Case Report Archives - Page 13 of 16 - The Western Journal of Emergency Medicine

Opioid Dependent Malingerer with Self-Induced Sepsis

Kelly A. Kesler, MD et al.

A 21-year-old woman was admitted to the emergency department (ED) with severe sepsis. Both the mechanism of infection and organisms discovered were unusual.

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E-cigarette Blast Injury: Complex Facial Fractures and Pneumocephalus

Benjamin A. Archambeau, DO et al.

Electronic cigarettes (also known as e-cigarettes or e-cigs) are becoming a popular method of recreational nicotine use over recent years. The growth of new brands and devices has been outpacing the FDA’s ability to regulate them. As a result, some of these devices fail without warning, most likely from malfunction of the lithium-ion batteries that are in close proximity to volatile compounds within the device.

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Large Posterior Communicating Artery Aneurysm: Initial Presentation with Reproducible Facial Pain Without Cranial Nerve Deficit

Stacie Zelman, MD et al.

Unruptured posterior communicating artery (PCOM) aneurysms can be difficult to diagnose and, when large (≥ 7mm), represent a substantial risk to the patient. While most unruptured PCOM aneurysms are asymptomatic, when symptoms do occur, clinical manifestations typically include severe headache (HA), visual acuity loss, and cranial nerve deficit. This case report describes an atypical initial presentation of a large unruptured PCOM aneurysm with symptoms mimicking trigeminal neuralgia, without other associated cranial nerve palsies or neurologic deficits.

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Role of Ultrasound in the Identification of Longitudinal Axis in Soft-Tissue Foreign Body Extraction

Al Lulla, MD et al.

Identification and retrieval of soft-tissue foreign bodies (STFB) poses significant challenges in the emergency department. Prior studies have demonstrated the utility of ultrasound (US) in identification and retrieval of STFBs, including radiolucent objects such as wood. We present a case of STFB extraction that uses US to identify the longitudinal axis of the object. With the longitudinal axis identified, the foreign body can be excised by making an incision where the foreign body is closest to the skin. The importance of this technique as it pertains to minimizing surrounding tissue destruction and discomfort for patients has not been previously reported.

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Point-of-Care Sonographic Findings in Acute Upper Airway Edema

Michael Schick, DO, MA et al.

We describe a case where a patient presented with acute angiotensin-converting enzyme inhibitor (ACE-I) induced angioedema without signs or symptoms of upper airway edema beyond lip swelling. Point-of-care ultrasound (POCUS) was used as an initial diagnostic test and identified left-sided subglottic upper airway edema that was immediately confirmed with indirect fiberoptic laryngoscopy. ACE-I induced angioedema and the historical use of ultrasound in evaluation of the upper airway is briefly discussed. To our knowledge, POCUS has not been used to identify acute upper airway edema in the emergency setting. Further investigation is needed to determine if POCUS is a sensitive and specific-enough tool for the identification and evaluation of acute upper airway edema.

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Two Cases of Anti-NMDA Receptor Encephalitis

Two Cases of Anti-NMDA Receptor Encephalitis
Jesse Baker, BA, et al.

Anti-N-methyl-D-aspartate receptor (anti-NMDAR) encephalitis is a form of autoimmune encephalitis with prominent neuropsychiatric features. Patients present with acute psychosis, memory impairment, dyskinesias, seizures, and/or speech disorders. The clinical course is often complicated by respiratory failure, requiring intubation. Approximately half of patients are found to have an associated ovarian tumor, which expresses NMDAR. Recognition of anti-NMDAR encephalitis by emergency physicians is essential in order to initiate early treatment and avoid psychiatric misdiagnosis. The disease is highly treatable with tumor removal and immunosuppression, and most patients demonstrate a full recovery. In this case series, we report two cases of anti-NMDAR encephalitis in adult women in the United States and provide a review of the literature.

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A Rare but Important Clinical Presentation of Induced Methemoglobinemia

A Rare but Important Clinical Presentation of Induced Methemoglobinemia
Faried Banimahd, MD et al.

Phenazopyridine is considered one of the classic causes of drug-induced methemoglobinemia. It is often taught as such and seen in board review courses. Nevertheless, the epidemiology is unknown, presentation quite rare, and less than five cases have been reported in PubMed in over 35 years.1-4 We present a case with a different set of patient characteristics than seen in the few recent case reports, and an approach to treatment that validates further uniqueness, justifying reporting the case in the literature. In particular, the patient was a young otherwise-healthy adult, with the initial diagnosis and decision to treat based on clinical grounds versus laboratory values.

