A 52 y.o. male sp esophagectomy and gastric pull up for esophageal ca 10 years pta presents with chest pain.

A cath showed the circumflex was occluded and the RCA had a tight lesion. A stent was placed. A week later he returned with an occluded stent and a trop of 25. Laser atherectomy and thrombectomy was done with placement of new stents . The pt became febrile. His xrays are shown below.

pneumo 1.jpeg
What do you notice on the images?

What do you notice on the images?

A 49 y.o. male presents with several months of hoarseness

His CT scan shows bilateral vocal cord infiltration with no nodes enlarged.

What is the differential for vocal cord infiltration?

What is the differential for vocal cord infiltration?

Our patient had bilateral infiltration of the vocal cords with vocal cord paralysis. His presentation was hoarseness which is the reason for 1% of all visits to primary care physicians. Vocal cord paralysis is present in 2.8-8% of the cases. This represents a more serious condition and laryngoscopy is recommended to rule it out.

anatomy of the arytenoids and cords

anatomy of the arytenoids and cords

While the prevalence of rheumatoid arthritis is 1% in the population at large, up to 88% in postmortem studies have laryngeal involvement of the cricoarytenoid joint. Other conditions which can causing  dysfunction in the cricoarytenoid joint are listed below:

Gout

Syphilis

Gonorrhea

Sarcoid, amyloidosis, lyme disease,  lupus, wegener’s, lymphoma,  and tuberculosis can cause laryngeal involvement as well. Neuropathy from diabetes may cause vocal cord dysfunction and reflux disease may also cause bilateral vocal cord immobility.  If no cause is found for vocal cord immobility a CT of the entire course of the vagus nerve is recommended.

the cricoarytenoid joint is the axis around which the cords pivot

the cricoarytenoid joint is the axis around which the cords pivot

In the case of our patient a biopsy was done showing squamous cell carcinoma.

Edema of the intraarytenoid space may occur as in this case in RA.

Edema of the intraarytenoid space may occur as in this case in RA.

Berterud A. Rheumatoid arthritis in the larynx. Scand J Rheumatol.  1991;20:215. Doi: 10.3109/03009749109103025.

Ramos H, Pillon J, et al. Revista Brasiliera fe Otorrinolaringolgia. Rev. Bras. Otorrinolaringol.2004  Vol 71(4)

Reiter R, Hoffmann T, Pickhard A, Brosch S. Hoarseness—causes and treatments. Dtsch Arztebl Int. 2015 May;112(10):329-237.  Doi: 10.3238/arztebl 2015.0329

Kamanli A, Gok S. Sahin I et al.  Bilateral cricoarytenoid joint involvement in rheumatoid arthritis: a case report 2001 Rheumatology, vol 40,(5), 593-594.

Fried MP, Sharpiro J. Acute and chronic laryngeal infections. In: Paperella MM, Shumrick DA, Gluckman J, Meyerhoff W, eds. Otolaryngology, edn 3. Philadelphia : W.B. Saunders, 1991:2245-56.

A 62 y.o. woman presents with chest pain after a roll over MVC

Why does she have chest pain?

airbag inj hayes.JPG

Our pt had a hx of breast reduction surgery and after the accident had active arterial extravasation within her L breast. So, while restraints are useful, they can also be a source of injury since the point of contact of a seat belt holds that portion of the body in a fixed position while the rest of the body rotates around it. Seat belts were first introduced in 1894 and the lap belt became standard in 1964.  In 1973 the three point restraint was introduced with airbags in the mid 1970’s.  

seat belt 2.JPG

Seat belts have two functions; to prevent ejection from the vehicle and to keep the head from hitting the windshield. It is estimated that seat belts reduce fatalities by 43%. Airbags on the other hand, were designed to provide a cushion between the driver and the steering wheel or dash in the event of a crash. Since there is a fixed point around which the body rotates with seat belts, compression of the bowel between the belt and the spine can occur.  For this reason bowel perforations have been reported.  Many other seat belt injuries have been reported, a few of them are listed below. 

seat belt 3.JPG

Airbags, defective ones that cause shrapnel to impale drivers have caused 24 deaths.  Even properly functioning airbags have caused death from myocardial rupture.

