JEM reports最新文献

Background

Prostate abscess differs from prostatitis as a complicated infection requiring appropriate early treatment. It typically presents with urinary symptoms plus rectal or pelvic pain in middle-aged or older men. Diabetic, immunosuppressed, or patients with urological procedures are at higher risk for serious infection. If untreated, prostate abscess can progress to critical illness including sepsis and death, thus early diagnosis and treatment is key.

Case report

A middle-aged male with diabetes, hypertension, emphysema, and hypothyroidism presented with severe constipation for one week but no urinary symptoms, fever, or vomiting. On examination, he had mild abdominal distension without tenderness, decreased bowel sounds, and a normal external rectal exam. Computed tomography scan demonstrated prostatomegaly and a large 5.2cm prostate abscess with multiple lobulations causing mass effect on the distal colon, thus blood cultures were sent, intravenous antibiotics started, and urology consulted. The patient was admitted for continued antibiotic treatment and underwent surgical transurethral resection with urology the next day. A foley catheter was maintained for seven days, with improvement until hospital discharge 3 days later, with oral antibiotics and close urology clinic follow up.

Why should an emergency medicine physician be aware of this?

Prostate abscess is difficult to diagnose clinically and can lead to severe illness without early recognition and treatment. Patients may present with pelvic or rectal pain plus fever or urinary symptoms. Urgent antibiotic therapy is key, and many patients require urology consultation for surgical or procedural management.

Background

Eczema Herpeticum (EH) is a dermatological emergency that may progress to viral meningitis in patients not treated urgently. We present a case of recurrent EH in a young, immunocompetent patient complicated by progressing herpetic meningitis and staphylococcal bacteremia.

Case report

Our patient was a 20-year-old male intercollegiate athlete with a past medical history of atopic dermatitis (AD) who presented with photophobia, purulence in the medial left eye, and a painful rapidly worsening acute rash for two days. Polymerase chain reaction was performed on the cerebrospinal fluid and vesicular drainage. Both tested positive for herpes simplex virus type 1 (HSV-1), confirming the suspected diagnosis of EH. Blood culture returned positive for Staphylococcus aureus believed to be contracted through the breaks in his skin. He received intravenous normal saline, ceftriaxone, and acyclovir. He was hospitalized for 9 days before being discharged with oral acyclovir. Our patient returned to the emergency department one month later with a milder case of EH. Intravenous acyclovir was started, and the patient was discharged the next day with 1 g oral valacyclovir twice daily.

Why should an emergency physician be aware of this?

It is crucial to establish a previous history of HSV-1 infection and recognize cutaneous presentations of EH in order to initiate early empiric antiviral therapy. The emergency physician must be hypervigilant and aggressively pursue diagnosis and treatment of suspected HSV-1 and -2 infections when confronted with an inexplicably worsening vesicular rash in a patient with AD. Delay in treatment can significantly worsen prognosis and lead to mortality.

Background

Pleural effusions are common problems for the emergency medicine physician and may require emergent therapeutic thoracentesis to prevent respiratory failure. Rarely, a pleural fluid collection may in fact be a spontaneous hemothorax.

Case report

A 22-year-old man presented to the emergency department with chest pain. He had a history of end-stage renal disease (ESRD) as a result of minimal change disease. The patient was in visible respiratory distress with absent breath sounds in the right chest. A chest x-ray revealed a large pleural effusion with mediastinal shift. Emergent thoracentesis relieved the patient’s symptoms, but the pleural fluid was grossly bloody. The patient’s cell counts and PT/PTT were normal. His thromboelastography (TEG) was borderline abnormal. The patient required video-assisted thoracoscopic surgery (VATS) for debulking and removal of the hemothorax. Otherwise, he had an unremarkable recovery. There was no obvious cause of the hemothorax. Clinicians must be wary that in patients with ESRD on hemodialysis, a pleural effusion may be in fact a spontaneous hemothorax. Why should an emergency medicine physician be aware of this? Patients with ESRD may present with massive spontaneous hemothorax that requires emergent thoracostomy and operative management. Emergency medicine physicians should be knowledgeable about the causes and work-up of patients with spontaneous hemothorax.

Background

Nerve hydrodissection (HD) has previously been described as a treatment for carpal tunnel syndrome and other musculoskeletal disorders; however, its use in the treatment of occipital neuralgia (ON) has rarely been reported. This is the first report of HD used to treat ON in the emergency department (ED).

Case report

A 34-year-old male presented to the ED with a 3-month history of posterior neck and scalp pain consistent with ON. He failed multiple outpatient therapies including oral medication and trigger point injections. An ultrasound (US)-guided HD of the greater occipital nerve (GON) was performed successfully. A 25 g needle was inserted in-plane and a solution of 9 mL normal saline and 1 mL 1 ​% lidocaine was injected within the fascial plane containing the GON until muscle layer separation was achieved.

Why should an emergency physician be aware of this? A case of refractory ON failing conventional therapy was successfully treated in the ED using US-guided nerve HD.

Background

Foreign body (FB) ingestion is a common presentation in the emergency department (ED). Point-of-care ultrasound (PoCUS) is useful for detecting ingested foreign bodies in pediatrics. However, its utility for diagnosing FB ingestions in adult patients has not been well described.

