The Case Files
Welcome to the Case Files!
The Case Files is an anecdotal collection of emergency medicine cases to enable physicians and researchers to find clinically important information on unusual conditions.
Case reports should focus on:
- Unusual side effects or adverse interactions.
- Unusual presentations of a disease.
- Presentations of new and emerging diseases, including new street drugs.
- Findings that shed new light on a disease or an adverse effect.
Comment on a case or submit your own case following the instructions in the Submissions box to the right.
Tuesday, June 23, 2015
By Charles Burtis, MD; Ann Haynes, MD & Andrew King, MD
A 59-year-old woman presented to the emergency department complaining of worsening abdominal pain and distension as well as four episodes of syncope and lightheadedness. The patient reported a past medical history of hypertension and hypothyroidism, but denied other comorbidities. The patient reported that she was walking her dog the previous night when the dog bolted forward, causing her to lose her balance and fall forward.
The patient reported that she was able to tuck into a ball and roll, sustaining minor trauma only to her right side. She denied any head trauma or loss of control after falling. She was able to walk home, and she felt fine apart from some bruising on her right lower ribs. Over the course of the evening, however, the patient's pain began to worsen. She had several episodes of nausea and non-bloody, non-bilious emesis. The next morning she began to feel short of breath, and her abdominal pain continued to worsen. She reported two episodes of syncope, which she attributed to the severity of her pain or because she was breathing too quickly.
The patient's systolic blood pressure was in the 80s when she arrived in the ED, and her heart rate was 130 bpm. Her respiratory rate was 26 bpm, and her SPO2 was 85% on room air. The patient was in distress and started on oxygen, intravenous access was obtained, and she was resuscitated with normal saline. She had significant abdominal pain that seemed to localize to the right upper quadrant, and a bedside FAST exam was positive for intra-abdominal fluid.
The patient was expeditiously transferred to a trauma center where she underwent a CT with IV contrast for the abdomen and pelvis. A large smoothly marginated cystic lesion was noted on the dome of the right hepatic lobe measuring 13.1 x 8.6 cm. A grade 3 liver laceration was noted at the base of the hepatic cysts with a surrounding large hematoma. Moderate amounts of fluid were noted in Morrison's pouch, the surrounding paracolic gutter, and the pelvis. A fracture was also noted in the right eighth rib that was not displaced.
The patient's hemoglobin levels continued to drop, and she was taken to interventional radiology, where she was noted to have a small pseudoanuerysm of a segmental branch of the right hepatic artery within the hepatic cyst, with evidence of active intraperitoneal extravasation. The patient then underwent an embolization of the segmental branch of the right hepatic artery, and hemostasis was successfully obtained.
The patient's hemoglobin levels stabilized after the embolization, and she was able to resume a regular diet. She was discharged on hospital day six with the plan to follow up with trauma surgery.
Unintended falls are the most common cause of injury in the United States. They lead to 7.9 million emergency department visits per year and 860,000 hospitalizations. (Acad Emerg Med 1998;5:1064.) In our particular case, what appeared to be a benign mechanism resulted in a serious injury because of the presence of a benign hepatic cyst that the patient didn't know about. Simple hepatic cysts are believed to be present in five to 10 percent of the population, with increasing incidence with age. (J Clin Ultrasound 1996;21:115.) Common complications of hepatic cysts include rupture, contained hemorrhage, and obstructive jaundice. (J Nippon Med Sch 2010;77:181; West J Med 1982;136:246; Am J Gastroenterol 1988;83:93.)
Multiple cases of traumatic rupture of hepatic cysts are reported, but these are typically contained within the cyst. Few reports exist suggesting hemoperitoneum after cyst rupture. In our case, the rupture of the hepatic cyst was accompanied by a liver laceration, which led to extravasation of blood leading to hemoperitoneum. (HPB Surg 1988;1:81; South Med J 1989;82:667.) Focused bedside ultrasonography and strong clinical suspicion assisted in expediting a transfer to a trauma center where intervention corrected the problem.
Dr. Burtis is a third-year emergency medicine resident at the Ohio State University East Medical Center and the Ohio State University Wexner Medical Center, where Drs. Haynes and King are assistant professors of emergency medicine.