 

TAKE HOME POINTS

1.    While restraints are good, they cannot prevent all injuries and they cause some injuries.

2.   It’s the deceleration injury that matters.  A clue to this is the presence of a “seat belt sign”, associated rib fractures, and ems report of the severity of the crash that help in determining severity.  A recent ED case of a patient involved in a crash with negative indications for a head CT but with sternal fracture and pericardial effusion brings this home.  The pt was found to have a subdural requiring surgery without striking his head.

Our patient was treated conservatively for her breast injury.

A classic seat belt injury

A classic seat belt injury

Campbell  B,  Porter R, Zhae N. Patterns of safety belt injury reduction related to crash severity and seat position. J Trauma 1987 Jul; 27(7):733-9.

Hayes C, Conway W. et al. Seat belt injuries: radiologic findings and clinical correlation. Radiographics .1991;11:23-26.

Thoma T. National Highway Traffic Safety Administration (NHTSA) Notes. Review of studies on pedestrian and bicyclist safety . 1991-2007.  Ann Emerg Med.  2012 Oc;60(4):495-6.

A 35 y.o. Asian male presents with gradual alteration of mental status and inability to speak over 8 weeks

His MRI is shown below.

Hint: the location of the thalami are shown below.

Hint: the location of the thalami are shown below.

The patient has increased signal in both thalami; What could be the cause?

The patient has increased signal in both thalami; What could be the cause?

Although our patient was thought at first to have Wernicke’s encephalopathy, he never improved with high dose thiamine.  His diagnosis was changed to limbic encephalitis.

Limbic encephalitis is characterized by inflammation of the brain caused by an autoimmune process. The main regions of the brain involved are the hippocampus, affecting memory, and the amygdala, causing emotional outbursts. Although it is called limbic encephalitis, on autopsy studies the inflammation involves other areas of the brain.

The majority of cases are associated with a tumor. Tumors of the lung, thymus, breast, testes, and ovary may be associated with limbic encephalitis. These receptor antibodies include:

  • Anti-Hu, associated with small cell carcinoma of the lung

  • Anti-Ma, associated with germ-cell tumors of the testis

  • Anti-NMDAR, associated with tumors of the ovaries, often teratomas

Non neoplastic causes include herpes simplex type 1 , AMPA, and GABA receptor antibodies., and voltage-gated potassium channel antibodies (VGKC-Abs).  These antibodies react with proteins in the neural cell membranes. The treatment for non neoplastic encephalitis is immune suppression.

Our patient followed simple commands, rarely spoke, had left esotropia, and developed 2nd and 3rd degree heart block requiring a pacemaker.  He also developed intractable hiccups and bulbar paralysis requiring intubation.  His LP came back positive for SSA/SSB antibodies and was ANA positive confirming autoimmune encephalitis. He is currently on steroids and plasmapheresis was begun.

A 13 y.o. with uptake in the left temporal area from limbic encephalitis.

A 13 y.o. with uptake in the left temporal area from limbic encephalitis.

Molloy A, Cassidy E, Ryan A, O’Toole O.  2011,  VGKC positive autoimmune encephalopathy mimicking dementia. BMJ Case Rep. doi:10.1136/bcr08.2011.4642.

Ganesan , Beri S, Khan B, Hussain N. Voltage gated potassium channel antibodies positive autoimmune encephalopathy in a child: A case report and literature review of an under-recognized condition. 2013. Ann Indian Acad Neurol. Oct-Dec;16(4):593-596.

DIFFERENTIAL FOR ENCEPHALITIS.

DIFFERENTIAL FOR ENCEPHALITIS.

A 73 y.o. woman comes in after a fall and has severe knee pain.

what do you see?

bakers cyst 3.JPG

Our patient had a Baker’s cyst and a prepatellar hematoma.  She also has osteoarthritis. The cyst can be painful and can rupture into the calf mimicking a dvt.  Rarely,  the swelling can cause a dvt or compartment syndrome.

