A Pacchionian Puzzle

A 73-year-old male with a history of chronic ataxia presented with transient facial droop to the Emergency Department. A CT angiogram and MRI with diffusion weighted imaging (DWI) were negative for stroke. However, incidental note was made of numerous giant arachnoid granulation pits in the posterior fossa predominantly involving the left occipital bone (Figure 1). These arachnoid pits demonstrated multiple foci of herniation of the adjacent cerebellar parenchyma into the pits with gliosis of the herniated parenchyma and focal encephalomalacia of the subjacent cerebellar parenchyma. Review of bone windows on a remote CT brain performed almost 13 years earlier confirmed this to be a longstanding abnormality (Figure 2). The patient’s physical exam was suggestive of cerebellar ataxia with left-sided dysmetria on finger to nose testing and a wide-based unsteady gait.

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Pulmonary embolism as the primary presentation of IgA vasculitis

BMJ Case Reports ◽

10.1136/bcr-2020-235884 ◽

2020 ◽

Vol 13 (8) ◽

pp. e235884

Author(s):

Osama Mosalem ◽

Nora Hernandez Garcilazo ◽

Yehia Saleh ◽

Fawzi Abu Rous

Keyword(s):

Emergency Department ◽

Pulmonary Embolism ◽

Acute Onset ◽

Iga Vasculitis ◽

Erythematous Rash ◽

Ct Angiogram ◽

Right Ventricular Strain ◽

History Of ◽

Obstructive Shock ◽

Primary Presentation

A 47-year-old man presented to the emergency department with acute onset of dyspnoea and a week history of painful erythematous rash on both of his legs. CT angiogram of the chest showed saddle pulmonary embolism resulting in right ventricular strain and obstructive shock. Due to the atypical nature of his skin rash, a skin biopsy from one of these lesions was done and came consistent with the diagnosis of IgA vasculitis.

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The “butterfly wings” and midbrain “V” sign of Artery of Percheron infarction

Journal Of Cardiovascular, Neurovascular & Stroke ◽

10.32896/cvns.v3n3.56-58 ◽

2021 ◽

Vol 3 (3) ◽

pp. 56-58

Author(s):

Yong Chuan Chee ◽

Sanihah Abdul Halim

Keyword(s):

Emergency Department ◽

Mental Status ◽

Mri Scan ◽

Verbal Stimuli ◽

Artery Of Percheron ◽

Butterfly Wings ◽

History Of ◽

Ct Brain

An 80-year-old woman with history of hypertension presented to the emergency department following a fall. Her mental status quickly deteriorated and became obtunded. She was stuporous, and unresponsive to verbal stimuli. She had minimally reactive pupils and was moving extremities to painful stimuli. An MRI scan was performed following an unrevealing CT brain.

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I Kneed help!

Pediatric Traumatic Emergencies ◽

10.1093/med/9780190946623.003.0011 ◽

2020 ◽

pp. 89-94

Author(s):

Kristol Das

Keyword(s):

Emergency Department ◽

Natural History ◽

Sensitivity And Specificity ◽

Knee Pain ◽

Physical Exam ◽

Imaging Modalities ◽

X Rays ◽

Case Presentation ◽

History Of

This chapter reviews a case of an adolescent presenting to the emergency department with unilateral knee pain after a traumatic fall. This chapter reviews key history questions, physical exam maneuvers including special tests to examine the knee, the workup and management of this case presentation based on pediatric literature. Specifically, the chapter reviews indications to obtain x-rays versus other imaging modalities and the sensitivity and specificity of special tests based on recent data. Follow-up and subspecialty referral indications for knee pain are also reviewed. Lastly, the epidemiology, pathophysiology, management and natural history of this patient’s unique diagnosis are briefly discussed.

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A Rare Case of Bilateral Incarcerated Obturator Hernias and a Right-Side Femoral Hernia

10.31487/j.jscr.2020.01.03 ◽

2020 ◽

pp. 1-3

Author(s):

Jinping Xu ◽

Ruth Wei ◽

Salieha Zaheer

Keyword(s):

Emergency Department ◽

Abdominal Pain ◽

Femoral Hernia ◽

Rare Case ◽

Hernia Recurrence ◽

High Morbidity ◽

Diagnostic Challenge ◽

Abdominal Ct ◽

Abdominal Ct Scan ◽

History Of

Obturator hernias are rare but pose a diagnostic challenge with relatively high morbidity and mortality. Our patient is an elderly, thin female with an initial evaluation concerning for gastroenteritis, and further evaluation revealed bilateral incarcerated obturator hernias, which confirmed postoperatively as well as a right femoral hernia. An 83-year-old female presented to the outpatient office initially with one-day history of diarrhea and one-week history of episodic colicky abdominal pain. She returned 4 weeks later with diarrhea resolved but worsening abdominal pain and left inner thigh pain while ambulating, without changes in appetite or nausea and vomiting. Abdominal CT scan then revealed bilateral obturator hernias. Patient then presented to the emergency department (ED) due to worsening pain, and subsequently underwent hernia repair. Intraoperatively, it was revealed that the patient had bilateral incarcerated obturator hernias and a right femoral hernia. All three hernias were repaired, and patient was discharged two days later. Patient remained well postoperatively, and 15-month CT of abdomen showed no hernia recurrence.

