Clinical Practice and Cases in Emergency Medicine

Case Presentation: A 60-year-old female presented to the emergency department with unilateral eye pain and vision loss. Point-of-care ultrasound (POCUS) was performed, which demonstrated ocular metastatic lesions of breast cancer.

Discussion: Ocular metastasis is rare, clinically challenging, and may present with a wide range of ophthalmic symptoms. However, POCUS may safely and rapidly identify metastatic lesions to direct further care.

Introduction: Acute focal bacterial nephritis is an underdiagnosed condition. It clinically resembles acute pyelonephritis. If unrecognized and undertreated, it may progress into complications (kidney abscess and scars). Contrast-enhanced computed tomography (CT) reveals specific images of the disease and is considered the gold standard to make the diagnosis. 

Case Report: A 63-year-old male patient with solitary kidney presented with symptoms compatible with acute pyelonephritis. Kidney ultrasound was not conclusive. Because of persisting high-grade fever not resolving after 48 hours of antibiotics, a contrast-enhanced CT was then performed, and the diagnosis of acute focal bacterial nephritis was made. A repeat CT after three weeks of intravenous (IV) antibiotics showed marked improvement of the intrarenal lesions, and a fourth week of IV antibiotics was dispensed.

Conclusion: Diagnosing acute focal bacterial nephritis is important (particularly in a patient with solitary kidney). This will dictate the therapy duration. Unlike acute pyelonephritis, acute focal bacterial nephritis requires at least three weeks duration of antibiotics to avoid progress into further complications. 

Introduction: Lemierre’s syndrome is septic thrombophlebitis of the internal jugular vein, most commonly associated with head and neck infections. While central catheters are associated with venous thromboembolism and catheter-associated bacterial infections, cases of Lemierre’s syndrome caused by central catheters are extraordinarily rare.

Case Report: We detail a case of Lemierre’s syndrome resulting from a peripherally inserted central catheter in a pregnant female patient. Diagnosis of this rare and potentially life-threatening disease process was expedited using point-of-care ultrasound.  

Conclusion: Diagnosis of rare but potentially life- or limb-threatening pathologies is paramount to the successful practice of emergency medicine. Identifying these rare disease processes requires a high index of suspicion and a work-up strategy that includes consideration of medical history in combination with lab and imaging findings to determine appropriate interventions.

Introduction: Renal artery aneurysm rupture is a rare but morbid diagnosis, often requiring emergency surgery and nephrectomy. Clinical presentation can mimic more common pathology in non-pregnant women such as ruptured ovarian cyst.

Case Report: We present a case of a woman with a prior history of ovarian cyst presenting with a ruptured renal artery aneurysm. Prompt computed tomography (CT) imaging revealed a left renal artery aneurysm rupture with hemoperitoneum and renal infarct. She underwent emergency laparotomy and nephrectomy and was ultimately discharged in good condition.

Conclusion: While ovarian cyst rupture is the most common cause of spontaneous hemoperitoneum in non-pregnant women of childbearing age, renal artery aneurysm rupture should be considered and prompt CT imaging obtained, particularly in cases of hemodynamic instability, to ensure prompt treatment.

Introduction: Acute confusional migraine (ACM) is a rare variant of migraine that is benign and self-resolving but difficult to diagnose. Without known causative pathophysiology and a lack of recognition in the International Classification of Headache Disorders (ICHD-3), ACM offers a puzzling clinical presentation. There currently is no standardized treatment for ACM, but with a growing anecdotal dataset there is the opportunity to formally recognize and establish protocols to improve patient care and outcomes.

Case Report: A 14-year-old female presented to the emergency department (ED) with acute onset of confusion, vision changes, right-sided weakness, and dysarthria one hour prior to arrival. A stroke workup at the initial ED offered no pertinent findings. The patient was transferred to a pediatric specialty ED where all symptoms, aside from numbness and a mild headache, resolved during transfer. After administration of a migraine cocktail at the pediatric specialty ED, all remaining symptoms completely resolved. The patient was discharged home from the ED the same evening with outpatient follow-up.

Conclusion: This case presents the difficulty of diagnosing and treating ACM prior to its self-resolution. It highlights the need for formal recognition of the condition by the ICHD-3. In doing so, greater recognition will promote more research, awareness, and establishment of a standardized treatment for ACM.

Introduction: Wünderlich syndrome (WS) refers to subcapsular, perirenal, or pararenal hemorrhage due to non-traumatic and iatrogenic conditions. Neoplasms, vascular disease, renal etiology, and anticoagulant use are underlying risk factors.

Case Report: We describe a case of WS in a 79-year-old male who was undergoing hemodialysis, which resulted in hemorrhagic shock requiring multiple transfusions and embolization by interventional radiology.

Conclusion: Most commonly, patients present with flank pain; a computed tomography with contrast of the abdomen is essential for diagnosis. Surgical intervention is considered in hemodynamically unstable patients. Conservative therapy and intravenous resuscitations with blood products are considered a priority in hemodynamically stable patients.

Introduction: Pit viper envenomation may cause coagulopathy. The coagulopathy has been treated with crotalidae polyvalent immune fragment antigen-binding (Fab) ovine antivenom for the last few decades in the United States and usually corrects the acute coagulopathy within hours. Days after receiving Fab, coagulopathy may recur in approximately half of the patients. Another divalent antivenom, crotalidae immune F(ab’)2 (equine)–F(ab’)2–was approved by the US Food and Drug Administration for the treatment of pit viper envenomation. F(ab’)2 is composed of two linked antigen-binding fragments of immunoglobulin G. Several studies have demonstrated that F(ab’)2 is less likely to be associated with recurrence. There is no reported case of F(ab’)2-associated late coagulopathy in very young patients. We report the first case of recurrence associated with F(ab’)2 use in a preschool-age child.

