflammatory markers, liver enzymes, or lipase. Computed tomography showed no evidence of acute appendicitis, colitis, or hernia recurrence. After morphine and reassessment, the patient still had a focal peritoneal exam in the RLQ. Surgical consultation was obtained and recommended additional non-opioid analgesia as well as serial abdominal exams. After several repeat abdominal exams, there was no change in the focality of the patient’s pain. Surgery was reconsulted and opted to take the patient to the operating room for exploratory laparoscopy with “appendicitis” as the presumptive diagnosis. Pathology report revealed a perforated cecal diverticulum that was adherent to the abdominal wall. The patient did well and was discharged on his third postoperative day.
Conclusion: This case further underlines that even in the era of sensitive imaging tools, the diagnostic value of a targeted physical exam with clinical re-evaluation can never be overestimated.
Introduction: Many patients seen in the emergency department (ED) have central venous access placed or previously established placement. Catheters inadvertently placed in the arterial circulation may lead to complications or adverse events.
Case Report: We present a case of hemiplegia in a 63-year-old man following intravenous fluid administration through a malpositioned catheter that was initially unrecognized. The patient initially presented to the ED for stroke-like symptoms and was discharged following workup. On a subsequent visit for similar symptoms, intra-arterial placement of the catheter was diagnosed.
Conclusion: It is important for emergency physicians to be aware of this potential complication of central venous cannulation and that arterial malposition of a previously placed central line may go unrecognized with the potential to cause cerebral ischemia when cerebral blood flow is reduced by the infusion of intravenous fluids or medications.
Introduction: Ethylene glycol intoxication can be lethal if diagnosis is delayed. Often, prompt diagnosis may need to be based on indirect laboratory findings.
Case report: We present a case of severe ethylene glycol intoxication whose diagnosis was based on an unusual “lactate gap.” The patient responded well to the treatment and had a full recovery.
Conclusion: A “lactate gap” can be helpful in establishing a diagnosis of ethylene glycol intoxication.
Introduction: During the coronavirus disease 2019 pandemic caused by the severe acute respiratory syndrome coronavirus 2, deaths from opiate drug overdoses reached their highest recorded annual levels in 2020. Medication-assisted treatment for opiate use disorder has demonstrated efficacy in reducing opiate overdoses and all-cause mortality and improving multiple other patient-centered outcomes. Treatment of tramadol dependence in particular poses unique challenges due to its combined action as opioid agonist and serotonin-norepinephrine reuptake inhibitor. Tramadol puts patients with dependence at risk for atypical withdrawal syndromes when attempting to reduce use. Little evidence is available to guide treatment of tramadol dependence.
Case Report: We present a case of high-dose tramadol addiction that began with misuse of medically prescribed tramadol for treatment of musculoskeletal back pain. The patient’s use reached oral consumption of 5000-6000 milligrams of illicit tramadol daily. She complained of common complications of tramadol use disorder including memory impairment, excessive sedation, and tramadol-induced seizures. The patient was referred to the emergency department in a withdrawal crisis seeking treatment where she was successfully managed with buprenorphine and phenobarbital and then linked to ongoing outpatient treatment.
Conclusion: Our report adds to the limited guidance currently available on the acute management of tramadol withdrawal and treatment of tramadol use disorder. Our case suggests the initiation of high-dose buprenorphine may be an effective and feasible option for emergency clinicians.
Introduction: A myriad of pathologies can cause abdominal pain. Genitourinary causes including testicular torsion must be considered.
Case Report: In this report, we present a 17-year-old male evaluated in the emergency department for lower abdominal pain. After physical exam, computed tomography, and ultrasound were completed, torsion of undescended testicle within the inguinal canal was diagnosed. Surgical exploration revealed a twisted, ischemic testis, and subsequent orchiectomy was performed.
Conclusion: This case highlights the importance of a thorough genitourinary exam in patients with lower abdominal pain.
