Abstract: Background. Over several decades, standard management of blunt spleen injury (BSI) has been changed from operative intervention to the selective operative and nonoperative management (NOM). However, some patient needs laparotomy first. This article describes a case of a BSI patient who failed nonoperative management after angioembolization (AE). Case Presentation. A 58-year-old man fell from his motorcycle and was brought to our hospital. His vital sign was stable after extracellular fluid bolus. A contrast-enhanced computed tomography scan of the abdomen showed AAST grade V spleen injury. AE was performed for the splenic artery, but his systolic blood pressure suddenly dropped under 60 mmHg. The resuscitative endovascular balloon occlusion of the aorta was inserted, and immediate laparotomy was performed. A pancreatic tail injury was detected, and the splenic artery and vein were burst at the pancreatic tail and controlled by hemostatic suture. After splenectomy, a drain was placed at the pancreatic tail and the abdomen was temporally closed. The postoperative course was not remarkable except for abdominal abscess treated with antibiotics, and he was discharged on foot. Conclusion. Although NOM is becoming one of the choices for severe BSI, there will still be a patient who requires surgery. Surgeons should be aware of the mechanism of injury and the limitation of AE as an adjunct to NOM. Patient selection for initial NOM and timing to convert to laparotomy are important. PubDate: Thu, 29 Oct 2020 15:35:00 +000
Abstract: An 80-year-old man with flu symptoms collapsed at his house and had a backache worsened over time. His family called for an ambulance. On arrival, chest X-ray showed reduced permeability of the right lung field, and truncal computed tomography (CT) suggested right multilobular empyema and right iliopsoas abscess. A blood test showed an acute inflammatory response. The patient underwent right small thoracotomy for empyema and ultrasonic-guided drainage for the right iliopsoas abscess and started the administration of antibiotics. We started the administration of doripenem by intravenous drip and then deescalated to ampicillin based on the culture results. Streptococcus intermedius was cultured from all sites. Following these treatments for three months, his general condition improved. We herein report a unique case of complicated empyema and iliopsoas abscess in which a favorable outcome was obtained by an appropriate diagnosis and treatment. Reports of multiple abscesses have been increasing recently because of the growing geriatric population and aging-related complications. It is important to search the whole body to detect multiple abscesses in cases where an abscess is detected at a single site. PubDate: Mon, 26 Oct 2020 08:05:00 +000
Abstract: Introduction. Acidosis with traumatic brain injury is a common and serious cause of consciousness disorders in emergency medicine. Extreme acidosis is significantly associated with high mortality (more than 67% if pH levels are under 7). Case Presentation. We describe the case of a 23-year-old man with unknown medical history who was found near the entrance of the emergency department sweat with a tachypnea (55 per minute), a lot of blood around him, and confused. The initial hypothesis was a hemorrhagic shock after a fight, but he did not have any hemodynamic trouble. The initial venous gazometry showed a major lactic acidosis (pH less than 6,8, HCO3 incalculable and lactate up to 20 mmol/L). A Focused Assessment with Sonography in Trauma-echography (FAST-echo) and secondly a body-tomodensitometry were conducted and did not reveal any anomaly. The team was now thinking that the patient situation was caused by an epileptic seizure (association of lactic acidosis and confusion), and the bleed was a consequence of the head trauma. The patient was treated only by NaCl 0,9%. One hour after his admission, the tachypnea began to decrease and he could speak and explain what was happen. He had to run as fast as possible to escape to a fight. The last gazometry, realized 2 hours after his admission, finds a normal pH at 7,35, HCO3 24,5 mmol/L and lactate 2,6 mmol/L. He was authorized to going home. Conclusion. We report here a rare case of major lactic acidosis in emergency medicine caused by a supramaximal effort. PubDate: Sat, 24 Oct 2020 10:50:00 +000
Abstract: Intoxication and drug overdose as suicidal attempt are rare in pregnancy. We report here the case of aluminum phosphide poisoning in a pregnant lady through oral and intravaginal administration which was managed with aggressive supportive measures without resorting to extracorporeal life support. PubDate: Mon, 28 Sep 2020 10:35:01 +000
