Abstract: We report the case of a 26-year-old woman with an eight-week history of painfully enlarged cervical lymph nodes, recurrent headache, and malaise. Her medical history was unremarkable. The physical examination showed multiple enlarged cervical lymph nodes. Laboratory examination was unremarkable, and magnetic resonance tomographic imaging showed multiple enlarged cervical lymph nodes with aspect of a lymphoma. Lymph node biopsy revealed Kikuchi-Fujimoto disease, histologically characterized by histiocytic necrotizing lymphadenitis. A therapeutic trial with nonsteroidal anti-inflammatory drugs (NSAID) showed no effect, so steroid therapy was started. Due to relapse of symptoms after steroid withdrawal the tapering regimen was prolonged for a total of seven months. PubDate: Thu, 07 Mar 2019 13:05:00 +000
Abstract: Massive acetaminophen (N-acetyl-p-aminophenol; APAP) ingestion is characterized by a rapid onset of mitochondrial dysfunction, including metabolic acidosis, lactemia, and altered mental status without hepatotoxicity which may not respond to the standard doses of N-acetylcysteine (NAC). A 64-year-old woman without medical history presented comatose after an ingestion of 208 tablets of Tylenol PM™ (APAP 500 mg and diphenhydramine 25 mg). The initial APAP concentration measured 1,017 µg/mL (therapeutic range 10-30 µg/mL), and elevated anion gap metabolic acidosis, lactemia, and 5-oxoprolinemia were detected. High-dose intravenous (IV) NAC, 4-methylpyrazole (4-MP), and hemodialysis (HD) were initiated. She was transferred to a liver transplant center and continued both NAC and HD therapies until complete resolution of metabolic acidosis and coma without developing hepatitis. She was discharged without sequelae. This is the fourth highest APAP concentration recorded in a surviving patient. Moreover, this is the first report of a novel “triple therapy” using NAC, 4-MP, and HD in the setting of massive APAP ingestion that presents with coma, elevated anion gap metabolic acidosis, and lactemia. Emergency physicians should recognize these critically ill patients and consider high-dose NAC, 4-MP, and HD to be initiated in the emergency department (ED). PubDate: Tue, 05 Mar 2019 07:05:03 +000
Abstract: Tension pneumocephalus is a rare medical emergency. Spontaneous atraumatic tension pneumocephalus is reported in cases of neoplasm, Valsalva manoeuvres, and air cell hyperpneumatization. For the first time, we describe a case of atraumatic tension pneumocephalus induced by nasal cannula in a patient with ventriculoperitoneal shunt. Our case report discusses the possible mechanisms of the tension pneumocephalus in this case. PubDate: Sun, 17 Feb 2019 09:05:06 +000
Abstract: The clothing of a forty-five-year-old man became entrapped by the mixing rotator while he was operating a soybean milling machine. His clothing was wound around the rotator, and tightened around his neck and chest, causing strangulation and a loss of consciousness. He was rescued by his coworkers and transported to our hospital by helicopter. Upon arrival, he regained consciousness. A physiological examination revealed multiple petechiae on his face and strangulation marks with subcutaneous hemorrhage on his neck and upper trunk. In addition, he had motor weakness of the right upper extremity and bilateral paresthesia from C5 to Th1. All radiological studies were negative. He was admitted for observation. After the patient’s creatine phosphokinase level peaked and his focal neurological signs improved, he was discharged on foot on the hospital day. Accidental ligature strangulation with cervical nerve root injury, in which an article of clothing is caught in an electrical machine and strangles the wearer, is very rare. This case is presented for its rarity and the unique pattern of injury. PubDate: Tue, 05 Feb 2019 07:05:23 +000
Abstract: Gluteal compartment syndrome is a rare condition that often develops following immobilization either secondary to illicit drug and alcohol abuse or improper surgical positioning. A case of a 22-year-old female with left lower extremity pain, weakness, and numbness after prolonged stasis from a night of drug and alcohol use is presented. She also complained of left low back pain. Her initial neurologic examination was significant for decreased deep tendon reflexes, decreased motor strength, and decreased sensation in the left lower extremity. Severe pain in the affected region persisted despite several attempts at pain control utilizing multiple modalities. An emergent MRI of the lumbar spine revealed gluteal compartment syndrome. The patient ultimately underwent emergent fasciotomy with resultant improvement in neurologic symptoms. Because presenting symptoms are frequently nonspecific in initial stages, gluteal compartment syndrome is often misdiagnosed. This can lead to unnecessary morbidity and mortality. It is important to maintain a high index of suspicion for gluteal compartment syndrome because delay in diagnosis can lead to nerve palsy, acute kidney injury, sepsis, and/or death. PubDate: Tue, 29 Jan 2019 07:05:12 +000
