Journal of the American College of Emergency Physicians open最新文献

A 32-year-old man presented to the emergency department with a new rash on his left hand that has a clear discharge. He was employed at a livestock slaughterhouse and did not wear gloves when handling animals. The most common animals he was in contact with were sheep and goats. The rash was only in one location, between his third and fourth digit on his left hand (Figures 1 and 2) and worsened over the previous 4 days. The blister is approximately 1 cm × 1 cm × 1 cm and tender to touch. He denied any fevers, chills, or additional rashes. Due to the uniqueness of the patient's profession, dermatology was consulted and a shave biopsy was performed.

The patient was ultimately diagnosed with Orf virus based on clinical presentation alone. Tissue biopsy showed epidermal hyperplasia with vacuolated cytoplasm and eosinophilic inclusion bodies in upper epidermal keratinocytes, ulceration, and mixed inflammatory infiltrate, which aligned with the clinical diagnosis of Orf. Orf is caused by the Parapoxvirus and is often self-limiting, lasting around 4–6 weeks. It is found in people who have direct contact with animals, most commonly farms. Treatment is mainly supportive, cleaning the wound with soap and water, and keeping the wound dry and covered with a bandage. It is important to keep zoonotic diseases on the differential of rash.

A 38-year-old man presented to the emergency department (ED) with a 1-week history of left eye pain and redness (Figures 1-3). The eye pain radiated to his left forehead and was temporarily relieved by ibuprofen. He denied any associated change in his vision. On examination, his eye was diffusely injected, most prominently on the superior and lateral aspects. Instillation of 2.5% phenylephrine eye drops did not significantly change the injection.

Scleritis is a rare, vision-threatening inflammation of the sclera. It occurs most commonly in the middle-aged, with women more commonly affected.¹ Up to 50% of cases of scleritis occur in the setting of systemic autoimmune disease, most commonly rheumatoid arthritis.² Scleritis may be due to infectious causes, medication-induced, or occurring after intraocular surgery, and many cases are idiopathic.²

Patients with scleritis present with an injected, painful eye. The eye pain may radiate to the jaw, forehead or scalp, and is typically worse at night.³ The involved eye is usually diffusely injected, though the injection may be localized and nodular in appearance.⁴ As with this case, installation of topical vasoconstrictor agents such as phenylephrine will not cause a blanching of the injected vessels with scleritis, as it would with conjunctivitis and episcleritis. Further evaluation and treatment of scleritis in the ED should ideally be discussed with an ophthalmologist and may include investigations for rheumatologic and infectious etiologies. Oral nonsteroidal anti-inflammatory drugs and topical corticosteroids are considered first-line therapy for cases of noninfectious scleritis such as this.

A 35-year-old man with alcohol abuse presented to the emergency department with a 7-day history of cough and left-sided flank pain. His temperature, pulse rate, and blood pressure were 38.1°C, 104 beats/min, and 134/92 mmHg, respectively. Based on physical examination, his breath sounds were smooth without crackles; whereas, the left flank region was tender to palpation. His white blood cell count, platelet count, and C-reactive protein were 17,740/µL, 1101 × 10³ mm, and 18.5 mg/dL, respectively. An emergency physician performed ultrasonography revealing heterogeneous echoic lesions in the spleen (Figure 1), and the diagnosis was confirmed by computed tomography (Figure 2).

The patient received antibiotic treatment (moxifloxacin), laparoscopic splenectomy, and pus drainage by a surgeon (Figure 3). The tissue culture of the spleen grew Streptococcus constellatus.

Splenic abscess is an uncommon life-threatening disease, with incidence ranging from 0.14% to 0.7%. However, the patients are at high risk of mortality if appropriate treatment is not administered. The clinical presentation of fever, left upper quadrant tenderness, and leukocytosis is not usually present. It potentially causes misdiagnosis in patients presenting with nonspecific symptoms, such as cough, abdominal pain, back pain, and malaise.¹ Splenectomy is the gold standard treatment for splenic abscess. Percutaneous drainage can be an alternative therapy in patients with high surgical risk.²

The authors declare no conflicts of interest.

