scholarly journals A discrepant presentation of bacteremia in the emergency department linked to a Fusobacterium nucleatum infection: a case report

2022 ◽  
Vol 16 (1) ◽  
Author(s):  
Johnny Michel ◽  
Luc-Marie Joly ◽  
Virginie Eve Lvovschi
Keyword(s):  
Emergency Department ◽  
Antibiotic Therapy ◽  
Fusobacterium Nucleatum ◽  
The Elderly ◽  
Final Diagnosis ◽  
Early Discharge ◽  
Metastatic Infection ◽  
Physiological Serum ◽  
Oropharyngeal Infection ◽  
Transient Improvement

Abstract Background Fusobacterium nucleatum is an anaerobic bacterium mainly responsible for acute or chronic infection of the ear, nose, and throat, potentially bacteremic with a risk of extraoral metastatic infection. Bacteremia occurs mainly in the elderly or in immunodeficient individuals, with high mortality. F. nucleatum is not the first cause of tonsillar infection in emergency departments, which are more often the consequence of a viral or streptococcal infection, but it is a risk factor for severe bacterial infection, especially in a viral pandemic context. Case presentation A 25-year-old European woman with no history presented to the emergency department with fever (38.9 °C), pharyngeal symptoms, intermittent headaches, and alteration of general condition. On examination, she presented odynophagia associated with moderate tonsillar hypertrophy, her neck was painful but flexible. A rapid diagnostic test for beta-hemolytic group streptococcus was negative. First biological analyses revealed an inflammatory syndrome with C-reactive protein of 76 mg/L. Procalcitonin was measured secondarily, and was 2.16 µg/L. Faced with discordant clinical and biological findings, a lumbar puncture was performed, which came back negative. At hour eight, hypotension was observed but corrected after filling with physiological serum. The patient was hospitalized for monitoring, based on a hypothesis of severe viral presentation. At hour 24, pyrexia confirmed this hypothesis. A spontaneous but transient improvement and no new hemodynamic event led to early discharge. At day three, she was rehospitalized for increased and continuous headaches, without hemodynamic severity. A broad-spectrum probabilistic antibiotic therapy of ceftriaxone and metronidazole was started due to first blood cultures positive for anaerobic Gram-negative bacilli, while waiting for identification of the pathogen. Three days later, F. nucleatum was identified. According to the microbiological results, antibiotic therapy was adapted with amoxicillin and clavulanic acid, and no further complications were observed during clinical or complementary examinations. The final diagnosis was a F. nucleatum oropharyngeal infection complicated by bacteremia, without metastatic spread. Conclusion The etiologies of tonsillar infection are not limited to benign viruses or bacteria. These should not be overlooked in emergency medicine, especially when the clinical presentation is discrepant. A combination of early bacterial investigations as blood culture and close clinical monitoring is the only safe way to detect bacteremia, especially in immunocompetent patients.

Salicylate toxicity from chronic bismuth subsalicylate use

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.

scholarly journals Multicenter Trial of Rivaroxaban for Early Discharge of Pulmonary Embolism From the Emergency Department (MERCURY PE): Rationale and Design

2016 ◽  
Vol 23 (11) ◽  
pp. 1280-1286 ◽  
Author(s):  
Adam J. Singer ◽  
Jim Xiang ◽  
Christopher Kabrhel ◽  
Gino J. Merli ◽  
Charles Pollack ◽  
...  
Keyword(s):  
Emergency Department ◽  
Pulmonary Embolism ◽  
Early Discharge ◽  
Multicenter Trial

scholarly journals Diagnostic Accuracy of Neurological Problems in the Emergency Department

2008 ◽  
Vol 35 (3) ◽  
pp. 335-341 ◽  
Author(s):  
Jeremy J Moeller ◽  
Joelius Kurniawan ◽  
Gordon J Gubitz ◽  
John A Ross ◽  
Virender Bhan
Keyword(s):  
Emergency Department ◽  
Diagnostic Accuracy ◽  
Tertiary Care ◽  
Retrospective Chart Review ◽  
Primary Headache ◽  
Final Diagnosis ◽  
Initial Diagnosis ◽  
Educational Strategies ◽  
Diagnostic Uncertainty ◽  
Peripheral Vertigo

