Volume 6, Issue 2, 2022
CPC-EM Full-Text Issue
Clinicopathological Cases from the University of Maryland
Introduction: A 58-year-old male presents to the emergency department with headache, hand numbness, and phantosmia.
Case Presentation: Magnetic resonance imaging showed multiple acute and early subacute lesions involving the cortex and subcortical white matter of the left frontal lobe, left parietal lobe, left temporal lobe, left caudate, and left putamen.
Discussion: This case takes the reader through the subtle findings that led to the diagnosis and ultimately to treatment.
Testicular Torsion Appearance and Diagnosis on Computed Tomography of the Abdomen and Pelvis: Case Report
Introduction: Testicular torsion, or the twisting of the spermatic cord compromising blood flow to the testis, is a urologic emergency with the potential to cause infertility in male patients. The diagnosis may be clinical or confirmed using imaging, with ultrasound being the modality of choice.
Case Report: We present a case of right lower quadrant pain with radiation to the groin and right scrotum in a young male. A computed tomography of the abdomen and pelvis was ordered to assess for appendicitis, which showed a “whirl” sign on the inferior periphery of the images near the scrotum. The finding was not appreciated during the emergency department visit and the patient was discharged home. He returned 48 hours later due to continued pain and was ultimately diagnosed with testicular torsion via ultrasound and surgical pathology.
Conclusion: This is the first reported case to our knowledge identifying “whirl” sign for the diagnosis of testicular torsion. This finding was not appreciated by multiple clinicians during the initial patient presentation, highlighting the uncommon nature of the finding.
Introduction: Cardiac masses are a rare cause of chest pain. They can often be missed on a chest radiograph performed to evaluate non-specific chest pain and are not readily evaluated with traditional laboratory testing. However, these masses can be visualized with point-of-care ultrasound.
Case Report: We present a case of a 19-year-old female presenting with intermittent chest pain, palpitations, and weakness present for two months. The patient had previously been evaluated at our emergency department one week earlier and was diagnosed with anxiety before being discharged. Besides a tachycardic and labile heart rate, physical examination and laboratory testing were unremarkable. Point-of-care cardiac echocardiography subsequently demonstrated findings concerning for a cardiac mass.
Conclusion: Cardiac masses are a rare cause of chest pain and palpitations that are easily missed. The advent of point-of-care ultrasonography has afforded us the ability to rapidly assess for structural and functional cardiac abnormalities at bedside, and incorporation of this tool into the evaluation of patients with chest pain offers the ability to detect these rare pathologies.
- 1 supplemental video
Valsalva Retinopathy Masking as a Retinal Detachment on Point-of-care Ocular Ultrasound: A Case Report
Introduction: Approximately two million people present to the emergency department (ED) with eye-related complaints each year in the United States. Differentiating pathologies that need urgent consultation from those that do not is imperative. For some physicians, ocular ultrasound has eclipsed the dilated fundoscopic exam as the standard posterior segment evaluation in the ED.
Case report: A 60-year-old female presented with sudden onset visual disturbance in her right eye. Point-of-care ultrasound showed a hyperechoic band in the posterior segment concerning for a retinal detachment. Ophthalmology was consulted and diagnosed the patient with a condition known as Valsalva retinopathy. The patient was discharged from the ED with expectant management.
Conclusion: This case highlights an important differential diagnosis that should be considered when ocular ultrasound demonstrates a hyperechoic band in the posterior segment. While previous literature has demonstrated that emergency physicians are able to accurately identify posterior segment pathology using ultrasound, there is limited information regarding their ability to differentiate between pathologies, some of which may not require urgent consultation. We highlight the important differentials that should be considered when identifying posterior segment pathology on point-of-care ultrasound and their appropriate dispositions.