Abstract: A 45-year-old man was admitted to the Emergency Department with fatigue and muscular weakness. Soon after hospital admission, he developed “torsades de pointe” and was successfully resuscitated. The admission laboratory investigations had revealed a profound hypokalemia (1.65 mmol/L). The patient had a long-term use of alcohol-free “pastis” in an attempt to reduce his chronic ethanol consumption. As the beverage likely contained a significant amount of liquorice, the diagnosis of glycyrrhizin chronic intoxication was suspected. The diagnosis of liquorice-related pseudohyperaldosteronism was assessed by normal plasma aldosterone levels and low plasma renin activity. Intravenous and oral supplementation of potassium was required for 5 days, and the patient had an uneventful follow-up. PubDate: Tue, 22 Sep 2020 06:35:00 +000
Abstract: Hypermagnesemia is a rare disorder and commonly occurs in patients with renal dysfunction. Supportive therapy for hypermagnesemia consists of administration of high-volume fluids, calcium preparation, diuretics, and, in severe cases, hemodialysis. Few reports have described severe hypermagnesemia patients with normal renal function who improved without hemodialysis. A 56-year-old woman presented with a history of constipation in spite of taking constipation medicine, including MgO. She was brought to our emergency department due to vomiting and diffuse distension of the abdomen. Sudden vomiting, weakness, and lower level of consciousness occurred during examination. Her blood pressure dropped to 77/34 mmHg, and deep tendon reflexes of the limbs disappeared. Abdominal computed tomography showed bowel distension with wall edema, and biochemical testing showed serum Mg at 13.5 mg/dl. She was diagnosed with severe hypermagnesemia associated with intestinal obstruction and administered intravenous loop diuretics and calcium preparation in addition to high volumes of normal saline. As the serum Mg level steadily declined, her level of consciousness returned to usual. This case suggests that severe hypermagnesemia can occur in patients with normal renal function and constipation under MgO. Severe hypermagnesemia with normal renal function can improve with symptomatic treatment without hemodialysis. PubDate: Tue, 14 Jul 2020 13:50:01 +000
Abstract: Background.Exertional heat stroke is a life-threatening condition often complicated by multiorgan failure. We hereby present a case of a 25-year-old male presenting with syncope after a 10 km run in 28°C outside temperature who developed acute liver failure. Case Presentation. Initial temperature was found to be 41.1°C, and cooling measures were rapidly applied. He suffered from acute renal failure and rhabdomyolysis and proceeded to acute liver failure (ASAT 6100 U/l and ALAT 6561 U/l) due to hypoxic hepatitis on day 3. He did not meet criteria for emergency liver transplantation and recovered on supportive care. Conclusions. Acute liver failure due to heat stroke is a life-threatening condition with often delayed onset, which nevertheless resolves on supportive care in the majority of cases; thus, a delayed referral to transplant seems to be reasonable. PubDate: Mon, 30 Mar 2020 07:05:01 +000
Abstract: Introduction. Behcet’s disease is a multisystem disease. In sub-Saharan Africa, the prevalence of this disease is not known, with only one case report from Ethiopia. Case Presentation. We describe a case of a 29-year-old Ethiopian male who presented to the emergency room of Tikur Anbessa specialized hospital with 4 days history of back pain, recurrent history of oral and genital ulcers, right eye blindness, chronic cerebral vein thrombosis, gastrointestinal bleeding, aortic aneurysm with dissection, and positive pathergy test. He is retrospectively diagnosed with Behcet’s disease according to both the International Criteria for Behcet’s Disease (ICBD) and the International Study Group (ISG) consensus. Conclusion. Even if Behcet’s disease is rare in sub-Saharan Africa, it is important to know the clinical presentation for timely diagnosis and urgent management. PubDate: Tue, 17 Mar 2020 12:35:02 +000
Abstract: ST-segment elevation in absence of acute coronary syndrome can be seen in multiple conditions, including acute pericarditis and coronary vasospasm, but it is rarely seen with severe hypercalcemia. The authors present a case of an 81-year-old female with a history of stage 4 squamous cell cancer of the lung, who presented to the emergency room with profound fatigue, weakness, anorexia, and drowsiness two weeks after her first chemotherapy cycle. Additionally, she had complaints of right-sided chest pain associated with worsening shortness of breath, as well as right arm numbness. An EKG obtained on arrival to the hospital showed diffuse ST-segment elevation (leads V3–V6, I, II, III, and aVF). Basic lab work found a calcium level of 20.4 mg/dl with elevated parathyroid hormone-related protein (PTHrP) of 135 pg/ml. Troponin I remained within normal limits. Serial EKS obtained during the patient’s hospitalization demonstrated resolution of the ST elevation as calcium level normalized. This case emphasizes the importance of hypercalcemia as a differential diagnosis for ST-segment elevation and QT shortening when acute coronary syndrome is not present. Awareness of these EKG changes is critical for early diagnosis, recognition, and appropriate treatment. PubDate: Mon, 16 Mar 2020 15:50:26 +000