Background:Previous studies describe significant rates of misdiagnosis of stroke, seizure and other neurological problems, but there are few studies examining diagnostic accuracy of all emergency referrals to a neurology service. This information could be useful in focusing the neurological education of physicians who assess and refer patients with neurological complaints in emergency departments.Methods:All neurological consultations in the emergency department at a tertiary-care teaching hospital were recorded for six months. The initial diagnosis of the requesting physician was recorded for each patient. This was compared to the initial diagnosis of the consulting neurologist and to the final diagnosis, as determined by retrospective chart review.Results:Over a six-month period, 493 neurological consultations were requested. The initial diagnosis of the requesting physician agreed with the final diagnosis in 60.4% (298/493) of cases, and disagreed or was uncertain in 35.7% of cases (19.1% and 16.6% respectively). In 3.9% of cases, the initial diagnosis of both the referring physician and the neurologist disagreed with the final diagnosis. Common misdiagnoses included neurocardiogenic syncope, peripheral vertigo, primary headache and psychogenic syndromes. Often, these were initially diagnosed as stroke or seizure.Conclusions:Our data indicate that misdiagnosis or diagnostic uncertainty occurred in over one-third of all neurological consultations in the emergency department setting. Benign neurological conditions, such as migraine, syncope and peripheral vertigo are frequently mislabeled as seizure or stroke. Educational strategies that emphasize emergent evaluation of these common conditions could improve diagnostic accuracy, and may result in better patient care.

scholarly journals Is Procalcitonin-Guided Antibiotic Therapy Working in Emergency Department Outpatients?

2018 ◽  
Vol 72 (2) ◽  
pp. 226-228 ◽  
Author(s):  
Rebekka Bolliger ◽  
Meret Merker ◽  
Yannick Wirz ◽  
Beat Mueller ◽  
Philipp Schuetz
Keyword(s):  
Emergency Department ◽  
Antibiotic Therapy

scholarly journals Randomised controlled trial of the Limit of Detection of Troponin and ECG Discharge (LoDED) strategy versus usual care in adult patients with chest pain attending the emergency department: study protocol

BMJ Open ◽  
2018 ◽  
Vol 8 (10) ◽  
pp. e025339 ◽  
Author(s):  
Edward Carlton ◽  
Sarah Campbell ◽  
Jenny Ingram ◽  
Rebecca Kandiyali ◽  
Hazel Taylor ◽  
...  
Keyword(s):  
Emergency Department ◽  
Chest Pain ◽  
Randomised Controlled Trial ◽  
Limit Of Detection ◽  
Controlled Trial ◽  
High Sensitivity ◽  
Early Discharge ◽  
High Sensitivity Troponin ◽  
Randomised Controlled ◽  
Rule Out

IntroductionObservational data suggest a single high-sensitivity troponin blood test taken at emergency department (ED) presentation could be used to rule out major adverse cardiac events (MACE) in 10%–60% of ED patients with chest pain. This is done using an ‘undetectable’ cut-off (the Limit of Detection: LoD). We combined the LoD cut-off with ECG findings to create the LoDED strategy. We aim to establish whether the LoDED strategy works under real-life conditions, when compared with existing strategies, in a way that is cost-effective and acceptable to patients.Methods and analysisThis is a parallel-group pragmatic randomised controlled trial across UK EDs. Adults presenting to ED with suspected cardiac chest pain will be randomised 1:1. Existing rule-out strategies in current use across study centres, using serial high-sensitivity troponin testing, will be compared with the LoDED strategy. The primary outcome is successful early discharge (discharge from hospital within 4 hours of arrival) without MACE occurring within 30 days. Secondary outcomes include initial length of hospital stay; comparative costs; patient satisfaction and acceptability to patients. To detect a 9% difference between the early discharge rates (assuming an 8% rate in the standard care group) with 90% power, 594 patients need to be recruited, assuming a 95% follow-up rate.Ethics and disseminationThe study has been approved by the Frenchay Research Ethics Committee (reference 18/SW/0038). Results will be published in an international peer-reviewed journal. Lay summaries will be made available to patients.Trial registration numberISRCTN86184521; Pre-results.