- 1 supplemental video
Ultrasound in the Emergency Department Identifies Ectopic Pregnancy Post Hysterectomy: A Case Report
Introduction: Ruptured ectopic pregnancy is one of the leading causes of maternal death. Point-of-care ultrasound (POCUS) has been shown to be highly sensitive for excluding ectopic pregnancy.Ectopic pregnancy after a hysterectomy is a rare but life-threatening occurrence. We present a case where POCUS helped to diagnose a post-hysterectomy ectopic pregnancy.
Case report: A 36-year-old female with a prior surgical history of hysterectomy without oophorectomy presented to the emergency department with lower abdominal pain. A POCUS revealed free fluid in the right upper quadrant with an unremarkable gallbladder. Subsequently, the pelvic POCUS noted free fluid as well as a heterogeneous structure in the right adnexa. The clinician ordered a serum beta human chorionic gonadotropin level, which was 173.2 international units per milliliter (lU/mL) (negative: < 5m IU/ml). Transvaginal ultrasound revealed a right adnexal echogenic structure with surrounding vascularity and moderate, complex free fluid suggestive of hemorrhage. Given the concern for possible ectopic pregnancy, obstetrics took the patient to the operating room where a right tubal ectopic pregnancy was confirmed.
Conclusion: A ruptured ectopic pregnancy is a life-threatening condition that requires rapid diagnosis. Ectopic pregnancy post hysterectomy is an uncommon occurrence infrequently considered in the differential diagnosis of lower abdominal pain, leading to considerable delays in diagnosis. Although uncommon, emergency clinicians must consider this diagnosis in female patients with lower abdominal pain.
Introduction: Uterine rupture is a rare but potentially fatal complication of pregnancy. The incidence of uterine rupture is estimated to be between 0.3 and 11 per 10,000. Additionally, uterine sacculation is a sac or outpouching of the uterus that can lead to uterine rupture in pregnancy. Here we describe a case of a patient who was found to have a uterine sacculation on point-of-care ultrasound in the emergency department (ED) that was complicated by uterine rupture.
Case Report: A 32-year-old female at approximately 18 weeks gestation presented to the ED with three days of abdominal discomfort. The patient’s medical history was significant for prior uterine fibroids requiring recent myomectomy. On arrival the patient was tachycardic, and her abdominal exam revealed distention with mild tenderness to palpation in all quadrants. A point-of-care transabdominal obstetric ultrasound was performed to evaluate the fetal heart rate, which was 157 beats per minute; it also revealed a defect in the uterine wall compatible with a uterine sacculation. The patient underwent magnetic resonance imaging, which revealed a sac-like structure in the fundal portion of the uterus containing a portion of gestational sac and pregnancy contents. Subsequently, she became hypotensive and tachycardic and was taken emergently to the operating room for concern for uterine rupture. Intraoperatively, uterine rupture was confirmed. The patient underwent surgical repair with evacuation of fetal tissue and recovered in the surgical intensive care unit.
Conclusion: Point-of-care ultrasound is a useful and readily available procedure to identify uterine sacculation. Early identification can help escalate the urgency of the patient complaint and may lead to a need for further maternal-fetal evaluation. Emergency physicians should keep a high index of suspicion when evaluating the pregnant patient with a history of uterine surgery.
Introduction: As ketamine gains traction as an alternative to opiates in the treatment of chronic pain, ketamine-induced ulcerative cystitis is now being recognized as a complication of its use. The first-line treatment is phenazopyridine, an over-the-counter medication for dysuria that historically has been known to cause methemoglobinemia. This report details the case of a patient presenting to the emergency department (ED) with methemoglobinemia.
Case Report: A 66-year-old woman with a complicated medical history presented to the ED with anemia and hypoxia after extended use of phenazopyridine for treatment of ketamine-induced ulcerative cystitis. She was found to have methemoglobinemia secondary to phenazopyridine used to treat her ketamine-induced ulcerative cystitis, a previously undocumented sequelae of chronic ketamine use. She was admitted to the hospital for three days and made a full recovery.
Conclusion: This case highlights the need to suspect ketamine-induced ulcerative cystitis in patients who use ketamine chronically and be judicious in the use of phenazopyridine for symptom management to prevent life-threatening complications.
