Case Reports in Emergency Medicine最新文献

We report the case of a 26-year-old woman with an eight-week history of painfully enlarged cervical lymph nodes, recurrent headache, and malaise. Her medical history was unremarkable. The physical examination showed multiple enlarged cervical lymph nodes. Laboratory examination was unremarkable, and magnetic resonance tomographic imaging showed multiple enlarged cervical lymph nodes with aspect of a lymphoma. Lymph node biopsy revealed Kikuchi-Fujimoto disease, histologically characterized by histiocytic necrotizing lymphadenitis. A therapeutic trial with nonsteroidal anti-inflammatory drugs (NSAID) showed no effect, so steroid therapy was started. Due to relapse of symptoms after steroid withdrawal the tapering regimen was prolonged for a total of seven months.

Massive acetaminophen (N-acetyl-p-aminophenol; APAP) ingestion is characterized by a rapid onset of mitochondrial dysfunction, including metabolic acidosis, lactemia, and altered mental status without hepatotoxicity which may not respond to the standard doses of N-acetylcysteine (NAC). A 64-year-old woman without medical history presented comatose after an ingestion of 208 tablets of Tylenol PM™ (APAP 500 mg and diphenhydramine 25 mg). The initial APAP concentration measured 1,017 µg/mL (therapeutic range 10-30 µg/mL), and elevated anion gap metabolic acidosis, lactemia, and 5-oxoprolinemia were detected. High-dose intravenous (IV) NAC, 4-methylpyrazole (4-MP), and hemodialysis (HD) were initiated. She was transferred to a liver transplant center and continued both NAC and HD therapies until complete resolution of metabolic acidosis and coma without developing hepatitis. She was discharged without sequelae. This is the fourth highest APAP concentration recorded in a surviving patient. Moreover, this is the first report of a novel "triple therapy" using NAC, 4-MP, and HD in the setting of massive APAP ingestion that presents with coma, elevated anion gap metabolic acidosis, and lactemia. Emergency physicians should recognize these critically ill patients and consider high-dose NAC, 4-MP, and HD to be initiated in the emergency department (ED).

Tension pneumocephalus is a rare medical emergency. Spontaneous atraumatic tension pneumocephalus is reported in cases of neoplasm, Valsalva manoeuvres, and air cell hyperpneumatization. For the first time, we describe a case of atraumatic tension pneumocephalus induced by nasal cannula in a patient with ventriculoperitoneal shunt. Our case report discusses the possible mechanisms of the tension pneumocephalus in this case.

The clothing of a forty-five-year-old man became entrapped by the mixing rotator while he was operating a soybean milling machine. His clothing was wound around the rotator, and tightened around his neck and chest, causing strangulation and a loss of consciousness. He was rescued by his coworkers and transported to our hospital by helicopter. Upon arrival, he regained consciousness. A physiological examination revealed multiple petechiae on his face and strangulation marks with subcutaneous hemorrhage on his neck and upper trunk. In addition, he had motor weakness of the right upper extremity and bilateral paresthesia from C5 to Th1. All radiological studies were negative. He was admitted for observation. After the patient's creatine phosphokinase level peaked and his focal neurological signs improved, he was discharged on foot on the 6^th hospital day. Accidental ligature strangulation with cervical nerve root injury, in which an article of clothing is caught in an electrical machine and strangles the wearer, is very rare. This case is presented for its rarity and the unique pattern of injury.

Gluteal compartment syndrome is a rare condition that often develops following immobilization either secondary to illicit drug and alcohol abuse or improper surgical positioning. A case of a 22-year-old female with left lower extremity pain, weakness, and numbness after prolonged stasis from a night of drug and alcohol use is presented. She also complained of left low back pain. Her initial neurologic examination was significant for decreased deep tendon reflexes, decreased motor strength, and decreased sensation in the left lower extremity. Severe pain in the affected region persisted despite several attempts at pain control utilizing multiple modalities. An emergent MRI of the lumbar spine revealed gluteal compartment syndrome. The patient ultimately underwent emergent fasciotomy with resultant improvement in neurologic symptoms. Because presenting symptoms are frequently nonspecific in initial stages, gluteal compartment syndrome is often misdiagnosed. This can lead to unnecessary morbidity and mortality. It is important to maintain a high index of suspicion for gluteal compartment syndrome because delay in diagnosis can lead to nerve palsy, acute kidney injury, sepsis, and/or death.