Baker’s cyst and prepatellar hematoma

Baker’s cyst and prepatellar hematoma

Baker’s cysts rarely require treatment  and are often associated with arthritis as in this case or meniscal cartilage tear. If they are very symptomatic they can be aspirated and steroids are injected.

 Our patient was seen in the ortho clinic following her ED CTscan and managed conservatively.  She has not yet had her knee replacement.

bakers cyst showing the valve where it is leaking from the joint.

bakers cyst showing the valve where it is leaking from the joint.

Hubbard M, Hildebrand B , gattafarano M, Battafarano D. Common soft tissue musculoskeletal pain disorder. 2018 Primary Care 45 (2):289-303.

Herman A, Marzo J, Popliteal cysts: a current review. Orthopedics, 201837(8)e678-84.

Snir N, Hamula M, et al. Popliteal cyst excission using open posterior approach after arthroscopic partial medial meniscectomy. Arthrosc Tech 2013 Aug 2(3) e295-e298.

A 67 y.o. male comes in with shortness of breath

his cxr is shown

goiter.JPG

Our patient had a large substernal goiter compressing the bronchi. 

Early Chinese medical writings in 3600 BC were the first to record a decrease in goiter size with ingestion of burnt sea sponge.  The discovery of iodine was an accidental discovery during the making of gunpowder in 1811.  Courtois, a French chemist, observed a purple smoke arising for seaweed ash treated with sulphuric acid.  It was eventually purified from this reaction and named iodine after the Greek word “ioeides” or violet colored.

goiterbeltf.JPG

Goiters were most prevalent in the upper Midwest and west until the 1920’s when salt became iodized.  When salt was originally iodized,  an outbreak of thyrotoxicosis occurred and many states did not adopt iodized salt until the 1950’s. In patients with underlying goiters even ICU exposure to betadiene or IV contrast can trigger thyrotoxicosis .  Currently only 70-76% of households use iodized salt. Certain segments of the population notably pregnant women and women of child bearing age are at risk for iodine deficiency.

THE MESSAGE IS: Iodine administration can result in hyperthyroidism in patients with goiters and hypothyroidism in autoimmune thyroiditis.

Our patient had R phrenic nerve paralysis which made him inoperable.  He worsened in the ED and developed hypercarbic respiratory failure.  Multiple attempts to intubate in the ED were unsuccessful including a failed cricoid trach.  The pt was placed on ecmo and a #7 Shiley XLT was eventually placed.  He was decannulated but remains vent dependent with ongoing pneumonia.

 

 

Leung A, Braverman L, Pearce E.  History of US Iodine fortification and supplementation. 2012 Nutrients Nov;4(11):1740-1746.

Caldwell K, Makhmudov A, Ely E, et al. Iodine status of the US Population National Health and Nutrition Examination Survery 2005-6 and 2007-8. Thyroid.  2011;21:419-427.

Delange F, Benoist B, Alnwick D.  Risks of iodine-induced hyperthyroidism after correction of iodine deficiency by iodized salt. 1999. Thyroid . liebertpub.com doi.org/10.1089/thy.1999.9.545

Brotfain E, Koyfman L et al. Iodine-induced hyperthyroidism—an old clinical entity that is still relevant to daily ICU practice: A case report.  Case Reports in Endocrinology 2013. Vol 2013, article ID 792745.

goiter on ct

goiter on ct

A 75 y.o. woman presents with hoarseness and coughing up blood.

She has a T2 weighted MRI which shows a mass on the vocal cord

vocal cordf.jpg
But the lesion surrounds the carotid without compressing it and also extends into the mediastinum. What is it?

But the lesion surrounds the carotid without compressing it and also extends into the mediastinum. What is it?

Our patient had a hemangioma.  This is an abnormal proliferation of blood vessels and can occur anywhere in the body.

