J Emerg Med
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Review Case Reports
Group C Streptococcus Causing Rheumatic Heart Disease in a Child.
Human infection with group C Streptococcus is extremely rare and a select number of cases have been reported to cause acute pharyngitis, acute glomerulonephritis, skin and soft tissue infections, septic arthritis, osteomyelitis, pneumonitis, and bacteremia. In pediatrics, this bacteria is known to cause epidemic food-borne pharyngitis, pneumonia, endocarditis, and meningitis, and has reportedly been isolated in the blood, meninges, sinuses, fingernail, peritonsillar abscess, and thyroglossal duct cyst, among others. ⋯ Our patient was a 7-year-old previously healthy female who presented with abnormal movements of her upper body and grimaces of her face that progressively worsened over time. Initial laboratory resulted revealed 3+ protein on urinalysis and elevated antistreptolysin-O and anti-DNAse antibody levels, and echocardiogram showed mild-to-moderate mitral regurgitation. We describe a rare case of group C Streptococcus resulting in rheumatic heart disease in a child, with a detailed review of the literature pertaining to the diagnosis and management of this infection. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Early recognition of rheumatic heart disease is crucial in the overall outcome of the condition and therefore knowledge of the symptoms associated with condition is also imperative. Group C Streptococcus is rarely associated with rheumatic heart disease and most children exhibiting acute onset of common symptoms, such as chorea, fever, carditis, and rash (erythema marginatum) will present to the emergency department first. Increased awareness and prompt recognition, as done with this child, will result in proper follow-up and adequate management of this condition in all patients.
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In part 1 of this two-part review, we discussed which risk factors, historical features, and physical findings increase risk for pulmonary embolism (PE) in symptomatic emergency department (ED) patients. ⋯ Reasonable and prudent emergency clinicians can exclude PE in symptomatic ED patients on clinical grounds alone in many patients, and many more can have PE ruled out by use of the D-dimer.
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Review Case Reports
Crowned Dens Syndrome: Report of Three Cases and a Review of the Literature.
Patients with crowned dens syndrome (CDS), which is pseudogout of the atlantoaxial junction induced by "crown-like" calcifications around the dens, present with symptoms of severe neck pain, rigidity, and high fever. CDS patients are often misdiagnosed as having meningitis or polymyalgia rheumatica, leading to potentially unnecessary invasive procedures for diagnosis and treatment. ⋯ We report 3 patients with CDS who had characteristic findings on computed tomography (CT), all of whom quickly recovered with nonsteroidal antiinflammatory drug (NSAID) administration. In addition, we reviewed 72 published cases, including our patients. CDS typically occurs in elderly people (mean age 71.4 years). Common symptoms include neck pain (100%), neck rigidity (98%), and fever (80.4%), and most show elevated inflammatory markers (88.3%) on serum laboratory tests. Neck pain on rotation is a characteristic and helpful symptom in the diagnosis. The most useful modality is CT (97.1%), showing linear calcium deposits around the dens, mostly in the transverse ligament of atlas (TLA). CT number is especially helpful to distinguish a normal TLA (35-110 HU) from a calcified one (202-258 HU) in our cases. The most effective treatment is NSAID administration (85%), which usually leads to marked resolution of symptoms within days or weeks. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Due to acute and severe symptoms, CDS patients often present to an emergency department. To avoid unnecessary invasive procedures for diagnosis and treatment, CDS should be considered in the differential diagnosis of febrile neck pain.
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Review Practice Guideline
Safety of Droperidol Use in the Emergency Department.
Droperidol (Inapsine®, Glaxosmithkline, Brent, UK) is a butyrophenone used in emergency medicine practice for a variety of uses. QT prolongation is a well-known adverse effect of this class of medications. Of importance to note, QT prolongation is noted with multiple medication classes, and droperidol increases QT interval in a dose-dependent fashion among susceptible individuals. The primary goal of this literature search was to determine the reported safety issues of droperidol in emergency department management of patients. ⋯ Droperidol is an effective and safe medication in the treatment of nausea, headache, and agitation. The literature search did not support mandating an electrocardiogram or telemetry monitoring for doses < 2.5 mg given either intramuscularly or intravenously. Intramuscular doses of up to 10 mg of droperidol seem to be as safe and as effective as other medications used for sedation of agitated patients.