Abstract: Nitric acid (HNO3) is a strong acid and oxidizing agent used for various applications including production of ammonium nitrate in the fertilizer industry. Nitrogen oxides formed when nitric acid interacts with the environment have been implicated in inhalation injuries. This describes a case of a 49-year-old male who presented to the emergency department complaining of an acute onset of shortness of breath approximately 12 hours after being exposed to nitric acid fumes. He presented with a room air oxygen saturation of 80 percent with moderate to severe respiratory distress. His plain film chest radiograph showed bilateral pulmonary infiltrates and pulmonary edema. Over a seven-day hospital course, he had an improvement in his clinical status and chest X-ray with normal pulmonary function tests one month after discharge. Although exposure to the fumes of nitric acid is known to cause delayed pulmonary edema, it is rarely reported in the medical literature. This case serves as a reminder to consider exposure to fumes of nitric acid in a patient presenting with pulmonary edema and highlights the importance of obtaining a work history. PubDate: Tue, 15 Jan 2019 09:05:04 +000
Abstract: Lamotrigine is a new generation antiepileptic which blocks sodium channels and can cause significant toxicity in overdose. A case of a three-year-old child who suffered a seizure and required endotracheal intubation after accidental lamotrigine ingestion is presented. The lamotrigine concentration measured 23.2 mcg/mL which is the highest reported after accidental pediatric exposure. A review of the literature regarding pediatric lamotrigine poisoning is also included. PubDate: Sun, 13 Jan 2019 08:05:07 +000
Abstract: Pneumothorax is the entry of air into the virtual space between the visceral and the parietal pleurae, which can occur spontaneously or to a greater extent in a traumatic way. In daily clinical practice it is frequent to find injuries that generate traumatic pneumothorax that is ipsilateral to the lesion. However, there are case reports of contralateral pneumothorax that occurred in procedures such as insertion of pacemakers, or in cases of pneumonectomy. The following is the case report of a 37-year-old man who was admitted with a sharp wound to the right paravertebral region who developed a left haemopneumothorax due to a tangential course of the injuring agent. Adequate clinical judgment was followed, and several imaging studies were carried out, leading to the diagnosis of traumatic pneumothorax that was contralateral to the described injury. PubDate: Wed, 19 Dec 2018 09:04:56 +000
Abstract: Ergotamine toxicity has become a rare condition which can be caused by, among others, drug-drug interaction. In this work we report a case with vasospastic ischemia induced by the wrongful combination of ergotamine with recently started Antiretroviral Therapy. Clinicians were not aware that patient was self-medicating for years with medication containing ergotamine and caffeine for migraines. This diagnosis was established after evaluating the evolving ‘and spreading’ ischemia and CT scans and thoroughly interviewing patient’s family. Treatment was started with intravenous nimodipine and intra-arterial sodium nitroprusside on the affected limbs. The patient developed severe limb ischemia, cerebral ischemia, and metabolic encephalopathy. Unfortunately no improvements were noticeable and due to evolving cerebral edema as a result of the ischemia, the patient developed brain herniation and died shortly after. PubDate: Wed, 19 Dec 2018 06:31:28 +000
Abstract: Lemierre’s syndrome is an acute oropharyngeal infection with a secondary septic thrombophlebitis of the internal jugular vein (IVJ) that was first reported in literature in 1936. It involves the progression of disease from a focal suppurative peritonsillar infection to a local septic thrombophlebitis with hematogenous progression to and distant septic emboli. It is a rare and potentially fatal syndrome requiring prompt diagnosis and management. We present the case progression of an 18-year-old male who presented to our hospital with resolved sore throat, fever, and chest discomfort who experienced a sharp clinical decline. His case, physical exam, laboratory abnormalities, and radiologic studies highlight important facets of this rare but important syndrome. PubDate: Thu, 06 Dec 2018 10:18:04 +000