Abstract: Carbamazepine is an antiepileptic drug that can cause seizures in overdose. In certain patient populations, this may be misdiagnosed as a seizure disorder. We describe a case of a 20-month-old female who presented with fever and seizure-like activity who was initially thought to have complex febrile seizures. Further historical information prompted carbamazepine level to be checked, which was found to be 29 mcg/ml (therapeutic range of 4–12 mcg/ml). Her carbamazepine levels downtrended with multidose activated charcoal. Her condition improved, and she was discharged without evidence of permanent neurologic sequelae. This case illustrates that xenobiotic exposure should often be considered, even if historical clues are not present, as they can often present as other conditions leading to misdiagnosis and delayed treatment. PubDate: Mon, 16 Mar 2020 14:20:01 +000
Abstract: Kounis syndrome is a form of acute coronary syndrome caused by allergic reactions. No cases of cardiac arrest caused by Kounis syndrome that arose after the administration of sugammadex have been reported. A 71-year-old female suffered two cardiac arrests. The first occurred after sugammadex was administered at the end of an operation for a right radial distal fracture. The patient was resuscitated and transferred to our intensive care unit. She was subsequently discharged home. Five months later, she suffered a second cardiac arrest after sugammadex was administered at the end of an operation for a right femoral neck fracture at our hospital. Urgent coronary angiography revealed multiple coronary spasms. Kounis syndrome was diagnosed based on the patient’s elevated serum trypsin levels and a positive result in a skin allergy test of sugammadex. In cases of cardiac arrest with unclear etiologies, Kounis syndrome should be considered. PubDate: Mon, 17 Feb 2020 15:20:01 +000
Abstract: Descending necrotizing mediastinitis and pharyngeal perforation are uncommon complications of pharyngitis that are associated with high morbidity and mortality. This case report describes a previously healthy 18-year-old male who presented to the emergency room with 5 days of severe sore throat, intermittent fevers, and vomiting and was found to have extensive posterior pharyngeal and mediastinal air along with extravasation of contrast on computed tomography, consistent with perforation of the left aryepiglottic fold as well as descending necrotizing mediastinitis. The patient had a complicated hospital course including multiple operative interventions, abscess formation, and development of pericardial and pleural effusions. Successful treatment required swift resuscitation including broad-spectrum antibiotics and significant coordination of emergent operative intervention between otolaryngology and cardiothoracic surgery. It is important to recognize descending necrotizing mediastinitis as a clinical entity that may result from oropharyngeal infections as early intervention significantly decreases subsequent complications and mortality. Furthermore, pharyngeal perforation is an extremely rare complication which requires either CT with oral contrast or esophagram for diagnosis. PubDate: Thu, 13 Feb 2020 04:35:02 +000
Abstract: Achilles tendon and malleolar fractures are commonly seen in isolation, but only a few cases of combined injuries have been reported. In this case, we present a 53-year-old male who sustained an isolated lateral malleolus fracture with an Achilles tendon rupture. Emergency Medicine physicians should consider the possibility of these injuries in combination. PubDate: Tue, 11 Feb 2020 09:50:02 +000
Abstract: We report the case of an 84-year-old female presented to us with acute onset altered sensorium. On investigation, neurological and infectious causes were ruled out. On further evaluation, her serum calcium was found elevated (15.07 gm/dl). The diagnosis of hypercalcemic encephalopathy was made with the possibility of multiple myeloma due to raised total protein and globulin levels. Serum electrophoresis, immunofixation, and bone marrow examination confirmed the diagnosis of multiple myeloma. The patient was treated with bortezomib, dexamethasone, and lenalidomide. After 1 week, she improved with normalization of serum calcium. Herein, we highlight hypercalcemia as an important cause of encephalopathy. As our report suggests, metabolic encephalopathy can be the first presentation in multiple myeloma. PubDate: Sat, 08 Feb 2020 14:35:02 +000