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A Curious Case of Right Upper Quadrant Abdominal Pain

A Curious Case of Right Upper Quadrant Abdominal Pain
Andrew Grock, MD et al.

An otherwise healthy 36-year-old man presented with sudden-onset right upper quadrant abdominal pain and vomiting. A bedside ultrasound, performed to evaluate hepatobiliary pathology, revealed a normal gallbladder but free intraperitoneal fluid. After an expedited CT and emergent explorative laparotomy, the patient was diagnosed with a small bowel obstruction with ischemia secondary to midgut volvulus. Though midgut volvulus is rare in adults, delays in definitive diagnosis and management can result in bowel necrosis. Importantly, an emergency physician must be able to recognize bedside ultrasound findings associated with acutely dangerous intrabdominal pathology.

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Check the Head: Emergency Ultrasound Diagnosis of Fetal Anencephaly

Volume 17, Issue 4, July 2016
John Hall, MD, et al.

Early pregnancy complaints in emergency medicine are common. Emergency physicians (EP) increasingly employ ultrasound (US) in the evaluation of these complaints. As a result, it is likely that rare and important diagnoses will be encountered. We report a case of fetal anencephaly diagnosed by bedside emergency US in a patient presenting with first-trimester vaginal bleeding.

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Diagnosis of Pyomyositis in a Pediatric Patient with Point-of-Care Ultrasound

Volume 17, Issue 4, July 2016
Siamak Moayedi, MD, et al.

A three-year-old girl presented to the emergency department (ED) for five days of pain and decreased mobility of the left shoulder. She had been evaluated in the ED five days prior for shoulder pain after a minor slip and fall with negative clavicle radiographs, and was discharged home with supportive care. Since the initial visit, her shoulder pain increased and she would not use her arm. Physical examination demonstrated subtle swelling of the left anterior shoulder without erythema, warmth, or fluctuance. Her exam yielded mild tenderness to palpation and markedly decreased range of motion secondary to pain. Point-of-care shoulder ultrasound revealed an enlarged deltoid muscle with a heterogeneous fluid collection within the muscle, but no joint effusion (Video).

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Anti-N-Methyl-D-Aspartate Receptor Encephalitis, an Underappreciated Disease in the Emergency Department

Volume 17, Issue 3, May 2016
Daniel R. Lasoff, MD et al.

Anti-N-Methyl-D-Aspartate Receptor (NMDAR) Encephalitis is a novel disease discovered within
the past 10 years. Antibodies directed at the NMDAR cause the patient to develop a characteristic
syndrome of neuropsychiatric symptoms. Patients go on to develop autonomic dysregulation and
often have prolonged hospitalizations and intensive care unit stays. There is little literature in
the emergency medicine community regarding this disease process, so we report on a case we
encountered in our emergency department to help raise awareness of this disease process.

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Case Series of Synthetic Cannabinoid Intoxication from One Toxicology Center

Volume 17, Issue 3, May 2016
Kenneth D. Katz, MD, et al.

Synthetic cannabinoid use has risen at alarming rates. This case series describes 11 patients exposed to the synthetic cannabinoid, MAB-CHMINACA who presented to an emergency department with life-threatening toxicity including obtundation, severe agitation, seizures and death. All patients required sedatives for agitation, nine required endotracheal intubation, three experienced seizures, and one developed hyperthermia. One developed anoxic brain injury, rhabdomyolysis and died. A significant number were pediatric patients. The mainstay of treatment was aggressive sedation and respiratory support. Synthetic cannabinoids pose a major public health risk. Emergency physicians must be aware of their clinical presentation, diagnosis and treatment.

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Electronic Vapor Cigarette Battery Explosion Causing Shotgun-like Superficial Wounds and Contusion

Volume 17, Issue 2, March 2016.
Siri Shastry, MD, et al.

Electronic vapor cigarettes (E-cigarettes) were created
in 2003 as an alternative to traditional tobacco cigarettes.
E-cigarettes have been available in the United States since
2006. The typical E-cigarette consists of a cartridge that
contains liquid, an atomizer that heats the liquid (i.e. acts
as a vaporizer), as well as a battery. The liquid contained
within the cartridge contains nicotine, propylene glycol and/
or glycerol as well as flavorings.The consumer uses an
E-cigarette through either pushing a button or inhalation,
which triggers heating and therefore aerosolizes the liquid
within the cartridge, emulating cigarette “smoke.” The newest
E-cigarettes are larger than nicotine cigarettes and employ
stronger, rechargeable batteries as a power source.

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Salicylate Toxicity from Genital Exposure to a Methylsalicylate-Containing Rubefacient

Volume 17, Issue 2, March 2016.
Trevonne M. Thompson, MD, et al.