Tuesday, May 26, 2015
By Mohammed Hassan-Ali, MSC & Ahmed Raziuddin, MD
A 56-year-old black man presented to the ED complaining of face and neck swelling. An initial history was difficult to obtain because the patient did not speak English fluently and had slurred speech. Symptoms started approximately a week earlier when the patient was at his nursing home. He denied dysphagia or odynophagia, he had no rashes, pruritus, dyspnea, or peripheral edema, his face was flushed, and he had visibly-engorged neck veins. He noticed that his tongue was mildly swollen, so he took Benadryl for a week with no relief. The patient said he believed that the symptoms might have been because a nurse gave him an incorrect medication at the nursing home. He had been a pack-a-day smoker for 30 years, and had a history of schizoaffective disorder, bipolar disorder with psychotic features, and GERD.
A CBC with differential, PT, PTT, BMP, and UA were all within normal limits. A chest x-ray confirmed a large mediastinal mass, and a soft tissue neck CT scan with contrast found a large mass in the upper mediastinum with extensive adenopathy in the base of the right side of his neck on the right, a right lobe thyroid mass, and occlusion of the superior vena cava and left subclavian vein. The report suggested that the findings were consistent with aggressive lymphoma or lung cancer.
The patient was admitted to the hospital with a scheduled emergent biopsy of the neck mass/lymph nodes. He was diagnosed with superior vena cava (SVC) syndrome and small cell lung carcinoma (SCLC) by tissue biopsy and pathology.
The SVC drains venous blood from the head, neck, upper extremities, and thorax. Obstruction of the SVC is usually because of neoplasms that invade the tissue wall or put pressure on the SVC. (J Clin Oncol1984;2:961.) SCLC accounts for 25 percent of SVC syndrome because of malignancy. (HemOnc Today Feb. 10, 2012;http://bit.ly/1H3Uggt.) Clinical features of SVC syndrome include facial edema, difficulty swallowing, engorged neck veins, cough, and dyspnea. (Int J Radiat Oncol Biol Phys 1987;13:531.) Obstruction of the SVC can divert blood flow to the azygous veins, internal mammary veins, superior and inferior epigastric veins, or femoral and vertebral veins, but the venous pressure remains elevated. Complications of this condition include cerebral edema, coma, and death. (Joint Bone Spine 2002;69:416.)
The patient presented with only neck swelling and difficulty speaking. The speech impediment was most likely from the combination of SVC syndrome and right-sided thyroid mass occluding the right recurrent laryngeal nerve. The prognosis of SVC syndrome is poor because of the underlying neoplasm. The patient was promptly started on a dose of approximately 2900 cGy in 13 fractions to the mediastinum and neck nodes and scheduled to receive chemotherapy. After three weeks, he was medically stabilized, and had tolerated chemotherapy and radiation. The SVC syndrome did not compromise his breathing. The patient was advised that he could be discharged with a PORT-A-CATH for future chemotherapy, but the prognosis of his condition remained poor.
Lung cancer is the leading cause of cancer-related death in the United States. (CA Cancer J Clin 2008;58:71.) Its incidence is decreasing, but 13 percent of all new cancers are still from lung cancer. (“Lung Cancer Statistics,” American Cancer Society, March 4, 2015;http://bit.ly/1JSd82D.) Even with current screening techniques, approximately half of patients have a metastatic presentation and a 45 percent five-year survival rate. Approximately 90 percent of lung cancer patients are active smokers or had recently stopped.
Signs and symptoms of this cancer include shortness of breath, cough, bone pain, weight loss, fatigue, and neurologic dysfunction. (Medscape, March 26, 2014; http://bit.ly/1dPWx29.) None of these were present in the patient. Most SCLCs are metastasized by the time of diagnosis, and are not curative by surgery. A combination of chemotherapy and radiation therapy is required. SCLCs are centrally located masses found in the lung parenchyma. (J Clin Oncol2006;24:4526.) These pale gray tumors are fusiform-shaped and quite fragile. They can also express neuroendocrine markers and secrete polypeptide hormones that can cause paraneoplastic syndromes (PNS), such as syndrome of inappropriate antidiuretic hormone (SIADH). (Chest 2003;123[1 Suppl]:97S.)