Introduction: Postpartum ovarian vein thrombosis (POVT) is an uncommon diagnosis that may lead to morbidity or mortality if unrecognized.
Case Report: This report discusses a single case of POVT in a community hospital, along with the treatment and clinical course.
Conclusion: The mechanism is believed to be right-sided clot formation provoked by anatomical and hormonal changes of gestation. Diagnosis is challenging as most patients are previously healthy and symptoms are often vague. Although the differential is broad, modern imaging is sensitive and specific for diagnosis. Prompt treatment with broad-spectrum antibiotics and anticoagulation may reduce morbidity, and prognosis following treatment is excellent.
Introduction: Traumatic carotid artery dissections (CAD) are rare but produce potentially devastating injuries. Most patients develop symptoms within 72 hours of traumatic injury.
Case Report: We report the case of a 33-year-old, previously healthy male who presented to the emergency department for evaluation of transient, right-sided facial droop with visual changes. His symptoms began 12 days after falling off a scooter. Imaging revealed an extracranial internal CAD.
Conclusion: Symptoms of CAD may present weeks after blunt trauma, making clinical diagnosis difficult. Clinicians must have high suspicion for vascular injury and consider neuroimaging in cervical flexion/extension injuries.
Introduction: Achilles tendon ruptures often occur during physical activity where the tendon is frequently stressed. Although rare, rupture can also result from electric shock.
Case Report: We present the case of a 63-year-old female who presented with pain in the lower leg after enduring an electric shock. She was diagnosed with a ruptured Achilles tendon based on physical exam and ultrasound.
Conclusion: This case highlights an uncommon mechanism for a relatively common injury. Because Achilles tendon ruptures are frequently misdiagnosed, clinicians need to be aware of unusual causes and use tools at their disposal to ensure timely and accurate diagnosis.
Introduction: Point-of-care ultrasound (POCUS) has great sensitivity in the diagnosis of abscesses and swollen lymph nodes. Many studies outline the characteristics that distinguish abscesses from lymph nodes on POCUS.
Case Report: We present a case from the emergency department in which a patient presented with a potential abscess but was found to have a malignant lymph node on imaging.
Conclusion: Point-of-care ultrasound can be used to differentiate an abscess from a swollen lymph node. Abscesses are generally anechoic or hypoechoic with septae, sediment or gas contents, and they lack internal vascularity. Benign lymph nodes are echogenic with hypoechoic cortex with hilar vascularity.
Introduction: Arterial dissection is well known as a potential cause of stroke in young patients. Vertebral artery dissection occurs most commonly in the setting of minor trauma but has been seen in cases of cervical manipulation. With advances in at-home therapeutic modalities for neck pain came the advent of handheld massage guns. These massage guns have gained considerable popularity in recent years, but their safety for use in the cervical region has not been well studied.
Case report: In this case report, we discuss a 27-year-old female who presented with headache, neck pain, and dizziness who was found to have vertebral artery dissection after repetitive use of a handheld massage gun.
Conclusion: In young patients presenting with headache, neck pain, and vague neurologic symptoms it is important to consider vertebral artery dissection as a cause of symptoms as it can lead to serious morbidity. When considering an inciting event such as minor trauma, it may also be important to assess whether there has been use of a handheld massage gun. Although causality is difficult to establish, with the increase in use of handheld massage guns we may find more frequent association between their use and vertebral artery dissection.
Introduction: Brown-Séquard syndrome is a rare neurological disorder due to hemisection of the spinal cord that can occur from a variety of causes, most commonly trauma.
Case Report: We present a case of a 25-year-old woman presenting with Brown-Séquard syndrome as her first clinical presentation of multiple sclerosis.
Conclusion: This case highlights the need to have demyelinating disease on the differential as an exceedingly rare, but important, possible cause of Brown-Séquard syndrome.