A 50-year-old man presented at the emergency department (ED) with pain in the right iliac fossa (RIF) for 10 days associated with nausea, vomiting, fever, and dysuria. On admission examination, he was afebrile, anicteric, with negative Giordano's sign, and there was severe tenderness on deep palpation of the RIF. His vital signs were normal. Blood tests revealed elevated leukocytosis, no anemia, normal kidney function, amylase, and lipase level. A computed tomography (CT) scan of the abdomen was performed showing the presence of a foreign body (FB), a fishbone, inside cecal appendix, with the formation of an abscess (Figure 1). An open appendectomy was performed, with signs of perforation. The patient was discharged 5 days after surgery.

FB ingestion is a common condition at ED, mainly among children (80% cases).^{1, 2} In appendix, the FB can cause acute appendicitis, perforations, periappendiceal abscess, and peritonitis.³ Although fishbone is one of the most ingested FB, it rarely causes perforation of the appendix.⁴ Ingested fishbone can get impacted in any part of the digestive tract and cause serious complications (perforation, abscess, and tract obstruction). Due to poor peristaltic movement, the appendix is unable to expel the FB back to the cecum, leading progressively to inflammation with a high risk of appendix perforation.⁵ CT scan has high sensitivity and specificity to detect fishbone showing as a linear calcified object surrounded by inflammation.⁶ Surgical treatment is the best management in the case of fishbone-induced appendicitis.⁷

The authors declare no conflicts of interest.

A 22-year-old man presented to the emergency department with new left hip pain and chronic firmness after a fall. He has a history of multiple traumatic injuries and quadriplegia secondary to a motor vehicle accident 8 months prior. Examination reveals a firm, irregularly shaped left thigh with mild tenderness to the hip and thigh.

X-ray of the left hip shows extensive bulky heterotopic ossifications, and a computed tomography scan shows myositis ossificans about the left iliopsoas bursa (Figures 1 and 2). Prior to discharge, the patient was counseled on the importance of continuing physical therapy, the use of nonsteroidal anti-inflammatory drugs (NSAIDs) for symptomatic management, and the importance for a follow-up outpatient x-ray.

Heterotopic ossificans refers to bone deposition within soft tissue, with myositis ossificans specifically referring to muscle. This can occur in up to half of spinal cord injury patients, most commonly 12 weeks after injury.¹ Plain radiographs are of low utility early on, as calcification may take months to appear. Early ultrasound² or triple phase bone scan has high reliability as a diagnostic method. Treatment modalities include range of motion exercises to support joint mobility and NSAIDs. More recently, bisphosphonates have shown utility in halted progression of ossification.³ Surgery remains an option for refractory cases, but recurrence is common.

A 73-year-old patient presented to the emergency department after a fall from a 3-m height, complaining of headache and light pain in the abdomen. Upon examination his vital signs were stable, his abdomen tender, and a small hematoma was observed in the left hemiabdomen. Laboratory results showed a normal bleeding profile and leukocytosis. Ultrasound examination demonstrated hyperechoic mesenteric fat. Head computed tomography (CT) showed no signs of trauma. Contrast-enhanced CT of the abdomen revealed the Janus sign (Figure 1), the complete cutoff sign (Figures 2 and 3), free fluid, and small gas particles.

The patient underwent immediate surgery: jejunal resection and sigmoid resection with terminal colostomy were performed. He recovered well and was discharged in good condition. Closing of the colostomy is planned for the end of the year.

Bowel injury is rare in blunt abdominal trauma, often presenting with few signs and symptoms.¹ CT is the primary imaging modality for evaluating these patients.² Bowel transection is the most severe form of bowel trauma, and the findings include the Janus sign—specific for small bowel transection, representing a hyper enhancing loop continuous with a loop that shows no or decreased enhancement, as well as the complete cutoff sign—the circular disruption of the bowel wall, specific of both small and large bowel transection.³ Knowledge and prompt observance of these signs, as well as of nonspecific findings, such as pneumoperitoneum or free fluid, is the key to the correct diagnosis and timely surgical treatment.

The authors declare they have no conflicts of interest.