Abstract: The risk of a brain abscess is a complication of odontogenic infection that is rarely considered by physicians and little spoken of, yet treating dental infections may avoid a potentially life-threatening condition. We report a case of 7-year-old boy with a brain abscess secondary to a dental infection. He was immediately taken to the operating theatre for drainage and cleaning of the abscess. A dental examination revealed root abscesses on temporary molars, which were extracted under general anaesthetic. Two months after his admission, the child was switched to oral antibiotherapy and could return home. A brain abscess represents a life-threatening disease. Childhood brain abscess is uncommon but may be encountered by all physicians and students as a clinical emergency. It is indispensable that physicians finding symptoms similar to those in this case study refer the patient for emergency care and that possible dental foci of infection be assessed, whether or not the patient is being followed for dental care. PubDate: Thu, 06 Feb 2020 23:50:01 +000
Abstract: Background. Alkyl nitrites or “poppers” are widely used as sex-drugs due to their aphrodisiac and muscle relaxant effects. We describe the rare case of a large-sized dermatitis after direct skin contact with the poppers-fluid in a poppers user. Case Presentation. A 52-year-old patient presented to the emergency department due to burning pain on his proximal right thigh and scrotum. Clinical examination showed an 8 × 5 cm measuring burning wound resembling lesion. During further history the patient mentioned that the day before presentation a “poppers” phial unintentionally opened in his pocket and the fluid leaked. Conclusions. The present case shows severe skin defects after skin-contact with alkyl nitrates in a “poppers” user. Maculopathy and methemoglobinemia are prominent unwanted side effects of “poppers” use. However, our report demonstrates that attention should also be paid to potential harm for the skin. PubDate: Thu, 30 Jan 2020 23:58:00 +000
Abstract: The ginkgo tree is a well-known, highly adaptable urban plant. Ginkgo nuts are the product of the ginkgo tree. Interior ginkgo nuts are cooked and served in Asian countries; however, the potential toxicity of the gingko nuts is not commonly known. Herein, we report a 48-year-old male patient experiencing acute convulsions presumably due to overconsumption of gingko nuts. The patient was transferred to our department after several episodes of acute generalized tonicclonic seizures lasting approximately 30 seconds each and starting one hour before the visit. The patient also complained of vomiting, vertigo, diarrhea, and tremors in both upper limbs following the seizures. Elevated 4-O-methylpyridoxine (312 ng/mL), low blood pyridoxal phosphate (2.4 μg/L), and low vitamin B1 (20 ng/mL) levels were found in the blood analysis. No other remarkable abnormalities were detected. We diagnosed the patient with ginkgo nut intoxication, and he was orally administered 400 mg of pyridoxal phosphate. His symptoms resolved after treatment, and no seizures recurred thereafter. Our report may help raise awareness of the clinical presentation and management of this intoxication among emergency physicians. PubDate: Tue, 28 Jan 2020 10:05:00 +000
Abstract: We describe a case of a 27-year-old female without any prior underlying immunodeficiency syndromes who presented with hemoptysis secondary to subacute invasive pulmonary aspergillosis and subsequently diagnosed with lymphoid interstitial pneumonia (LIP). CT chest demonstrated bilateral interstitial disease with patchy opacities and multiple large cysts and bullae. Diagnosis was confirmed histologically after surgical lung resection of the mycetoma containing cavitation. Therefore, LIP should be suspected in patients presenting with opportunistic infections in the setting of cystic lung disease. PubDate: Mon, 20 Jan 2020 10:50:03 +000
Abstract: This is a case report, which explores the presentation to the emergency department of a fit and well female with a known ventricular bigeminy. She presented with convulsive episodes. The working differential diagnosis was of possible cardiac syncope with anoxic seizure activity or neurogenically mediated arrhythmia secondary to subarachnoid haemorrhage. On further collateral history, the patient was on citalopram. The ECGs demonstrated PVCs of multiple morphologies that were transiently bidirectional, raising the possibility of catecholaminergic polymorphic ventricular tachycardia. The presentation of a young fit patient with syncope and seizure-like episodes should always raise concern for the admitting emergency medicine clinician of an underlying cardiac pathology. PubDate: Wed, 08 Jan 2020 01:20:00 +000
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