Hemangiomas occur in 5 to 10% of children  and usually disappear by age 3-5. Hemangiomas that appear at birth are thought to be caused by placental trophoblastic proteins and indeed are more common in infants born after chorionic villus sampling.

hemangioma in a child

hemangioma in a child

Another group of hemangiomas appears in adults usually between the ages of 30 and 50. They occur in 10% of the world’s population. Symptomatic hematomas, like in our pt, occur in less than 1% of these individuals. Cherry hemangiomas are common in the skin of adults.

common cherry hemangiomas

common cherry hemangiomas

The brain, liver and spine can also be sites of hemangiomas.

the “corduroy sign” of spinal hemangiomas

the “corduroy sign” of spinal hemangiomas

cross section of the spinal hemangioma “the polka dot sign”

cross section of the spinal hemangioma “the polka dot sign”

RANDOM HEMANGIOMA FACTS-Hemangiomas tend to be prevalent in a specific condition called Von Hippel Lindau.  Estrogen is a trigger for hemangioma growth and pregnant women may have increase in the size of their hemangiomas.

Because our patient was having bleeding from her vocal cord, she underwent successful embolization.

Drolet B, Esterly N, Frieden I.  New England Journal of Medicine—Hemangiomas in Children 1999. 

Bree A, Siegfried E, Sotel-Avila,  C et al. Infantile Hemangiomas Speculation on Placetal Trophoblastic Origin. Arch Dermatol. 2001; 137(5): 573-577. 

Alfawareh M, Alotaibi T, Labeeb A, et al. A symptomatic case of thoracic vertebral hemangioma causing lower limb spastic paresis. 2016 Am J Cas Rep ;17:805-809.

A 67 y.o. female presents with shortness of breath

You notice a mass in her neck. what could be wrong?

hint: the patient has has a mass for 15 years and it is slowly enlarging

hint: the patient has has a mass for 15 years and it is slowly enlarging

Our patient had a Warthin’s tumor.  This is a benign cystic tumor of the salivary gland which  has mostly lymph-node like stroma.  It was named for Aldred Warthin who first described two cases in 1929.  This is the only benign tumor restricted to the parotid gland. It is the second most common tumor with the first being a pleomorphic adenoma. Smokers are at eight times greater risk than non smokers.

On US there are multiple cystic spaces which are surrounded by epithelial cells.  The epithelium contains lymphoid tissue with germinal center formation.

cystic appearance of a Warthin’s tumor

cystic appearance of a Warthin’s tumor

80/20 rule of neck masses.

80% of neck masses in children are benign with 20% malignant.  In adults the reverse occurs.  80% of masses are malignant and 20% benign.

cystic hygroma in an adult; it is more common in children

cystic hygroma in an adult; it is more common in children

Neck masses can be divided into congenital, inflammatory and neoplastic.

Congenital neck masses-Branchial cleft cysts account for 20% of neck masses in children. Other masses include ranulas, thyroglossal duct cysts, hemangiomas and cystic hygromas.

Inflammatory masses include viral including Epstein barr and bacterial. Common bacterial causes include strep and Staph. Less common infections include tularemia,  brucellosis , HIV, tuberculosis, cat scratch disease and actinomycosis.

Neoplastic causes include salivary gland tumors, throid tumors, paragangliomas of the carotid body, squamous cell mets from primary neck tumors, teratomas,and  lymphoma. Our patient was biopsied but no surgery was performed. Her hospital course was marked by Serratia sepsis and lung disease.

Will, R. ed.(2005) Benign tumors,cysts and tumor-like conditions of the salivary glands. Salivary gland Diseases: Surgical and Medical Management. New York. Thieme Medical Publishers. p. 123.  ISBN 1-58890-8.

McGurk M. Management of the ranula. J Oral Maxillofac Surg 2007 65:115.

Gujrathi C, Donald P. Current trends in the diagnosis and management of head and neck paragangliomas. Curr Opin Otolaryngol Head Neck Surg 2005;13:339.

 

branchial cleft cysts

branchial cleft cysts

A 73 y.o. woman presents with abdominal pain

What is wrong with her aorta?

