J Emerg Med
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Case Reports
Delayed Symptomatic Pulmonary Embolism Secondary to Bone Cement After Percutaneous Vertebroplasty.
Percutaneous vertebroplasty (PVP) is a common procedure performed on patients suffering from osteoporotic compression fractures. Complications of the bone cement escaping both locally as well as systemically into pulmonary circulation leading to pulmonary embolism (PE) have been reported in ≤26% of patients. ⋯ A 57-year-old woman presented to the emergency department with complaints of chest pain, fever, and cough. The patient had a history of an outpatient PVP from compression fractures of T5 and T7 performed 25 days before her presentation. She was in moderate respiratory distress and placed on bilateral positive airway pressure with improvement of her respiratory status. Laboratory results were remarkable for an elevated D-dimer, normal B-type natriuretic peptide, and decreased pH on venous blood gas. Pulmonary computed tomography angiography demonstrated bone cement PE in both the left lower lobe and a right middle lobe pulmonary artery. She was admitted to the hospital with improvement of her respiratory status with supportive treatment only. She was discharged after a 4-day hospital stay but died unexpectedly in her sleep 38 days after discharge. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: PVP is a common procedure that carries a risk of PE from bone cement embolization. Most of these events occur during the procedure, making the diagnosis obvious. However, delayed presentations from weeks to years have been reported. The emergency physician should consider bone cement embolization in the differential diagnosis in any patient with chest pain and shortness of breath that also has a history of PVP.
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Case Reports
Diabetic Ketoacidosis as a Delayed Immune-Related Event after Discontinuation of Nivolumab.
Nivolumab, an anti-programmed cell death-1 (PD-1) monoclonal antibody with immune checkpoint inhibitory activity, represents a novel treatment for several cancers. Immune checkpoint inhibitors cause side effects, known as immune-related adverse events (irAEs) or delayed immune-related events (DIRE), after immunotherapy discontinuation. Type 1 diabetes mellitus (T1DM) and diabetic ketoacidosis have been reported to develop as an irAE during the treatment with nivolumab. Here, we report on a patient who developed T1DM and diabetic ketoacidosis after discontinuation of treatment with nivolumab as a DIRE. ⋯ A 59-year-old man, who received nivolumab for an alpha fetoprotein-producing gastric cancer, presented with acute fatigue 4 months after discontinuation of nivolumab. Throughout therapy with nivolumab, the patient's hemoglobin A1c (HbA1c) level was ≤ 6%. However, 1 month prior to the patient's emergency department visit, he noticed weight loss, and 3 weeks prior to that, his HbA1c was 7.1%. Urinalysis showed ketone bodies, and arterial blood gas analysis suggested metabolic acidosis with hyperglycemia (690 mg/dL), which established the diagnosis of diabetic ketoacidosis. An endogenous insulin deficiency without verifiable anti-islet autoantibodies was confirmed; the patient had a human leukocyte antigen haplotype that does not increase the risk of acute-onset T1DM. We considered that T1DM in this patient developed possibly due to nivolumab. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This case highlights the need for clinicians to be vigilant of the fact that a history of anti-PD-1 monoclonal antibody therapy may increase the risk of diabetic ketoacidosis, whether treatment is ongoing or discontinued.
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Limping is a common chief complaint in the pediatric emergency department (ED) and can be difficult to assess in pediatric patients, particularly if they have developmental delay. ⋯ We present a case of a 5-year-old male with nonverbal autism who presented with a progressive limp, weakness, pain, and rash over the course of 1 month. A magnetic resonance imaging scan of the pelvis performed while the patient was sedated revealed multifocal osseous marrow signal abnormalities, ultimately consistent with vitamin C deficiency or scurvy. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Scurvy can present with nonspecific limp, rash, and bony pain and should be considered in pediatric patients with developmental/sensory delay who may restrict their diets. Emergency physicians should broaden their differential diagnoses to nutritional deficiencies such as scurvy in the evaluation of pediatric patients with limp.
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Case Reports
A Pounding Problem: A Case of Recurrent Headache Caused by Anti-NMDA Receptor Encephalitis.
Anti-N-methyl-d-aspartate receptor (Anti-NMDAR) encephalitis is a serious autoimmune disease in which antibody production against the NMDA receptor results in profound neurotransmitter dysregulation. Patients may present with a wide variety of symptoms, including psychosis, orofacial dyskinesias, dysautonomia, hallucinations, mental status changes, seizures, and headaches. ⋯ A previously healthy 25-year-old woman presented on several occasions to the Emergency Department with a severe pounding headache that initially responded well to treatment. She later developed signs consistent with meningoencephalitis along with altered mental status and neuropsychiatric changes. She was diagnosed with anti-NMDAR encephalitis after hospitalization. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Anti-NMDAR encephalitis is an under-recognized condition with diverse presentations. Recurrent headaches that improve with treatment may be an early sign of this disorder. Anti-NMDAR encephalitis should be considered in patients with recurrent undifferentiated headaches, and an appropriate work-up should be performed. Early recognition and diagnosis of this condition is critical to optimize favorable patient outcomes, as delays to diagnosis may lead to fatalities and long-term neurologic sequelae.
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Ultrasonography (US) is highly dependent on operators' skills. It is not only a matter of correct scan techniques; there are anatomical structures and variants, as well as artifacts, which can produce images difficult to interpret and which, if not properly understood, can be causes of errors. ⋯ We present possible anatomic pitfalls and artifacts that may affect correct interpretation of US images in patients with abdominal trauma and suggest how to avoid or to clarify them during the examination. Knowing their existence, their appearances, and the reasons why they are produced is important for proper use of this diagnostic technique.