Abstract: Flank pain with hematuria is a common presentation in the emergency department. The commonest differential diagnosis of these patients is renal/ureteric calculus or pyelonephritis. These patients are usually treated with analgesia, antibiotics in case of pyelonephritis, and are discharged with an outpatient referral to a urologist. This case report describes a 51 year old male who presented to the ED for recurrent flank pain and hematuria. Bedside ultrasonography in the ED demonstrated a cystic lesion in the renal area. CT urography revealed an appendiceal stump mucocele and patient was transferred under surgical care. This case highlights the importance of the utility of bedside ultrasound in patients presenting to the ED with flank pain or abdominal pain which can lead to expedited assessment and appropriate management. PubDate: Thu, 06 Dec 2018 09:52:20 +000
Abstract: Managing acutely agitated or violent patients in the emergency department (ED) represents a significant challenge. Acute agitation as an initial manifestation of neuro-Behcet’s disease (NBD) is an extremely rare clinical entity. A 44-year-old male, who had been complaining about a severe headache and fever for several days, was admitted to our ED due to acutely presented incontinence and agitation. On admission, physical restraint and sedation with sevoflurane and propofol were required for his combative and violent behavior. Cerebrospinal fluid examination revealed increased cell count. Fluid attenuated inversion recovery magnetic resonance imaging showed a high intensity signal in the left parietal lobe and bilateral occipital lobe. As infectious meningoencephalitis was suspected, empirical therapy was immediately started. He recovered uneventfully without neurological defect in seven days. Based on positive human leukocyte antigen B-51 and clinical manifestations, the diagnosis of NBD was made and remitted by steroid therapy. Although acute NBD commonly presents with focal neurological symptoms, psychiatric symptoms could be considered the first manifestation. A focused and thorough examination coupled with appropriate management strategies can assist emergency clinicians safely and effectively manage these patients. PubDate: Thu, 29 Nov 2018 08:38:37 +000
Abstract: High-quality cardiopulmonary resuscitation (CPR) is crucial for survival from cardiac arrest. However, various chest compression-associated injuries have been reported. Internal mammary artery (IMA) injury is one of the rare complications after CPR, and most of cases include rib and sternum fractures. In this report, we describe a rare case of IMA injury without chest wall fractures after CPR. An 85-year-old man with a history of acute myocardial infarction 2 weeks prior visited to our hospital for sustained ventricular tachycardia (VT). After admission, sustained VT requiring CPR occurred several times. Emergency coronary angiogram revealed 90% stenosis at the left anterior descending artery. Hence, emergency percutaneous coronary intervention (PCI) was performed. During the PCI, blood gas analysis showed decreasing serum hemoglobin levels. Contrast computed tomography revealed hemothorax and extravasation at the branch of the right IMA without chest wall fractures. The patient’s deteriorating hemodynamic condition precluded thoracotomy or embolization to stop the bleeding. The patient died on the next day of hospitalization. IMA injury can occur after CPR, regardless of chest wall fractures and can be fatal without early diagnosis. For an emergency physician, IMA injury should be considered as a cause of unknown anemia after CPR. PubDate: Tue, 23 Oct 2018 00:00:00 +000
Abstract: Emergency department (ED) physicians frequently encounter patients presenting with angioedema. Most of these involve histamine-mediated angioedema; however, less common forms of angioedema (bradykinin-mediated) also occur. It is vital physicians correctly recognize and treat this; particularly since bradykinin-mediated angioedema does not respond to antihistamines, corticosteroids or epinephrine and hereditary angioedema (HAE) laryngeal attacks can be fatal. Here we present four case reports illustrating how failures in recognizing, managing, and treating laryngeal edema due to HAE led to asphyxiation and death of the patient. Recognition of the specific type of angioedema is critical for rapid and effective treatment of HAE attacks. Bradykinin-mediated angioedema should be efficiently differentiated from the most common histamine-mediated form. Improved awareness of HAE and the associated risk of life-threatening laryngeal edema among emergency physicians, patients, and relatives and clear ED treatment protocols are warranted. Moreover, appropriate treatments should be readily available to reduce fatalities associated with laryngeal edema. PubDate: Mon, 22 Oct 2018 09:31:26 +000