A hint is in the picture below

A hint is in the picture below

coral reef 4f.jpg

Our patient had a coral reef aorta.  Coral reef aorta is described as rock-hard calcifications in the aorta above the renal arteries.  (most vascular occlusive disease is below the renal arteries)  The calcifications grow into the aorta and make stenting very difficult. This is a rare problem with a frequency of 6 in 1000 patients.

coral reef aorta.JPG

The first description of coral reef aorta was by the biographer of a Swiss anatomist Johann Jakob Wepfer in the 1600’s.  During Wepfer’s autopsy it was noted that he had semicircular projections into the lumen of the upper aorta similar to bone. Risk factors for coral reef aorta include RA and long-term use of steroids.  It has been reported to cause embolic disease and even cardiogenic shock by occluding the aortic outflow.

Our patient had mesenteric ischemia and died of shock liver. She was noted to have occlusion of the celiac artery, with hepatic ,and renal infarcts and active contrast extravasation from a branch of the pancreaticoduodenal artery with necrosis of the pancreas.

Grotemeyer D, Pourhassan S, Rehbein H, et al. The coral reef aorta—a single centre experience in 70 patients.  2007 Int J Angiol. Autumn 16(3):98-105.

Kopani K, Liao S, Shaffer K.  The coral reef aorta: diagnosis and treatment following CT. 2009 Radiol Case Rep;4(1):209.

Dinis da Gama A, Pedro L, et al. A new method of ostial revascularization of digestive and renal arteries in complex

A 61 y.o. sp treatment for epidural abscess with vancomycin for one month, presents with a rash.

What could be wrong?

Absolute eosinophil count was 3.5 (high), alt 78

Absolute eosinophil count was 3.5 (high), alt 78

hickey 3.JPG

Our patient had DRESS syndrome (Drug Rash with eosinophilia and Systemic Symptoms)

Cutaneous reactions to drugs are considered severe in only 2% of hospitalized patients. The reactions include: AGEP( acute generalized exanthomatous pustulosis),  DRESS, Stevens Johnson syndrome, and Toxic epidermal necrolysis. (TEN).

The cause for our patient was vancomycin

The cause for our patient was vancomycin

AGEP- Is the onset of small, sterile pustules  48-72 hrs after introduction of a drug.  Fever is uncommon.

DRESS- often presents with liver involvement and eosinophilia of over 10% anywhere from 2-8 weeks after exposure to the offending agent.  It usually presents with itching, fever and facial edema. All DRESS patients have liver involvement in several studies and 18% have kidney involvement. The maculopapular rash is not accompanied by epidermal detachment.

STEVENS JOHNSON SYNDROME-  In SJS there are often mouth lesions and skin necrosis affecting less than 10% of the body surface area. There is detachment of the surface of the skin.

There are genetic associations between human leukocyte antigen (HLA) and drug hypersensitivity. HLA B 1502 is associated with tegretol induced Stevens-Johnson syndrome and is found in a higher proportion of people of Chinese descent.

HLA-B 1508 is associated with allopurinol induced Stevens Johnson syndrome. Stevens Johnson syndrome often involves the oral mucosa.

TEN-Toxic epidermal necrolysis is  essentially a Stevens-Johnson syndrome involving more than 30% of the body surface area.  It was first described by Debre  in 1939 where it was known in French as l’erhthrodermie bulleuses avec epidermolyse.

 

necrotic epidermis seen in stevens-johnson syndrome

necrotic epidermis seen in stevens-johnson syndrome

In trying to differentiate between DRESS and SJS, the skin lesions are considered first since both conditions can have elevated eosinophils, fever, rash and elevated liver enzymes. The diagnosis of SJS is differentiated by the detachment of the surface of the skin which puts the patient at risk for sepsis. Our patient had a biopsy which did not show epidermal necrosis ( although he did have mouth lesions) so he was diagnosed as DRESS and treated with steroids. Vancomycin was the offending agent.

our patient did have mouth lesions which usually is found in SJS

our patient did have mouth lesions which usually is found in SJS

Choudhary S, McLeod M, Torchia D, Romanella P.  Drug reaction with Eosinophilia and Systemic Symptoms. 2013 J Clin Aesthet Dermatol. Jun;6(6) PMID 23882307

Hung S, Chung W, Jee S. et al. Genetic susceptibility fo carbamazepine-induced cutaneous adverse drug reactions. Parmacogenet Genomics. 2006;16:297-306.