Case report

We present a case of a 52-year-old female patient who presented to our ED with right upper abdominal pain. A PoCUS revealed a long echogenic structure between the gastric pylorus and the gallbladder wall. The appearance raised suspicion for a foreign body perforating through the gastric wall. A CT scan confirmed the diagnosis of a fishbone perforating through the gastric wall. The patient underwent exploratory laparoscopic surgery that confirmed the perforation. The fishbone was removed endoscopically, and the patient made an unremarkable recovery.

Why should an emergency physician be aware of this?

Foreign body ingestion is an important cause of abdominal pain in the ED and can lead to significant morbidity if there is a delay in diagnosis. Some patients may not be aware that they ingested a foreign body. Identification of an abnormal echogenic structure in the abdomen at the site of tenderness should prompt further investigation and consultation.

Background

Bacterial pericarditis is a rare cause of pericardial disease, with purulent pericarditis making up less than 1 ​% of bacterial cases worldwide.

Case report

We report the case of a 52-year-old male with diabetes and end-stage renal disease on dialysis who presented for chest pain with an electrocardiogram concerning for myocardial ischemia. He was found to have a large pericardial effusion with heterogenous material and signs of sonographic tamponade on bedside ultrasound. His vital signs did not have any fever, tachycardia, or hypotension. His physical examination was negative for diminished heart sounds or jugular venous distension. He underwent a pericardiocentesis that grew staphylococcus aureus and was found to have a mediastinal abscess that required excision.

“Why should an emergency physician be aware of this?”

Bedside point-of-care transthoracic echocardiography can diagnose purulent pericarditis in the absence of clinical examination findings, electrocardiogram changes, or vital sign abnormalities.

Background

Carbon monoxide (CO) poisoning is associated with high morbidity and mortality. Diagnosis can be challenging for the encountering physician due to vague and nonspecific presenting signs and symptoms. Confirmatory testing is typically prompted by historical information identifying a key exposure or risk factor.

Case report

A patient presented to the emergency department after having a seizure. The patient was diagnosed with CO poisoning, with a carboxyhemoglobin level of >20.9 ​%, caused by unintentional exposure to motor vehicle exhaust while idling in his car after his catalytic converter was stolen. The patient was transferred to a hospital with the capacity for treatment with hyperbaric oxygen.

Why should an emergency physician be aware of this? Increasing prevalence of catalytic converter theft puts people at risk for CO poisoning. Emergency physicians should consider CO poisoning broadly, especially in urban environments with high rates of petty crime.

Background

The ultrasound guided popliteal sciatic block is a nerve block commonly used for pain control in the setting of distal tibia and/or fibular fractures, ankle reductions, Achilles tendon ruptures, and injuries to the lateral/posterior calf (burns, abscesses, or lacerations. In the Emergency Department, this block is classically performed by positioning the patient in a lateral or prone position. Unfortunately, in the acute setting, patient repositioning is often not possible secondary to pain, limiting the use of this block. In this case series, we describe a novel approach to the popliteal sciatic nerve block that allows the patient to remain in the supine position and enter from a crosswise approach.

Case report

This paper describes three cases, all which have painful complaints in the distribution of the popliteal sciatic nerve. In the first case, the patient has a bimalleolar ankle fracture. In the second, the patient has second degree burns that get contaminated and need decontamination. In the third, the patient has an unstable ankle fracture but will not accept opiates. In each, the presentation limits the provider’s ability to reposition the patient therefore this novel, crosswise approach to the popliteal sciatic nerve block allows optimal care without painful repositioning.

Why should an emergency physician be aware of this?

While further research is still needed on the crosswise approach to the popliteal sciatic nerve block, it offers a novel approach to this classic block without the need for patient repositioning.

Background

Hypokalemia is a common problem encountered in the emergency department. Severe cases of hypokalemia are associated with increased morbidity and mortality. ECG is an immediately-available test that can clinch the diagnosis, leading to immediate intervention. The trick is to differentiate ECG changes of severe hypokalemia from severe ischemia.

Case report

We here present a case of a middle-aged woman whose ECG showed sinus tachycardia with atrioventricular block, then supraventricular tachycardia with marked ischemic changes due to severe hypokalemia. Potassium level was 1.1 mEq/L. The ECG could have been mistaken for a high-risk, acute myocardial infarction due to severe left main and/or multi-vessel coronary artery disease. After initial potassium replenishment, classic text-book findings of hypokalemia became apparent. Troponin was mildly positive, however clinical presentation, the absence of chest pain, and confirmatory laboratory results led to the accurate decision not to activate a “Code STEMI” An echocardiogram done later showed no wall motion abnormalities. Supraventricular tachycardia terminated spontaneously. An ECG done after correction of hypokalemia was normal. No Q waves were noted.

Why should an emergency physician be aware of this?

Emergency department physicians, cardiologists, and internists, among other physicians should be aware of the recently-described pattern of diffuse ST segment depression and ST segment elevation due to severe hypokalemia. This will lead to accurate measuring decisions by treating hypokalemia and avoiding activating the catheterization laboratory, performing an unnecessary intervention.