Weakness After an Intra-articular Steroid Injection: A Case Report of Acute Steroid-induced Myopathy
Introduction: Weakness is a common chief complaint in the emergency department, and the use of glucocorticoids is pervasive in medicine. Muscle weakness, or myopathy, is a well documented side effect of chronic glucocorticoid use. However, acute myopathy, with an onset shortly after initiation of glucocorticoids, is much rarer.
Case Report: We present a case of acute steroid-induced myopathy after a single intra-articular dose of triamcinolone in a young, healthy, active male. To our knowledge, this is the first case described in the medical literature of acute steroid-induced myopathy following a single intra-articular injection.
Conclusion: In a patient who presents with proximal muscle weakness and has a history of glucocorticoid use, the diagnosis of steroid-induced myopathy should be considered. Acute steroid-induced myopathy should be high on the differential in a patient who presents with typical symptoms and has been prescribed glucocorticoids for less than 14 days or, in rare cases, may have recently received a single dose of glucocorticoids. Treatment is supportive and outpatient management is typically indicated, as respiratory muscle involvement is rare.
Introduction: A vulvar hematoma is a hemorrhagic fluid collection in the female external genitalia. The majority occur as an obstetrical complication, especially during labor. Non-obstetrical vulvar hematomas are usually the result of trauma, with coitus being the most common etiology.
Case Report: We present the case of a 25-year-old woman with significant vaginal pain and swelling after vigorous sexual intercourse. She exhibited tenderness and swelling of the left labia majora and minora. The differential diagnosis included bleeding, abscess, and deep venous thrombosis. Laboratory studies were normal and computed tomography of the pelvis indicated the swelling was most likely due to blood. The patient was taken to the operating room, and approximately 150 cubic centimeters of clot was evacuated. The patient had an uneventful recovery and was discharged home the next day.
Conclusion: This case illustrates the unique presentation and challenges in making the diagnosis of vulvar hematoma.
Submucosal Duodenal Artery Pseudoaneurysm Causing Massive Gastrointestinal Hemorrhage: A Case Report
Introduction: Acute upper gastrointestinal bleeding is a common emergency presentation. The United States Centers for Disease Control and Prevention 2018 survey of emergency department (ED) visits reported 436,000 ED visits for unspecified gastrointestinal bleeding that year.
Case Report: We present the case of a submucosal duodenal pseudoaneurysm causing massive gastro-intestinal hemorrhage in a male on anticoagulation.
Conclusion: Prompt recognition of critical gastrointestinal bleeding, appropriate ED management, and early consultation for emergent intervention are the essential components to reduce morbidity and mortality for patients with massive gastrointestinal hemorrhages.
Images in Emergency Medicine
Identification of Spontaneous Shoulder Hemarthrosis with Point-of-Care Ultrasound in the Emergency Department
Case presentation: A 32-year-old man with a history of hemophilia A presented to the emergency department with right shoulder pain, swelling, and decreased range of motion.
Discussion: Emergency physicians can use ultrasound to quickly and accurately identify hemarthrosis at the bedside.
- 1 supplemental video
Case Presentation: An 88-year-old female presented to the emergency department (ED) with complaints of painful vision loss four days after an intravitreal injection for her neovascular macular degeneration. Her right eye visual acuity was markedly diminished with an absence of red reflex. A point-of-care ocular ultrasound was performed and demonstrated hyperechoic vitreous debris concerning for endophthalmitis.
Discussion: Endophthalmitis is an infection of the vitreous or aqueous humors commonly caused by exogenous sources, such as inoculation of bacteria into the eye from surgery, injections, or trauma. It is an ophthalmologic emergency as it is a vision-threatening infection. Although a rare complication, post-surgery or post-injection are the leading causes of endophthalmitis. Point-of-care ocular ultrasound findings suggestive of endophthalmitis, such as hyperechoic vitreous debris, aid in the timely diagnosis and treatment of patients in the ED.
