J Emerg Med
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Posterior circulation (PC) stroke in adults is a rare, frequently misdiagnosed, serious condition that carries a high rate of morbidity. ⋯ An understanding of PC stroke can assist emergency clinicians in diagnosing and managing this disease.
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Case Reports
Invasive Fungus Balls Diagnosed by Point-of-Care Ultrasound in the Emergency Department.
Genitourinary tract fungus balls are a rare complication of urinary tract infections (UTI). They arise from dense aggregations of hyphae that combine with surrounding urothelial cells and debris. Symptoms can progress to urosepsis and systemic dissemination. Unfortunately, fungus balls may remain unrecognized. Even with computed tomography (CT) and magnetic resonance imaging, fungus balls can be mistaken for malignancies, urinary calculi, or blood clots. ⋯ A 54-year-old man with past medical history of type 2 diabetes mellitus presented to the Emergency Department (ED) reporting urinary retention for one week. He had undergone Foley catheter insertion three separate times for this symptom over the past five weeks. The emergency physicians expected that point-of-care ultrasound (POCUS) would show a distended, anechoic bladder. Instead, there were multiple discrete, gravitationally-dependent, circular echogenic masses without posterior acoustic shadowing, floating freely within a mosaic-like background of mixed echogenicity urine. These findings, together with the CT scan subsequently ordered, raised concern for fungus balls. Instead of being discharged with antibiotics for UTI, the patient was admitted for antifungal coverage, with contingency plans for bladder irrigation and antifungal instillation as needed. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This is the first known case report in which emergency physicians used POCUS to diagnose invasive fungus balls in the ED. POCUS findings led to further CT imaging and specialist consultation that otherwise would not have occurred. Rather than discharge with antibiotics, goal-directed management and appropriate disposition mitigated the risk of systemic decompensation in an immunocompromised patient.
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Case Reports
Epstein-Barr in a Patient Presenting with Right Upper Quadrant Pain: A Case Report from the Emergency Department.
Right upper quadrant abdominal pain and elevated cholestasis blood tests are usually associated with bacterial calculous cholecystitis. However, viral infections, such as Epstein-Barr virus (EBV) can also manifest with a similar clinical picture and is an important differential diagnosis. ⋯ This case report discusses a young woman presenting to the emergency department with acute right upper quadrant abdominal pain. The initial assessment revealed a positive Murphy's sign, elevated white blood count, and a cholestatic pattern on liver function tests, leading one to suspect bacterial calculous cholecystitis and initiating antibiotic therapy. However, clinical examination also revealed tonsillar exudates and differential white blood cell count revealed monocytosis and lymphocytosis rather than a high neutrophil count. The patient tested positive for EBV. Furthermore, ultrasound and magnetic resonance imaging revealed gallbladder wall edema with no gallstones, leading one to conclude that the clinical manifestation and laboratory results were due to an EBV infection. Antibiotic therapy was ceased and the patient did not require surgical intervention. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Calculous bacterial cholecystitis usually entails antibiotic therapy and cholecystectomy. It is important to be aware of the differential diagnosis of EBV, as it usually does not require either of these and resolves spontaneously.
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Cardiac tamponade is associated with high mortality, and making the diagnosis is a core skill of emergency physicians. Proper diagnosis relies on specific clinical and echocardiographic findings. It is not known whether expert sonographers consistently recognize echocardiographic signs of tamponade. ⋯ There was poor agreement among expert emergency medicine sonographers in identifying echocardiographic signs of cardiac tamponade from a single cine loop or clip without clinical context. Further investigation is warranted to understand differences in recognition of clinical tamponade.
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Acute compartment syndrome can be caused by any condition that increases the pressure of an intracompartmental muscular space, resulting in ischemia, which is a limb-threatening emergency. This case report is the first known documented example of an exogenously injected peptide causing compartment syndrome. The use of natural supplements and holistic therapies is on the rise, specifically, peptide injections. It is important to obtain the history of use and routes of administration of these substances. ⋯ We present a case of a 43-year-old man who presented to the Emergency Department with worsening thigh pain. The patient had injected a "peptide cocktail" into his thigh 3 days prior. Physical examination revealed trace pitting edema of the left leg with moderate muscle spasm and tenderness of the medial aspect of the distal thigh with associated numbness along the medial aspect of the knee. Point-of-care ultrasound detected intramuscular edema and free fluid in the leg. He was found to have acute compartment syndrome of the thigh secondary to the peptide cocktail injection, causing a large hematoma posterior to the adductor magnus. The patient required fasciotomy and hematoma evacuation. He ultimately left against medical advice during his hospitalization. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: In an age when many patients look for supplements to aid with weight loss and muscle growth, it is essential to be aware of peptide injection therapies and the potential complication of compartment syndrome.