Abstract: We report the case of a person who went into cardiac arrest after being given chlorpromazine for hiccups and was subsequently diagnosed with congenital Long QT Syndrome. Long QT Syndrome is an uncommon, congenital condition that carries a high risk of sudden cardiac death. Clinicians need to recognize the risk that chlorpromazine may prolong the QTc and prepare to manage potential complications. PubDate: Wed, 10 Oct 2018 06:47:48 +000
Abstract: We describe a case of a young male who presents to the emergency department with severe sepsis and decompensated heart failure with underlying Methamphetamine-Associated Cardiomyopathy that was previously undiagnosed. This presentation is unique because Methamphetamine-Associated Cardiomyopathy is an uncommonly reported condition that presented in a complex clinical scenario of severe sepsis and decompensated congestive heart failure. We discuss how we used point-of-care ultrasound (POCUS) in this case to identify an unsuspected disease process and how it changed our initial resuscitation strategy and management. Emergency physicians can utilize point-of-care ultrasound (POCUS) to help identify these high-risk patients in the emergency department and guide appropriate resuscitation. Methamphetamine-Associated Cardiomyopathy (MAC) is an infrequently described complication of methamphetamine abuse, most commonly presented as a nonischemic dilated cardiomyopathy. With the rise in methamphetamine abuse in the United States, complications from methamphetamine use are more commonly presenting to the emergency department. Proper education and rehabilitation, with a goal of abstinence from amphetamine use, may allow patients to potentially regain normal cardiac function. Since the majority of patients present late with severe cardiac dysfunction, early detection is essential amongst critically ill patients since recognition may significantly influence ED management. PubDate: Tue, 09 Oct 2018 00:00:00 +000
Abstract: Background. Acute liver failure can result from acetaminophen overdose, viral infection, toxins, and other disease conditions. Liver transplant is available in limited fashion and the criteria are strict as to who should get an available liver. N- Acetyl Cysteine (NAC) has been used in non-acetaminophen induced liver failure with success. Here we report a case of acute liver failure from cocaethylene that was reversed with NAC along with other medical therapy. Case Presentation. A 50-year-old female patient presented to the Emergency Department (ED) with a two-day history of coffee ground vomiting and hematemesis. She reported occasional substance abuse and heavy alcoholism. She reported shortness of breath and chest pain from the recurrent forceful vomiting. The rest of the review of systems was unremarkable except a fall from intoxication. Physical examination revealed anicteric conjunctiva and nontender abdomen and her vital signs were within normal limits. Initial blood work revealed acute liver and renal failure. The patient was started with general medical management and liver transplant service rejected the case due to active substance abuse. She underwent brief hemodialysis and was started on NAC. Over the course of her hospital stay her liver function and kidney function improved significantly and patient was discharged to home. Conclusion. In cases where liver transplant is not an option for various reasons including active substance abuse, a trial of N-Acetyl Cysteine may be beneficial and should be considered in the Emergency Department. PubDate: Wed, 26 Sep 2018 09:04:32 +000
Abstract: This case describes a 70-year-old female who presented with right flank pain around the site where a stent had been placed in her right kidney at an outside hospital several months earlier. The patient arrived tachycardic with a leukocytosis and a lactic acidosis. Further imaging revealed a very hydronephrotic right kidney and an extremely large fluid collection in the right retroperitoneum extending into the right flank consistent with leakage of urine from the obstructed right kidney. Prompt treatment of this rare phenomenon is crucial for delay in medical care can lead to abscess, hydronephrosis, electrolyte instability, and a progressive loss of renal function. Treatment for small urinomas is usually conservative as the collection will most often be reabsorbed. Larger urinomas even without systemic signs often necessitate more aggressive medical treatment. A drainage catheter can be placed with ultrasound or CT guidance. Percutaneous nephrostomy tubes are often used as well for additional drainage and decompression. Fluid culture is recommended to guide antibiotic treatment. PubDate: Tue, 25 Sep 2018 10:08:55 +000