How to use C-reactive protein

2018 ◽  
Vol 104 (3) ◽  
pp. 150-153
Author(s):  
Emma M Dyer ◽  
Thomas Waterfield ◽  
Hannah Baynes
Keyword(s):  
Emergency Department ◽  
Clinical Practice ◽  
Antibiotic Therapy ◽  
Inflammatory Markers ◽  
Biochemical Test ◽  
Current Evidence ◽  
C Reactive Protein ◽  
Paediatric Emergency Department ◽  
Reactive Protein ◽  
Paediatric Emergency

A 3-month-old baby is brought to the paediatric emergency department by their parents because of a fever. You decide to check their inflammatory markers. Their C-reactive protein (CRP) level comes back as 20 mg/L. Does this affect whether or not you start antibiotic therapy? Does it influence your decision to admit or discharge the patient? CRP is a commonly used biochemical test and yet its use is constantly debated and challenged. We look at the current evidence and suggest the best way to use this test in clinical practice.

Abstract WP245: Hyperacute Blood Pressure Variability is Associated with Early Neurological Deterioration

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Joseph Kim ◽  
Jeffrey L Saver ◽  
David S Liebeskind ◽  
Sidney Starkman ◽  
Scott Hamilton ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Emergency Department ◽  
Cerebral Ischemia ◽  
Acute Stroke ◽  
Symptom Onset ◽  
Blood Pressure Variability ◽  
Final Diagnosis ◽  
Controlled Study ◽  
Double Blind ◽  
Neurologic Deterioration

Background: Increased blood pressure variability (BPV) has been associated with worse outcomes in acute stroke. The effect of hyperacute (<4 hours) BPV on early neurologic deterioration (END) has not been described. Objective: To investigate whether BPV in the first hours after stroke onset is associated with END from prehospital evaluation to presentation at the emergency department Methods: All patients enrolled in the NIH Field Administration of Stroke Therapy-Magnesium (FAST-MAG) phase 3 trial were included. FAST-MAG was a multicenter, randomized, double-blind, placebo-controlled study looking at whether initiation of magnesium sulfate (20 grams/24 hours) in the prehospital setting of acute stroke would reduce disability. Study agent was initiated prior to hospital arrival < 2 hours from symptom onset. BPV was defined as the standard deviation of systolic blood pressure of all readings obtained by 4 hours after initiation of study agent. END was diagnosed as Glasgow Coma Scale (GCS) decrease by ≥ 2 points between the prehospital evaluation and post-emergency department arrival assessment by a study nurse. Results: There were 1,700 cases evaluated by paramedics 24 minutes (15-45 IQR), and by study nurses 150 minutes (120-180) after symptom onset with a median of 6 (IQR 5-6) BP readings. The mean (±SD) age was 69±13 years, 42.6% were women, and the median prehospital GCS was 15 (IQR 14-15). The final diagnosis was cerebral ischemia in 73.3% of patients, intracranial hemorrhage in 22.8%, and a stroke-mimicking condition in 3.9%. END was seen in 202 (12%) of subjects, with higher rates noted in those with intracerebral hemorrhage (ICH) compared to cerebral ischemia (31% vs 6%). Overall, there was greater BPV in patients with END (23mmHg vs 15mmHg, p<0.001). Blood pressure variability was greater in cases of cerebral ischemia with END (N=1,245, 18mmHg vs 15mmHg, p=0.004) and in ICH cases with END (N=387, 23mmHg vs 15mmHg, p<0.001). Conclusion: Greater blood pressure variability is associated with early neurologic deterioration in patients with cerebral ischemia and ICH evaluated <2 hours from symptom onset.

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