The time frame of disease development was unclear, but this patient's presentation was unique because he had nonthreatening symptoms. Lung cancer and SVC syndrome symptoms are usually aggressive, and can compromise the quality of life for patients. Our patient is now being treated to try to prevent the expected disease outcomes.
Mr. Hassan-Ali is a third-year medical student at the Windsor University School of Medicine in Cayon, Saint Kitts. Dr. Raziuddin is an internist specializing in emergency medicine at Louis A. Weiss Memorial and Thorek Memorial hospitals in Chicago.
Tuesday, January 20, 2015
By Mikhail Elfond, DO; Esi Quayson, MD; & Joseph V.M. Kelly, MD, MBA
A 65-year-old man presented to the ED via EMS with symptoms of stroke. The paramedics stated his right-sided weakness and speech difficulty started 40 minutes prior to presentation in the ED. En route to the hospital, paramedics observed four episodes of facial twitching.
Vitals signs were significant for a rectal temperature of 100.2°F and a fingerstick blood sugar of 220 mg/dL. History of present illness was significant for a diagnosis of left otitis media treated with Augmentin and Vicodin at an urgent care center one day prior to presentation. Past medical history included hypertension, hypercholesterolemia, and diet-controlled borderline diabetes mellitus.
He appeared confused and did not follow commands. He had a right lateral gaze, a right pronator drift, and global aphasia. Left tympanic membrane was perforated with purulent discharge. No mastoid tenderness or overlying skin changes were noted.
A head CT scan without contrast was performed, and revealed an ill-defined low attenuation lesion within the posterior left temporal lobe with associated pneumocephalus. Given ipsilateral opacification of the mastoid air cell and middle ear, findings were concerning for otomastoiditis complicated by intracerebral abscess. A follow-up maxillofacial CT scan with contrast showed thinning of the overlying roof of the temporal bone with dehiscence at multiple locations. A focus of associated pneumocephalus was identified. No definite abnormal parenchymal enhancement was identified, but the findings were consistent with intracerebral abscess complicating otomastoiditis.
Laboratory studies including complete blood count with differential showed WBC 11.54 with 88.2% neutrophils. Pre-operative labs and blood cultures were drawn; the patient was given Levetiracetam, ceftriaxone, and vancomycin, and taken to the operating room by neurosurgery and ENT.
A left ear culture grew Pseudomonas oryzihabitans and Streptococcus pneumoniae. An intracranial abscess grew S. pneumoniae. The patient did well post-operatively, and was discharged home on IV antibiotics.
A brain abscess is a focal, suppurative collection in the brain parenchyma resulting from an infection, trauma, or neurosurgery. Approximately 1,500 to 2,000 cases of brain abscesses are diagnosed in the United States annually, with an estimated one in 10,000 being hospitalized. (Int J Infect Dis 2006;10:103.) Rates are higher in certain high risks groups, including patients with HIV/AIDS. (N Engl J Med 2014;371:447.)
Bacterial invasion is from direct or hematogenous spread. Direct spread makes up 20 to 60 percent of all abscesses, which are caused by otitis media, mastoiditis, dental and other oropharyngeal diseases, or sinusitis, and usually result in a single abscess. (Laryngoscope 1998;108:1635.) Ear infections are decreasing as a cause of brain abscesses in developed countries, but sinus infections continue to be an important consideration. (Laryngoscope 1998;108:1635.) When infection spreads from the mastoids or middle ear to the CNS, the cerebellum, temporal lobes, or both are most often involved. (Laryngoscope 1998;108:1635.) The most frequently isolated pathogen in acute mastoiditis is S. pneumoniae, with a prevalence of approximately 30 percent with minimal variation worldwide. (Laryngoscope 1998;108:1635; QJM 2002;95:501.)
Common symptoms and signs include headache in 70 percent of cases, mental status changes in 65 percent, focal neurological deficits in 65 percent, fever in 50 percent, seizures in 25 to 35 percent, nausea and vomiting in 40 percent, nuchal rigidity in 25 percent, and papilledema in 25 percent. (N Engl J Med 2014;371:447; QJM 2002;95:501.)
The classic triad of fever, headache, and a focal neurological finding is only present in 20 percent of patients. Fever is absent in about 50 percent of patients with brain abscess at the time of the initial presentation. (N Engl J Med 2014;371:447; QJM 2002;95:501.) A lesion in the temporal lobe may lead to an ipsilateral headache, aphasia, and possibly a visual field defect. Hematogenous spread from bacteremia usually leads to multiple abscesses, usually in the territory of the middle cerebral artery. (N Engl J Med 2014;371:447; QJM 2002;95:501.)