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A141 SPONTANEOUS ESOPHAGEAL PERFORATION: AN UNREPORTED COMPLICATION OF LYMPHOCYTIC ESOPHAGITIS

Journal of the Canadian Association of Gastroenterology ◽

10.1093/jcag/gwab002.139 ◽

2021 ◽

Vol 4 (Supplement_1) ◽

pp. 128-129

Author(s):

A LAGROTTERIA ◽

A W Collins ◽

A Someili ◽

N Narula

Keyword(s):

Computed Tomography ◽

Emergency Department ◽

Case Report ◽

Proton Pump Inhibitor ◽

Proton Pump ◽

Esophageal Perforation ◽

Distal Esophagus ◽

Chest Discomfort ◽

History Of ◽

Lymphocytic Esophagitis

Abstract Background Lymphocytic esophagitis is a new and rare clinicopathological entity. It is a histological pattern characterized by lymphocytic infiltrate without granulocytes. Its etiology and clinical significance remains unclear. The clinical manifestations are typically mild, with reflux and dysphagia the most commonly reported symptoms. Aims We describe a case report of spontaneous esophageal perforation associated with lymphocytic esophagitis. Methods Case report Results A previously well 31-year-old male presented to the emergency department with acute food impaction. His antecedent symptoms were acute chest discomfort and continuous odynophagia following his most recent meal, with persistent globus sensation. The patient had no reported history of allergies, atopy, rhinitis, or asthma. A previous history of non-progressive dysphagia was noted after resuscitation. Emergent endoscopy revealed no food bolus, but a deep 6 cm mucosal tear in the upper-mid esophagus extending 24 to 30 cm from the incisors. Chest computed tomography observed small volume pneumoperitoneum consistent with esophageal perforation. The patient’s recovery was uneventful; he was managed conservatively with broad-spectrum antibiotics, proton pump inhibitor therapy, and a soft-textured diet. Endoscopy was repeated 48 hours later and revealed considerable healing with only a residual 3-4cm linear laceration. Histology of biopsies taken from the mid and distal esophagus demonstrated marked infiltration of intraepithelial lymphocytes. There were no eosinophils or neutrophils identified, consistent with a diagnosis of lymphocytic esophagitis. Autoimmune indices including anti-nuclear antibodies and immunoglobulins were normal, ruling out a contributory autoimmune or connective tissue process. The patient was maintained on a proton pump inhibitor (pantoprazole 40 mg once daily) following discharge. Nearly six months following his presentation, the patient had a recurrence of symptoms prompting representation to the emergency department. He described acute onset chest discomfort while eating turkey. Computed tomography of the chest redemonstrated circumferential intramural gas in the distal esophagus and proximal stomach. Conclusions Esophageal perforation is a potentially life-threatening manifestation of what had been considered and described as a relatively benign condition. From isolated dysphagia to transmural perforation, this case significantly expands our current understanding of the clinical spectrum of lymphocytic esophagitis. Funding Agencies None

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Red Blood Cell Transfusion in the Emergency Department: An Observational Cross-Sectional Multicenter Study

Journal of Clinical Medicine ◽

10.3390/jcm10112475 ◽

2021 ◽

Vol 10 (11) ◽

pp. 2475

Author(s):

Olivier Peyrony ◽

Danaé Gamelon ◽

Romain Brune ◽

Anthony Chauvin ◽

Daniel Aiham Ghazali ◽

...