Images in Emergency Medicine
Case Presentation: A 53-year-old female presented to the emergency department with three days of nausea and dyspnea on exertion after using methamphetamine. Initial electrocardiogram revealed an ST-elevation myocardial infarction. While awaiting transfer to the cardiac catheterization lab the patient suffered a witnessed cardiac arrest. During resuscitative efforts an enlarging pericardial effusion on point-of-care ultrasound led to the detection of a left ventricular free-wall rupture (LVFWR). This case illustrates the progression of a left ventricular free-wall rupture using point-of-care ultrasound.
Discussion: Left ventricular free-wall rupture has a low incidence rate in the setting of an acute myocardial infarction. Ultrasonography is the tool of choice for detecting a LVFWR.
- 2 supplemental videos
Case Presentation: We describe a delayed case of tension pneumocephalus in a newly altered patient 21 days status-post auto-vs-pedestrian accident. After her initial hospital course, the patient was discharged to an acute rehabilitation facility in stable condition with Glasgow Coma Scale 15. The patient returned to the emergency department for an acute change in mental status.
Discussion: Tension pneumocephalus is a neurosurgical and otolaryngological emergency.
Case Presentation: A 37-year-old man with severe obstructive sleep apnea presented to the emergency department with burning pain, redness and swelling in his hands and feet, worsening for several weeks. Pertinent laboratory studies revealed polycythemia.
Discussion: Erythromelalgia is a clinical diagnosis characterized by painful burning, erythema, warmth, and edema usually involving the distal extremities. Therapeutic goals are focused on symptom reduction, while also managing the underlying condition in cases of secondary erythromelalgia. Pharmacological and non-pharmacological therapies have proven to be of limited success.
Case Presentation: A 44-year-old Black male presented to the emergency department with left scrotal pain. His initial workup did not identify an etiology of his symptoms; however, he returned the following day with worsening pain and a radiology-performed ultrasound then revealed a segmental testicular infarct.
Discussion: Segmental testicular infarcts are a rare, often idiopathic, source of scrotal pain. Diagnosis is made by ultrasound, and repeat imaging may be required if not apparent on initial evaluation. Management is typically conservative although some require surgical intervention.
Case Presentation: We describe a case of abdominal pain in a male patient who performed daily self-catheterization and developed a ruptured urinary bladder, which was diagnosed at bedside in the emergency department with point-of-care ultrasound (POCUS).
Discussion: Ruptured urinary bladder is commonly associated with blunt abdominal trauma. It is a rare complication of Foley catheter insertion. These images demonstrate that POCUS can be used as a screening tool to evaluate for bladder rupture when clinically suspected.
Case Presentation: An eight-week-old infant presented to the emergency department with two weeks of fluctuating swelling and erythema of her right upper eyelid. On examination, she had swelling of the right upper eyelid with ptosis and proptosis as well as a nevus simplex on the upper eyelid. Orbital magnetic resonance imaging demonstrated a proliferating orbital hemangioma.
Discussion: Periorbital erythema and swelling are often infectious or allergic, but in infants with a fluctuating course, underlying vascular malformation must be considered. Without early provider recognition, periocular hemangiomas have the potential to cause vision-related complications.
Case Presentation: A four-year-old female patient presented to the emergency department with an epinephrine auto-injector that had unintentionally discharged into her mandible. There was difficulty removing the auto-injector at bedside. Images we acquired noted needle curvature not present in an off-the-shelf model. She was sedated, and the auto-injector was removed by retracing the angle of discharge, with care taken not to inject epinephrine into the patient.
Discussion: Epinephrine auto-injector accidental discharges are an unusual injury pattern, but the incidence of such events is increasing in the United States. The emergency clinician should be cognizant of complicating factors with discharges, such as bent needles. Here we discuss a case of discharge into the maxillofacial region (lower jaw), with approaches to treatment.
Case Presentation: Arteriovenous malformations (AVM) have a variety of clinically significant manifestations. This report details a patient who presented with unilateral conjunctiva injection, which was found to be due to an atypical manifestation of an AVM with a large draining vein mimicking carotid cavernous fistula.
Discussion: While imaging for patients presenting with eye pain and unilateral conjunctiva injection is not always warranted, emergency physicians should keep their differential diagnosis broad and pursue additional workup when warning signs of more sinister pathology present.