As many as 85 organisms have been cultured from blood, CSF, or infection sites of patients with brain abscesses. The most common organisms are Streptococcus spp and Staphylococcus spp. (N Engl J Med 2014;371:447.) A meta-analysis by Brouwer, et al. found Pseudomonas spp in only two percent of all cultured bacteria. P. oryzihabitans is rare and opportunistic, and is an interesting isolate in our case. It is most commonly associated with catheters, other foreign body causes of bacteremia, and is interesting because this patient had no previous implantation of surgical objects. (Microb Ecol 2011;62:505.)
Case fatality rates from brain abscesses have decreased from 40 to 10 percent, with rates of full recovery increasing from 33 to 70 percent over the past 50 years. These improvements have been attributed to advancement in antibiotics, stereotactic biopsies, and advanced imaging techniques such as MRIs and CT scans. (N Engl J Med 2014;371:447.)
Wednesday, January 07, 2015
By Mikhail Elfond, DO, & Joseph V.M. Kelly, MD, MBA
A 63-year-old woman presented to the ED via ambulance with complaint of a draining abscess from her groin that had worsened over the past day. She also reported subjective fever and chills. The patient said she first noticed the abscess two days earlier.
The patient had had an appendectomy in 1994 and a hysterectomy in 2000, and she had type II diabetes, hypercholesterolemia, and hypertension. The patient was not compliant with her medications, and was not sure what they were. Her body mass index was 33.2, respiration rate was 18 bpm, oral temperature was 100.5°F, pulse was 108 bpm, blood pressure was 173/94 mm Hg, and pulse oximetry was 97% on room air. Physical examination was significant for a foul-smelling draining abscess in the perineal region that was tender, erythematous, and edematous with crepitus surrounding the site of drainage and copious amounts of pus that were expressed with light pressure during palpation.
Laboratory results were significant for a blood glucose level of 395 mg/dL and a white blood count of 20.3 cells/ml. A CT scan of the abdomen and pelvis with contrast showed multiple foci of air in the right lower anterior pubic region that was suspicious for a gas producing infection.
The diagnosis of Fournier’s gangrene was confirmed, and the patient was immediately started on broad-spectrum IV antibiotics, insulin, and IV fluids.
The patient was transferred to surgery where, after consulting with urology, a decision was made to perform a radical debridement of necrotic tissue and to drain the area surgically. The patient was stabilized after debridement and released from the ICU. The patient underwent reconstructive surgery, and was released three weeks after admission. The patient also received education on managing her chronic conditions. Because of immediate identification and intervention, the patient recovered.
Fournier’s gangrene is a rare form of necrotizing fasciitis with rapid onset and progression. Venereologist Jean Alfred Fournier was the first to describe a rapidly progressing case of necrotizing fasciitis in 1883. (AJR Am J Roentgenol 1998;170:163.) This form of necrotizing fasciitis is caused by anaerobic and aerobic microorganisms. The infection often begins as a simple cellulitis from a defect or break in the skin of the perineal or genital region, providing entry for bacteria. Because of the aggressive nature of the bacteria, even with early intervention, mortality rates remain high.
Multiple organisms can be present in the infection and may act synergistically, encouraging growth. The most common bacteria present are Escherichia coli, Bacteroides, Proteus, Staphylococcus, Enterococcus, Streptococcus, Pseudomonas, Klebsiella, and Clostridium species. (EMN 2005;27:24.) The byproducts of an anaerobic metabolism lead to soft tissue gas formation that is composed of hydrogen, hydrogen sulfide, and nitrous oxide. (AJR Am J Roentgenol 1998;170:163.)
It is important that surgical debridement be performed as soon as possible once Fournier’s gangrene is identified. Diagnosis can be made through physical examination, blood tests such as a CBC, imaging such as sonograms and CT scans that can provide evidence of the extent of subcutaneous infection, and a thorough history to help establish comorbidities such as diabetes, alcohol abuse, or immunodeficiency.