Methylsalicylate-containing rubefacients have been reported to cause salicylate poisoning after
ingestion, topical application to abnormal skin, and inappropriate topical application to normal
skin. Many over-the-counter products contain methylsalicylate. Topical salicylates rarely produce
systemic toxicity when used appropriately; however, methylsaliclyate can be absorbed through intact
skin. Scrotal skin can have up to 40-fold greater absorption compared to other dermal regions. We
report a unique case of salicylate poisoning resulting from the use of a methylsalicylate-containing
rubefacient to facilitate masturbation in a male teenager. Saliclyate toxicity has not previously been
reported from the genital exposure to methylsaliclyate.

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Critical Care

Seldinger Technique for Placement of “Peripheral” Internal Jugular Line: Novel Approach for Emergent Vascular Access

Volume 17, Issue 1, January 2016.
Adam J. Ash, DO, et al.

This is a case report describing the ultrasound-guided placement of a peripheral intravenous
catheter into the internal jugular vein of a patient with difficult vascular access. Although this
technique has been described in the past, this case is novel in that the Seldinger technique was
used to place the catheter. This allows for safer placement of a longer catheter (2.25”) without the
need for venous dilation, which is potentially hazardous.

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Tension Hydrothorax from Disseminated Endometriosis

Volume 17, Issue 1, January 2016.
AnnaKate Deal, MD, et al.

We present the case of a 34-year-old woman presenting to
the emergency department (ED) with dyspnea, cough, and fever.
She was found to have a tension hydrothorax and was treated
with ultrasound-guided thoracentesis in the ED. Subsequent
inpatient evaluation showed the patient had disseminated
endometriosis. Tension hydrothorax has not been previously
described in the literature as a complication of this disease.

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A Massive Overdose of Dalfampridine

Volume 16, Issue 7, December 2015.
Laura J. Fil, DO, et al.

Multiple sclerosis (MS) is an immune mediated inflammatory disease that attacks myelinated axons
in the central nervous system. Dalfampridine (4-aminopyridine) was approved by the Food and
Drug Administration in January 2010 for treatment of MS. Our patient was a 34-year-old male with a
history of MS, who was brought to the emergency department after being found unresponsive. His
current medications were valacyclovir, temazepam, dalfampridine (4-AP) and a tysabri intravenous
(IV) infusion. Fifteen minutes after arrival the patient seized. The seizures were refractory to
benzodiazepines, barbiturates and phenytoin. The 4-AP level was 530ng/mL (25ng/mL and 49ng/
mL). The patient stopped seizing on hospital day 3 and was discharged 14 days later with normal
mental status and neurologic exam. 4-AP is a potassium channel blocker that blocks the potassium
ion current of repolarization following an action potential. The blockade of the potassium channel at
the level of the membrane widens the action potential and enhances the release of acetylcholine,
thus increasing post-synaptic action potentials. The treatment of patients with 4-AP overdose is
supportive. Animal data suggest that patients with toxic levels of 4-AP may respond to phenytoin.
Our case illustrates the highest recorded level of 4-AP in an overdose. Our patient appeared to be
refractory to a combination of high doses of anticonvulsants and only improved with time.

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Endemic Infections

Tuberculoma-Induced Seizures

Volume 16, Issue 5, September 2015.
R. James Salway, MD, et al.

Seizures in human immunodeficiency virus (HIV) patients can be caused by a wide variety of
opportunistic infections, and, especially in developing countries, tuberculosis (TB) should be high
on the differential. In India, TB is the most common opportunistic infection in HIV and it can have
several different central nervous system manifestations, including intracranial tuberculomas. In this
case, an HIV patient presenting with new-onset seizure and fever was diagnosed with tuberculous
meningitis and multiple intracranial tuberculomas. The patient received standard TB medications,
steroids, and anticonvulsants in the emergency department and was admitted for further care.

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Critical Care

Interposed Abdominal Compression CPR for an Out-of-Hospital Cardiac Arrest Victim Failing Traditional CPR

Volume 16, Issue 5, September 2015.
Christian D. McClung, MD, MPhil, et al.

Interposed abdominal compression cardiopulmonary resuscitation (IAC-CPR) is an alternative
technique to traditional cardiopulmonary resuscitation (CPR) that can improve perfusion and lead to
restoration of circulation in patients with chest wall deformity either acquired through vigorous CPR
or co-morbidity such as chronic obstructive pulmonary disease. We report a case of out-of-hospital
cardiac arrest where IAC-CPR allowed for restoration of spontaneous circulation and eventual
full neurologic recovery when traditional CPR was failing to generate adequate pulses with chest
compression alone.