Case Report: A preschool-age male developed leg swelling and hypofibrinogenemia after rattlesnake envenomation. F(ab’)2 was administered to stabilize the leg edema and to correct the hypofibrinogenemia. The patient improved clinically and was discharged on hospital day five. Seven days after the rattlesnake envenomation, he returned to the emergency department as instructed. Laboratory data revealed recurrent hypofibrinogenemia.

Conclusion: There are two antivenoms available in the US to treat crotalid envenomation, Fab and F(ab’)2. F(ab’)2 is less likely to be associated with recurrent coagulopathy in comparison to Fab. We report the first case of recurrence associated with F(ab’)2 in a preschool-age child. It is important that the emergency physician be aware of potential F(ab’)2-associated recurrent coagulopathy. Adult and pediatric patients may need to follow up to be evaluated for hypofibrinogenemia and/or thrombocytopenia after receiving F(ab’)2.

Introduction: Acute mountain sickness, high-altitude pulmonary edema (HAPE), and high-altitude cerebral edema (HACE) are a spectrum of high-altitude conditions, with HACE being the most life-threatening. Most cases develop at altitudes of greater than 4,000 meters (~13,000 feet) above sea level and after one to five days.

Case Report: A previously healthy 46-year-old female presented to the emergency department with ataxia, altered mental status, and vomiting that developed after rapidly ascending to ~2,400 meters (~7,800 feet) above sea level. She was treated for HACE and HAPE with resolution of her symptoms within 24 hours.

Conclusion: High-altitude pulmonary edema and HACE can develop rapidly and at moderate altitudes. Expeditious recognition and treatment is imperative to avoid life-threatening complications.

Introduction: Opioid use is an epidemic that plagues the United States. Patients frequently present to the emergency department (ED) after opioid toxicity, which can lead to respiratory failure, apnea, and death. Although there is an effective antidote, naloxone, the current guidelines surrounding post-naloxone administration monitoring are loosely defined.

Case Report: We present a case in which an individual was administered naloxone after an intentional opioid overdose and was monitored for four hours, as is standard in our institution. He remained in the ED for additional workup following this observation period and subsequently experienced signs of severe respiratory depression, requiring bag-valve-mask ventilation, naloxone, and admission. Had he been discharged, as is typical after a four-hour observation period, the consequences could have been fatal. We present multiple theories as to why his opioid toxidrome may have presented in a delayed manner, including ingestion of fentanyl analogues and variability in metabolization of both opioids and naloxone. We also explore alternative overdose antidote products approved by the US Food and Drug Administration, which may impact post overdose care.

Conclusion: This case suggests that the correct amount of time to monitor patients after naloxone administration may be longer than originally thought. Our aim in this article was to further the discussion regarding the most appropriate observation period in cases of opioid toxicity.

Introduction: Recognizing testicular torsion is extremely important in patients presenting to the emergency department (ED) with acute scrotal pain. Traditional manual detorsion techniques are frequently employed by emergency physicians but are not always successful. Delays in detorsion increase the risk of testicular infarction and infertility, and the need for orchiectomy. Novel techniques such as the testicular traction technique have been described as a potential solution for difficult-to-detorse testicles.

Case Report: Our case report describes a 20-year-old male with no significant past medical history who presented to a rural ED with acute, atraumatic testicular pain secondary to testicular torsion with an intact cremasteric reflex. After confirming the diagnosis using Doppler ultrasound, manual detorsion using the traditional “open book” technique was attempted and unsuccessful. The patient was subsequently successfully detorsed using the novel testicular traction technique.

Conclusion: The testicular traction technique is a safe, rapid, and effective primary or adjunctive technique in manual testicular detorsion. Given the time-sensitive nature of testicular torsions, adjunctive techniques play a crucial role in managing challenging detorsions, particularly in resource-limited rural settings with limited access to urologic services. Although it is commonly thought that the cremasteric reflex is absent in testicular torsions, it may be present in rare circumstances, and its presence should not be an absolute in ruling out torsion.

Introduction: Spontaneous intracranial hypotension (SIH) is an uncommon and frequently misdiagnosed condition characterized by a lower-than-normal volume of cerebrospinal fluid (CSF) caused by leakage of CSF through the dural membrane. The primary manifestation of SIH is an orthostatic headache, which is frequently accompanied by nausea and vomiting. Patients with connective tissue disorders are at increased risk for spontaneous CSF leaks due to the structural weakness of their dural membranes.

Case Report: An 18-year-old woman with no reported past medical history presented to the emergency department with 10 days of a bifrontal headache that was orthostatic in nature with associated nausea and vomiting. She was noted to have several marfanoid features on physical examination. Spontaneous intracranial hypotension was ultimately diagnosed and treated successfully with an epidural blood patch. Subsequent genetic testing revealed a diagnosis of Marfan syndrome.

Conclusion: Spontaneous intracranial hypotension is an uncommon cause of headache. Individuals with connective tissue disorders such as Marfan syndrome are at increased risk for SIH. Knowledge of the relationship between these two conditions allows for a more rapid diagnosis of SIH.