Jeung Y, Lee J, Oh M, Choi D, Lee B. Comparison of the casues and clinical features of drug rash with eosinophilia andsystemic symptoms and Stevens-Johnson syndrome.  Allergy Asthma Immunol Res. 2010 Apr;2(2):123-6.

Casagranda A, SuppaM, Dehavay F, Mamol V. Overlapping DRESS and Stevens-Johnson Syndrome: Case Report and Review of the Literature. Cas Rep Dermatol. 2017 May-aug: 9(2):1-7.

A 40 y.o. presents with a fever and a lesion on her arm.

what is wrong?

brachial art.JPG

Our patient had a brachial artery pseudoaneurysm.  The astute ED physician recognized it immediately and did not attempt an I+D.  this condition was first described in the mid 1800’s. A right brachial artery interposition bypass with vein bypass was done with closure of the R antecubital fossa wound with an adjacent tissue transfer. 6-acetylmorphine rose to 15 on hospital admission presumably from IV drug use. She signed out AMA but continued to take her antibiotics. .  Cultures of the pseudoaneursym grew MRSA and blood cultures grew Pseudomonas. With an estimated 16 million IV drug users world wide, this problem will become more prevalent. 

femoral artery pseudoaneursym

femoral artery pseudoaneursym

Infected femoral  artery pseudoaneursyms (mycotic) are the most common arterial complications in IV drug abusers in a study from India. In this study by Saini, 40% were Staph aureus, 20% pseudomonas,  15% E coli. With the rest being Strep, and Acinetobacter. The current approaches are: ligation of the artery with local debridement, concomitant revascularization and delayed revascularization. Delayed bypasses involve a temporary bypass graft or a vein graft. Amputation was a complication of treatment in 4 of 72 patients.

Pseudosneursym of the R subclavian

Pseudosneursym of the R subclavian

pseudoaneursym of the R subclavian

pseudoaneursym of the R subclavian

Nearly one-third of patients in one survey of injection drug users admitted to licking their needles prior to injection. Int J Drug Policy 2008;19(4):342.  This is done to test the quality of the drug, but exposes IV drug users to multiple pathogens. A second source of infection is using bottled water which is not sterile and often contains gram negative organisms. Counseling on these two risks may mitigate infections.

 

 

Saini N, Luther A, Mahajan A, Joseph A. Infected pseudoaneursyms in intravenous drug abusers: ligation or reconstruction? 2014.  Int J Appl Basic Med Res. Sep;4(Suppl1):S23-S26.

Lenartoya M, Tak T. Iatogenic pseudoaneursym of the femoral artery: case report and literature review.  Clin Med Res 2003Jul;1(3):243-247.

Tufnell J. On the influence of vegetations on the valves of the heart, in the production of secondary arterial disease. Q J Med Sci (Dublin). 1853;15(2):371-382.

A 22 y.o. returns from Africa with a fever of 103 and a rash. She has a history of autoimmune hepatitis.

What could she have?

A diffuse rash is seen

A diffuse rash is seen

Our patient remained febrile for seven days.  She initially was treated with ceftriaxone by her PMD and then developed diarrhea.  She was seen in ID clinic and admitted. She was pancytopenic and had mild elevations in liver functions.  AST was 78.  In the hospital she was treated with ceftriaxone and typhoid was the presumed diagnosis. Two days later doxy was added for African tick bite fever.  Her immuran was stopped. The differential for infectious diseases acquired in South Africa is broad.

fever and africa1.JPG
fever and africa 2.JPG

African tick bite fever was first described in 1931 by Troup and Pijper.   It is transmitted by dog ticks in urban areas and cattle or game in rural areas. The incidence of infection in European visitors is 5% with visitors to game reserves at high risk of infection

Chikungunya

Chikungunya

Typhoid fever is most often contracted from exposure to water contaminated with sewage. Since one in twenty  people infected become chronic carriers, it is difficult to eradicate.