Keyword(s):

Emergency Department ◽

Logistic Regression ◽

Blood Cell ◽

Red Blood Cell ◽

Cross Sectional Study ◽

Red Blood Cell Transfusion ◽

Cross Sectional ◽

Acute Bleeding ◽

History Of ◽

Rbc Transfusion

Background: We aimed to describe red blood cell (RBC) transfusions in the emergency department (ED) with a particular focus on the hemoglobin (Hb) level thresholds that are used in this setting. Methods: This was a cross-sectional study of 12 EDs including all adult patients that received RBC transfusion in January and February 2018. Descriptive statistics were reported. Logistic regression was performed to assess variables that were independently associated with a pre-transfusion Hb level ≥ 8 g/dL. Results: During the study period, 529 patients received RBC transfusion. The median age was 74 (59–85) years. The patients had a history of cancer or hematological disease in 185 (35.2%) cases. Acute bleeding was observed in the ED for 242 (44.7%) patients, among which 145 (59.9%) were gastrointestinal. Anemia was chronic in 191 (40.2%) cases, mostly due to vitamin or iron deficiency or to malignancy with transfusion support. Pre-transfusion Hb level was 6.9 (6.0–7.8) g/dL. The transfusion motive was not notified in the medical chart in 206 (38.9%) cases. In the multivariable logistic regression, variables that were associated with a higher pre-transfusion Hb level (≥8 g/dL) were a history of coronary artery disease (OR: 2.09; 95% CI: 1.29–3.41), the presence of acute bleeding (OR: 2.44; 95% CI: 1.53–3.94), and older age (OR: 1.02/year; 95% CI: 1.01–1.04). Conclusion: RBC transfusion in the ED was an everyday concern and involved patients with heterogeneous medical situations and severity. Pre-transfusion Hb level was rather restrictive. Almost half of transfusions were provided because of acute bleeding which was associated with a higher Hb threshold.

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Recurrent noncirrhotic hyperammonemia causing acute metabolic encephalopathy in a patient with a continent ileocecal pouch: a case report

Journal of Medical Case Reports ◽

10.1186/s13256-021-02842-1 ◽

2021 ◽

Vol 15 (1) ◽

Author(s):

T. M. Skipina ◽

S. Macbeth ◽

E. L. Cummer ◽

O. L. Wells ◽

S. Kalathoor

Keyword(s):

Emergency Department ◽

Metabolic Acidosis ◽

Mental Status ◽

Rare Case ◽

Liver Function Tests ◽

Altered Mental Status ◽

Potassium Citrate ◽

Metabolic Encephalopathy ◽

History Of ◽

Normal Urine

Abstract Introduction Acute encephalopathy, while a common presentation in the emergency department, is typically caused by a variety of metabolic, vascular, infectious, structural, or psychiatric etiologies. Among metabolic causes, hyperammonemia is relatively common and typically occurs in the setting of cirrhosis or liver dysfunction. However, noncirrhotic hyperammonemia is a rare occurrence and poses unique challenges for clinicians. Case presentation Here we report a rare case of a 50-year-old Caucasian female with history of bladder cancer status post chemotherapy, radical cystectomy, and ileocecal diversion who presented to the emergency department with severe altered mental status, combativeness, and a 3-day history of decreased urine output. Her laboratory tests were notable for hyperammonemia up to 289 μmol/L, hypokalemia, and hyperchloremic nonanion gap metabolic acidosis; her liver function tests were normal. Urine cultures were positive for Enterococcus faecium. Computed tomography imaging showed an intact ileoceal urinary diversion with chronic ileolithiasis. Upon administration of appropriate antibiotics, lactulose, and potassium citrate, she experienced rapid resolution of her encephalopathy and a significant reduction in hyperammonemia. Her hyperchloremic metabolic acidosis persisted, but her hypokalemia had resolved. Conclusion This case is an example of one of the unique consequences of urinary diversions. Urothelial tissue is typically impermeable to urinary solutes. However, when bowel segments are used, abnormal absorption of solutes occurs, including exchange of urinary chloride for serum bicarbonate, leading to a persistent hyperchloremic nonanion gap metabolic acidosis. In addition, overproduction of ammonia from urea-producing organisms can lead to abnormal absorption into the blood and subsequent oversaturation of hepatic metabolic capacity with consequent hyperammonemic encephalopathy. Although this is a rare case, prompt identification and treatment of these metabolic abnormalities is critical to prevent severe central nervous system complications such as altered mental status, coma, and even death in patients with urinary diversions.

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Salicylate toxicity from chronic bismuth subsalicylate use

BMJ Case Reports ◽

10.1136/bcr-2020-236929 ◽

2020 ◽

Vol 13 (11) ◽

pp. e236929

Author(s):

Sheliza Halani ◽

Peter E Wu

Keyword(s):