- 1 supplemental video
Case Presentation: A 73-year-old male presented to the emergency department complaining of pain in his right eye for four weeks. He denied any trauma, and the pain was accompanied by ptosis, proptosis, swelling, redness, blurred vision, and a frontal headache. On examination, conjunctival arterialization was also appreciated. Magnetic resonance imaging and angiography showed evidence of a carotid cavernous fistula for which the patient underwent successful transvenous coiling and embolization.
Discussion: Carotid cavernous fistulas are classified as higher flow, direct fistulas or lower flow, indirect fistulas; the latter is more insidious in onset. Classic symptoms include conjunctival arterialization, proptosis, ptosis, palpebral edema, ocular palsy, vibratory sensation, elevated intraocular pressure without pupillary or visual acuity deficits, and headache. The treatment of choice is transvenous embolization.
CASE PRESENTATION: A seven-year-old male presented to the pediatric emergency department with one day of abdominal pain. His physical exam was significant for rebound, guarding, and tenderness in the right lower quadrant, and his labs demonstrated a leukocytosis. Both a point-of-care ultrasound and radiology-performed ultrasound were concerning for acute appendicitis with a periappendiceal abscess, but on emergent laparoscopy the patient was found to have an infected urachal cyst.
DISCUSSION: Infected urachal remnants are a rare but important cause of pediatric abdominal pain. In this case, inflammation surrounding the patient’s midline urachal cyst triggered a serositis that involved the appendix and pulled the cyst to the right. This created a clinical and radiologic presentation similar to appendicitis. This atypical presentation of an already rare anomaly highlights the importance of maintaining a broad differential during the work-up of pediatric abdominal pain.
- 1 supplemental video
Adult Presentation of Anomalous Pulmonary Artery from the Descending Aorta: A Rare Cause of Exertional Chest Pain
Case Presentation: A 20-year-old female presented to the emergency department for evaluation of exertional, right-sided chest pain. The patient underwent a computed tomography angiogram of her chest as part of her workup, demonstrating the right lower-lobe pulmonary artery arising from the abdominal aorta.
Discussion: Anomalous pulmonary arterial supply is exceedingly rare. In adult patients, it is likely to be found incidentally during workup for more common medical conditions. Symptoms may include chest pain, exertional dyspnea, or hemoptysis. The high pressure of systemic blood in a low-pressure pulmonary system can result in right heart strain, pulmonary hypertension, and high-output cardiac failure.
Case Presentation: A previously healthy 45-year-old man presented to the emergency department with bilateral knee pain and inability to extend his knees after a slip and fall on ice. The clinical diagnosis of bilateral quadriceps tendon rupture was confirmed by computed tomography (CT) of bilateral knees. The patient underwent successful operative repair the following day.
Discussion: Bilateral quadriceps tendon rupture is rare and can be difficult to diagnose due to the impossibility of comparing the affected to the unaffected limb. Plain radiographs are usually not helpful, but ultrasound, CT, and magnetic resonance imaging may be used to confirm the clinical diagnosis.
ACOEP Case Reports (Invitation Only)
Introduction: A 38-year-old with suicidal ideation and alcohol intoxication received conducted energy from a conducted energy weapon (CEW) and subsequently was found to have a transient electrocardiogram (ECG) abnormality consistent with Brugada waveform that resolved over a period of three hours.
Case Report: A 38-year-old male with no pertinent medical history presented with suicidal ideation and alcohol intoxication after an altercation with the police. The patient received two CEW exposures during an encounter with law enforcement prior to transport to the emergency department. He was asymptomatic, but an ECG was performed as part of the triage process given his reported CEW exposure. His initial ECG showed ST-segment and T-wave changes in the precordial leads similar to those found in Brugada syndrome. After a three-hour period of observation and resolution of the patient’s alcohol intoxication, a repeat ECG was performed that showed resolving Brugada morphology.
Conclusion: Review of the literature surrounding the safety profile associated with CEW exposure shows few if any documented concerning cardiac electrophysiology changes and suggests that routine electrocardiographic studies or monitoring is not required. This case presents an isolated but interesting instance of a transient ECG abnormality associated with a CEW exposure.