Abstract: We report an unusual presentation of Guillain-Barré wherein a patient with an extensive history of psychiatric illness had a dream that his legs were crushed in an earthquake and awoke from the dream with paresthesias and rapid paralysis of bilateral lower extremities. This article discusses an atypical presentation of pathology and diagnostic evaluation for a form of Guillain-Barré called Acute Inflammatory Demyelinating Polyneuropathy (AIDP). PubDate: Sun, 23 Sep 2018 09:10:03 +000
Abstract: The first-line recommended treatment for stable paroxysmal supraventricular tachycardia (PSVT) is the use of vagal maneuvers. Often the Valsalva maneuver is conducted. We describe two patients who converted to sinus rhythm without complications, using a head down deep breathing (HDDB) technique. PubDate: Sun, 23 Sep 2018 00:00:00 +000
Abstract: Open globe injury (OGI) is a severe form of eye trauma. It is an important cause of monocular blindness worldwide. Ruptures from blunt trauma are most common at the sites where the sclera is thinnest, at the insertions of the extraocular muscles, and at the limbus. Most often, rupture is equatorial. We present a unique case of open globe injury due to blunt ocular trauma from a thrown rock that resulted in a meridional rupture of the eye. The pertinent literature is reviewed. PubDate: Tue, 18 Sep 2018 06:34:15 +000
Abstract: We present two cases of young women with a past medical history significant for systemic lupus erythematosus (SLE), who presented to the Emergency Department with a ruptured abdominal aortic aneurysm (AAA). These cases are of particular interest because the patients did not fit the typical demographic for patients who present with a ruptured AAA. Based on these cases and a review of the relevant literature, ED providers should maintain a higher index of suspicion for AAA rupture in patients with autoimmune diseases, especially SLE. PubDate: Sun, 16 Sep 2018 07:08:01 +000
Abstract: Retroperitoneal bleeding is a rare and difficult to diagnose condition, defined as bleeding in the retroperitoneal space without associated trauma or iatrogenic manipulation. It has been associated with hematologic diseases and malignancies and is more common in patients receiving systemic anticoagulation. A 50-year-old man on aspirin presented with abdominal pain. Physical examination revealed abdominal tenderness and a palpable mass at the left abdominal area. An abdominal CT revealed a spontaneous retroperitoneal hematoma due to bleeding of an intraparenchymal branch of the left renal artery. The patient underwent left nephrectomy in order to control the bleeding. Pathology of the kidney showed evidence of acute and chronic microangiopathy, renal artery stenosis, and renal vein thrombosis. Further work-up led to diagnosis of primary antiphospholipid syndrome. Treatment of spontaneous retroperitoneal bleeding varies from conservative in hemodynamically stable patients to invasive or even surgery in hemodynamically unstable patients. In our case, open surgery was performed due to the rapidly deteriorating patient’s condition and the inability to embolize the bleeding vessel by interventional radiology. Physicians should always think of retroperitoneal bleeding in patients presenting with abdominal pain and signs of hypovolemia, especially if they have a bleeding disorder or receive anticoagulants or antiplatelets. PubDate: Thu, 06 Sep 2018 00:00:00 +000
Abstract: A positive seatbelt sign following a motor vehicle accident is associated with an increased risk of intra-abdominal injury and hemoperitoneum. Injury to the uterus in reproductive-age women can also occur. In this report, we describe a 29-year-old nulligravida female who presented to the emergency room following a motor vehicle accident at freeway speeds. A positive seatbelt sign was noted, and a focused assessment with sonography for trauma revealed hemoperitoneum with an incidental finding of uterine leiomyomata. Upon exploratory laparotomy, a free-floating intraperitoneal mass was identified as an avulsed uterine leiomyoma. A uterine laceration containing a subserosal leiomyoma was also identified. The gynecological team was consulted, and a myomectomy of the subserosal leiomyoma followed by a closure of the uterine laceration was performed. The patient was transfused with a total of three units of packed red blood cells and two units of fresh frozen plasma. The postoperative course was without major complication. A positive seatbelt sign and hemoperitoneum in a reproductive-age woman with leiomyomata should increase the clinical suspicion for uterine injury and decrease the threshold for obtaining a gynecological consultation. PubDate: Sun, 26 Aug 2018 08:45:43 +000