Treatment consists of broad-spectrum antibiotics, surgical debridement of necrotic tissue, and surgical drainage. Hyperbaric oxygen therapy is not a mainstay of treatment, but it can be beneficial and reduce mortality. (J Urol 1997;158[3 Pt 1]:837.) Primary closure of the skin is done once granulation tissue begins to form after surgical debridement. Depending on the amount of debridement, local skin flap coverage or skin grafts can be used for closure of surgical site. Differential diagnosis of Fournier’s gangrene includes cellulitis, abscess, hernia, hydrocele, orchitis, testicular torsion, balanitis, fungal infections, and vulvovaginitis. Patients should have appropriate surgical and urological follow-up.
Dr. Elfond is the associate medical director and director of Academic Affairs in the Department of Emergency Medicine at Nassau University Medical Center in East Meadow, NY. Dr. Kelly works at Premier Care, an urgent care office in New York.
Wednesday, January 07, 2015
By Tamara Halaweh, MD, & Ashish Panchal, MD
A 53-year-old man with fair control of his diabetes presented with three-and-a-half weeks of scrotal pain. He reported difficulty sitting, and complained of significant dysuria and inability to initiate a urine stream. He was also constipated, but had no fevers or chills.
A rectal exam was consistent with an exquisitely tender and boggy prostate and significant perineal tenderness. His labs were consistent with a leukocytosis of 20,000. A CT scan with rectal contrast displayed a prostate abscess measuring 5.6 x 6.2 x 6.1 cm in maximum dimensions with extension into the puborectalis sling.
The patient was given intravenous antibiotics, and had a drain placed by Interventional Radiology transrectally. A total of 120 mL of purulent fluid was aspirated before a 10-French pigtail catheter was inserted using real-time ultrasound guidance. Culture of the aspirate grew methicillin-resistant Staphylococcus aureus (MRSA). The patient received broad-spectrum antibiotic treatment with Zosyn and ciprofloxacin in the hospital, and he did well after a month course of doxycycline. He was admitted two weeks later to the hospital for hyperglycemia and had a repeat CT at that time, which showed resolution of his prostatic abscess, and his perirectal drain was removed.
Prostatitis is a common presentation for emergency physicians, and a large prostate abscess was quite an unexpected finding in this patient with almost a month of symptoms prior to presentation. Prostatic abscesses have been noted in the literature previously, but none with the size demonstrated in this case. Escherichia coli and sexually transmitted infections, especially Neisseria gonorrhea, are described as the most common etiologies of prostatitis. (Harefuah 2008;147:594.) A few case reports have also demonstrated the presentation of emphysematous prostatic abscesses in alcoholic diabetics and grew Klebsiella pneumoniae. (J Infect 2007;54:e51.)
Community-acquired MRSA as the responsible organism in prostatic abscesses is seen in less than five previous case reports. (Int J Case Rep Images 2012;3:20.) Few case reports discuss size and volume of aspirated fluid, with the largest being 50 mL of thick fluid with average of 12 mL depending on abscess size. (Cent European J Urol 2012;65:224; J Ultrasound Med 2000;19:609.)
With the time frame, size, and uncommon bacterial etiology, it is remarkable that the patient did not present with constitutional symptoms or even sepsis in the face of his immunocompromised status. This case provides a humbling example of how an immunocompromised patient could mask a significant infection. Had the emergency physicians treated this patient as uncomplicated prostatitis, he likely would have had a far worse outcome and delayed management.
Considering the presentation of complicated prostatitis, emergency physicians need to pay particular attention to a number of signs and symptoms that may indicate a possible deep space abscess. Diagnosis of this process is often difficult because it mimics lower urinary tract infections. Possible deep space infection are indicated not just by the common complaint of tender prostate but also by associated complaints of dysuria, fever, new onset symptoms of benign prostatic hypertrophy (hesitancy, weakened stream), and generalized perineal pain. (Harefuah 2008;147:594.)
The patient did well with proper drainage and follow-up despite his late presentation. In-hospital broad-spectrum antibiotic treatment and outpatient treatment with doxycycline, with known penetration to the prostate, treated the infection to complete resolution in two weeks.
Dr. Halaweh is a third-year emergency medicine resident at the Wexner Medical Center at the Ohio State University, and Dr. Panchal is an assistant professor of emergency medicine, also at Wexner Medical Center.
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