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Injury Prevention

Injuries Following Segway Personal Transporter Accidents: Case Report and Review of the Literature

Volume 16, Issue 5, September 2015.
John Ashurst DO, MSc, et al.

The Segway® self-balancing personal transporter has been used as a means of transport for
sightseeing tourists, military, police and emergency medical personnel. Only recently have reports
been published about serious injuries that have been sustained while operating this device. This
case describes a 67-year-old male who sustained an oblique fracture of the shaft of the femur
while using the Segway® for transportation around his community. We also present a review of the
literature.

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Focused Cardiac Ultrasound Diagnosis of Cor Triatriatum Sinistrum in Pediatric Cardiac Arrest

Volume 16, Issue 5, September 2015.
Thompson Kehri, MD, et al.

Cardiac arrest in the adolescent population secondary to congenital heart disease (CHD) is rare.
Focused cardiac ultrasound (FoCUS) in the emergency department (ED) can yield important clinical
information, aid in resuscitative efforts during cardiac arrest and is commonly integrated into the
evaluation of patients with pulseless electrical activity (PEA). We report a case of pediatric cardiac
arrest in which FoCUS was used to diagnose a critical CHD known as cor triatriatum sinistrum
as the likely cause for PEA cardiac arrest and help direct ED resuscitation.

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Ruptured Splenic Artery Aneurysm: Rare Cause of Shock Diagnosed with Bedside Ultrasound

Volume 16, Issue 5, September 2015.
Terri Davis, MSHS, PA-C, et al.

Splenic artery aneurysm rupture is rare and potentially fatal. It has largely been reported in pregnant
patients and typically not diagnosed until laparotomy. This case reports a constellation of clinical and
sonographic findings that may lead clinicians to rapidly diagnose ruptured splenic artery aneurysm
at the bedside. We also propose a rapid, but systematic sonographic approach to patients with
atraumatic hemoperitoneum causing shock. It is yet another demonstration of the utility of bedside
ultrasound in critically ill patients, specifically with undifferentiated shock.

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Tension Pneumoperitoneum Caused by Obstipation

Volume 16, Issue 5, September 2015.
Daniel Miller, MD

Emergency physicians are often required to evaluate and treat undifferentiated patients suffering
acute hemodynamic compromise (AHC). It is helpful to apply a structured approach based on a
differential diagnosis including all causes of AHC that can be identified and treated during a primary
assessment. Tension pneumoperitoneum (TP) is an uncommon condition with the potential to be
rapidly fatal. It is amenable to prompt diagnosis and stabilization in the emergency department. We
present a case of a 16-year-old boy with TP to demonstrate how TP should be incorporated into a
differential diagnosis when evaluating an undifferentiated patient with AHC.

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ST-Elevation Myocardial Infarction After Sumitriptan Ingestion in Patient with Normal Coronary Arteries

Volume 16, Issue 5, September 2015
Christian Jensen, DO, et al.

Sumitriptan has been used by millions as a migraine abortant; however, there have been studies
showing angina pectoris, coronary vasospasm, and even myocardial infarction in patients with
predisposing cardiac risk factors. The majority are patients using the injectable form subcutaneously.
We present the case of a patient who presents with ST-elevation myocardial infarction, with no
cardiovascular risk factors, after ingesting oral sumitriptan for her typical migraine.

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Uterine Incarceration: Rare Cause of Urinary Retention in Healthy Pregnant Patients

Volume 16, Issue 5, September 2015.
Richard Slama, MD, et al.

Gravid uterine incarceration (GUI) is a condition that is well discussed in literature; however, there
are few acute diagnoses in the emergency department (ED). We present a case series where
three multiparous females presented to the ED with non-specific urinary symptoms. On bedside
ultrasound, each patient was noted to have a retroverted uterus and inferior bladder entrapment
under the sacral promontory. GUI is a rare condition that can lead to uremia, sepsis, peritonitis, and
ultimately maternal death. Emergency physicians should include GUI in their differential diagnosis in
this patient population and use bedside ultrasound as an adjunct to diagnosis.

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Leriche Syndrome Presenting with Multisystem Vaso-Occlusive Catastrophe

Volume 16, Issue 4, July 2015.
C. Eric McCoy, MD, MPH, et al.

Leriche syndrome, also referred to as aortoiliac
occlusive disease, has been described as a triad of
claudication, impotence and decreased femoral pulses.
The syndrome results from thrombotic aortoiliac occlusion and
was first described by a French surgeon, Rene Leriche, in
1940. The disease most commonly occurs in men, and risk
factors include hypertension, diabetes, hyperlipidemia, and
smoking.

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