Nitric acid (HNO₃) is a strong acid and oxidizing agent used for various applications including production of ammonium nitrate in the fertilizer industry. Nitrogen oxides formed when nitric acid interacts with the environment have been implicated in inhalation injuries. This describes a case of a 49-year-old male who presented to the emergency department complaining of an acute onset of shortness of breath approximately 12 hours after being exposed to nitric acid fumes. He presented with a room air oxygen saturation of 80 percent with moderate to severe respiratory distress. His plain film chest radiograph showed bilateral pulmonary infiltrates and pulmonary edema. Over a seven-day hospital course, he had an improvement in his clinical status and chest X-ray with normal pulmonary function tests one month after discharge. Although exposure to the fumes of nitric acid is known to cause delayed pulmonary edema, it is rarely reported in the medical literature. This case serves as a reminder to consider exposure to fumes of nitric acid in a patient presenting with pulmonary edema and highlights the importance of obtaining a work history.

Lamotrigine is a new generation antiepileptic which blocks sodium channels and can cause significant toxicity in overdose. A case of a three-year-old child who suffered a seizure and required endotracheal intubation after accidental lamotrigine ingestion is presented. The lamotrigine concentration measured 23.2 mcg/mL which is the highest reported after accidental pediatric exposure. A review of the literature regarding pediatric lamotrigine poisoning is also included.

Ergotamine toxicity has become a rare condition which can be caused by, among others, drug-drug interaction. In this work we report a case with vasospastic ischemia induced by the wrongful combination of ergotamine with recently started Antiretroviral Therapy. Clinicians were not aware that patient was self-medicating for years with medication containing ergotamine and caffeine for migraines. This diagnosis was established after evaluating the evolving 'and spreading' ischemia and CT scans and thoroughly interviewing patient's family. Treatment was started with intravenous nimodipine and intra-arterial sodium nitroprusside on the affected limbs. The patient developed severe limb ischemia, cerebral ischemia, and metabolic encephalopathy. Unfortunately no improvements were noticeable and due to evolving cerebral edema as a result of the ischemia, the patient developed brain herniation and died shortly after.

Pneumothorax is the entry of air into the virtual space between the visceral and the parietal pleurae, which can occur spontaneously or to a greater extent in a traumatic way. In daily clinical practice it is frequent to find injuries that generate traumatic pneumothorax that is ipsilateral to the lesion. However, there are case reports of contralateral pneumothorax that occurred in procedures such as insertion of pacemakers, or in cases of pneumonectomy. The following is the case report of a 37-year-old man who was admitted with a sharp wound to the right paravertebral region who developed a left haemopneumothorax due to a tangential course of the injuring agent. Adequate clinical judgment was followed, and several imaging studies were carried out, leading to the diagnosis of traumatic pneumothorax that was contralateral to the described injury.

Flank pain with hematuria is a common presentation in the emergency department. The commonest differential diagnosis of these patients is renal/ureteric calculus or pyelonephritis. These patients are usually treated with analgesia, antibiotics in case of pyelonephritis, and are discharged with an outpatient referral to a urologist. This case report describes a 51 year old male who presented to the ED for recurrent flank pain and hematuria. Bedside ultrasonography in the ED demonstrated a cystic lesion in the renal area. CT urography revealed an appendiceal stump mucocele and patient was transferred under surgical care. This case highlights the importance of the utility of bedside ultrasound in patients presenting to the ED with flank pain or abdominal pain which can lead to expedited assessment and appropriate management.