Abstract: The urachus is a midline tubular structure that stretches from the apex of the bladder and connects to the umbilicus. Urachal remnants result from incomplete regression of the fetal urachus in infancy. We report the case of a 21-year-old male who presented to the emergency department with purulent drainage from his umbilicus in association with a chronic intermittent “pulling sensation” in the umbilicus and suprapubic areas. An infected urachal remnant was diagnosed and was treated with an oral antibiotic and ultimately with outpatient excision of the remnant. Such cases are rare but have the potential to progress to sepsis. In addition, chronic inflammation can lead to neoplastic transformation (adenocarcinoma). Urachal remnant infections can be considered in adults with umbilical purulent drainage. We propose that the “pulling sensation” described may be a clue to the diagnosis in some patients in which the urachal remnant is attached to the bladder and that the sensation was due to the mechanical connection between the bladder and the umbilicus. The sensation resolved postremoval status of the remnant. This does not appear to have been previously proposed in the literature. PubDate: Tue, 14 Aug 2018 06:10:26 +000
Abstract: The development of a retropharyngeal hematoma may lead to acute airway compromise requiring emergent airway stabilization. We describe the development of a retropharyngeal hematoma in an elderly woman who sustained a fall from standing approximately 10 hours prior to symptom onset who was taking the antiplatelet agents clopidogrel and aspirin. This delayed onset of rapid airway compromise secondary to a retropharyngeal hematoma following a fall in a patient taking clopidogrel is an unusual and potentially life threatening event. PubDate: Mon, 13 Aug 2018 06:17:28 +000
Abstract: Blunt cerebrovascular injury (BCVI) is a term encompassing traumatic carotid and vertebral artery dissection or disruption. While the reported incidence appears to be increasing as diagnostic modalities improve, these injuries are often diagnosed only after patients have developed acute neurologic symptoms. These injuries often result in severe permanent neurologic disability or death. The gold standard for diagnosis has historically been a 4-vessel arteriogram. However, newer data are suggesting that computed tomographic angiography may be more appropriate for most patients and new criteria for its utilization have been developed. We report a case of bilateral carotid dissection in a 23-year-old woman involved in a motor vehicle collision (MVC). She initially presents with a normal neurologic exam and two hours later develops hemiparesis. She is treated with antiplatelet therapy and given intravascular catheter directed tissue plasminogen activator with carotid stent placement. Nonetheless, the patient goes on to require intubation and, ultimately, a tracheostomy and transfer to an inpatient rehabilitation setting due to continued hemiparesis. This case highlights the need for increased awareness of a potentially debilitating, life-threatening disease process. A high index of suspicion is required among emergency medicine physicians for early diagnosis and treatment of trauma patients with BCVI. PubDate: Wed, 08 Aug 2018 07:22:17 +000
Abstract: Influenza is a contagious viral illness that usually presents with upper respiratory and pulmonary symptoms. While generally self-limited, pulmonary, renal, metabolic, neurologic, and cardiac complications have all been described in the literature. Here we describe a case of a 46-year-old male with multiple episodes of syncope, found to have severe bradycardia, sinus arrest, and positive influenza B, requiring permanent pacemaker placement. The viruses responsible for the flu can be differentiated into four types: A, B, C, and D. The two primary viruses responsible for the seasonal winter epidemic influenza in the United States are Human Influenza A and B viruses. It has been postulated that the influenza virus may be responsible for activating acute inflammatory cytokines, which then alter electrical conduction properties of endothelial cells. Although there have been cases of sinus arrest in association with influenza, some requiring pacemaker placement, our patient’s presentation with multiple episodes of syncope with severe bradycardia and sinus arrest requiring permanent pacemaker placement, in association with influenza B, is very unusual and possibly unique. Since emergency physicians are at the forefront in the diagnosis, treatment, and disposition of these patients, awareness of influenza triggered cardiac events is essential and lifesaving, especially in unvaccinated patients. PubDate: Thu, 02 Aug 2018 08:58:06 +000
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