Emergency Department ◽

Adverse Effects ◽

Hearing Impairment ◽

Reference Range ◽

The Elderly ◽

Intravenous Fluids ◽

Over The Counter ◽

Bismuth Subsalicylate ◽

Salicylate Concentration ◽

History Of

A 79-year-old man presented to the emergency department with a 1-week history of worsening confusion, falls and hearing impairment. An initial workup for infectious, metabolic and structural causes was unrevealing. However, further history discovered that he had been ingesting one to two bottles of Pepto-Bismol (bismuth subsalicylate) daily for gastro-oesophageal reflux symptoms. On his second day of admission, the plasma salicylate concentration was 2.08 mmol/L (reference range 1.10–2.20 mmol/L), despite no sources of salicylate in hospital. He was diagnosed with chronic salicylate toxicity and Pepto-Bismol use was discontinued. The patient was treated supportively with isotonic intravenous fluids only and plasma salicylate concentration fell to less than 0.36 mmol/L. Concurrently, all his symptoms resolved. This case highlights the potential adverse effects of over-the-counter medications. The diagnosis of chronic salicylate toxicity is challenging, specifically in the elderly and in undifferentiated presentations, as it can be missed if not suspected.

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Classification of paediatric brain tumours by diffusion weighted imaging and machine learning

Scientific Reports ◽

10.1038/s41598-021-82214-3 ◽

2021 ◽

Vol 11 (1) ◽

Author(s):

Jan Novak ◽

Niloufar Zarinabad ◽

Heather Rose ◽

Theodoros Arvanitis ◽

Lesley MacPherson ◽

...

Keyword(s):

Diffusion Coefficient ◽

Apparent Diffusion Coefficient ◽

Posterior Fossa ◽

Brain Tumours ◽

Diffusion Weighted Imaging ◽

Regions Of Interest ◽

Apparent Diffusion Coefficients ◽

Diffusion Weighted ◽

Apparent Diffusion ◽

Paediatric Brain Tumours

AbstractTo determine if apparent diffusion coefficients (ADC) can discriminate between posterior fossa brain tumours on a multicentre basis. A total of 124 paediatric patients with posterior fossa tumours (including 55 Medulloblastomas, 36 Pilocytic Astrocytomas and 26 Ependymomas) were scanned using diffusion weighted imaging across 12 different hospitals using a total of 18 different scanners. Apparent diffusion coefficient maps were produced and histogram data was extracted from tumour regions of interest. Total histograms and histogram metrics (mean, variance, skew, kurtosis and 10th, 20th and 50th quantiles) were used as data input for classifiers with accuracy determined by tenfold cross validation. Mean ADC values from the tumour regions of interest differed between tumour types, (ANOVA P < 0.001). A cut off value for mean ADC between Ependymomas and Medulloblastomas was found to be of 0.984 × 10−3 mm2 s−1 with sensitivity 80.8% and specificity 80.0%. Overall classification for the ADC histogram metrics were 85% using Naïve Bayes and 84% for Random Forest classifiers. The most commonly occurring posterior fossa paediatric brain tumours can be classified using Apparent Diffusion Coefficient histogram values to a high accuracy on a multicentre basis.

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Occupational Sharp Injury and Splash Exposure among Healthcare Workers in a Tertiary Hospital

Journal of Laboratory Physicians ◽

10.1055/s-0041-1731135 ◽

2021 ◽

Author(s):

Roshan Mathew ◽

Ritin Mohindra ◽

Ankit Sahu ◽

Rachana Bhat ◽

Akshaya Ramaswami ◽

...

Keyword(s):

Emergency Department ◽

Hepatitis B ◽

Healthcare Workers ◽

Hepatitis B Surface Antigen ◽

Tertiary Hospital ◽

Needle Stick Injury ◽

Medical Procedures ◽

Immunodeficiency Virus ◽

History Of ◽

Hepatitis C Virus Antibody

Abstract Background Occupational hazards like sharp injury and splash exposure (SISE) are frequently encountered in health-care settings. The adoption of standard precautions by healthcare workers (HCWs) has led to significant reduction in the incidence of such injuries, still SISE continues to pose a serious threat to certain groups of HCWs. Materials and Methods This was a retrospective study which examined the available records of all patients from January 2015 to August 2019 who self-reported to our emergency department with history of sharp injury and/or splash exposure. Details of the patients, mechanism of injury, the circumstances leading to the injury, status of the source (hepatitis B surface antigen, human immunodeficiency virus, and hepatitis C virus antibody status), and the postexposure prophylaxis given were recorded and analyzed. Data were represented in frequency and percentages. Results During the defined period, a total of 834 HCWs reported with SISE, out of which 44.6% were doctors. Majority of the patients have SISE while performing medical procedures on patients (49.5%), while 19.2% were exposed during segregation of waste. The frequency of needle stick injury during cannulation, sampling, and recapping of needle were higher in emergency department than in wards. More than 80% of HCWs received hepatitis B vaccine and immunoglobulin postexposure. Conclusion There is need for periodical briefings on practices of sharp handling as well as re-emphasizing the use of personal protective equipment while performing procedures.

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