Arbovirus diseases are also common in South Africa.  Mosquitoes are the vector for Rift Valley fever, west Nile, dengue  Chikungunya. Ticks are the vector for Crimean-Congo hemorrhagic fever.  This is the most important hemorrhagic fever virus in South Africa.   Retinitis, meningitis and skin bleeds can be seen within two days of contracting the virus. 

typhoid rose spots

typhoid rose spots

When testing for arboviruses, the antibody-based assays may initially test negative as the immune system needs time to mount an immune response. In the case of our pt she had immune suppression from her immuran She was negative for malaria. Tbc, HIV,dengue, chikungunya and strongyloides tests pending at the time of discharge.

She was treated with doxy and Cipro for presumed typhoid fever and African tick bite fever.  She remained febrile although her fever was only 38 on discharge.

Delfos N, Schippers E, Rauoult D, Visser L. Fever and vesicular rash in a traveler returning from South Africa. Oxford Academia South African Fam Pract 2008 Vol 50(2) 33-35.

Prinsloo B. Arboviral diseases in Southern Africa. SA Fam Pract 2006: 48(8). 25-28

A 56 y.o. male presents with paraplegia

His MRI is shown below

what is wrong?

what is wrong?

Our patient was paraplegic because of spinal epidural lipomatosis. There is proliferation of fatty tissue in the spinal canal which compresses the cord. The first case was reported in 1975.  Many of the cases are due to long term use of steroids but it has also been associated with Cushings, hypothyroidism, prolactinoma and obesity. It has even been reported after epidural spinal injections.

lipomatosis grade II.JPG

Back pain is the initial presenting symptom. This is followed by lower extremity weakness and only rarely is incontinence reported. Since there is no fat in the cervical spine; symptoms are most often in the lower extremities.

 

Treatment can range from weight loss to surgical debulking of fat in the canal. Our patient was recognized late and was already paraplegic so no intervention was performed.

Rustom D, Gupta D, Chakrabortty S. Epidural lipomatosis: a dilemma in interventional pain management for the use of epidural steroids. J Anaesthesiol Clin Pharmacol. 2013;29:410-411

Fassett, D, Schmidt M.Spinal epidural lipomatosis: a review of its causes and recommendations for treatment. Neurosug Focus 16(4): Article 11, 2004. 1-3.

a 48 y.o. male loses control of his bicycle and skids off a slick road into a ditch. He has an obvious partial avulsion of the R ear.

because of ED overcrowding he waits hours and is never placed in a room. The triage MD orders a head and Cspine CT and a plastics consult. Plastics repairs his ear. While waiting for his ride he has an episode of syncope and is placed in a room. The head CT done previously is shown below.

do you agree with the radiologists read?

do you agree with the radiologists read?

The pt actually had a subdural along the falx

The pt actually had a subdural along the falx

There was an overread the next day on the head CT confirming the posterior subdural along the L falx.  The pt was admitted to ICU. In addition, although the CT had been read as normal the pt continued to have severe neck pain and MRI confirmed all the interspinous ligaments on the L side from C2-C5 were torn.  He was admitted to neurosurgery for both injuries and was instructed to were a cervical collar for although the anterior and posterior spinous ligaments were intact, he was unstable in lateral movement of the neck.

On T2 MRI the injury appears white over tthe posterior cervical spines

On T2 MRI the injury appears white over tthe posterior cervical spines

Cervical spine injuries occur in 3% of major trauma patients.  Morbidity and mortality from cervical injuries are high.  The litigation pay out for missed cervical spine injury on average in the US is $2.9 million. If the injury is missed on the initial presentation, the pt is ten times more likely to have neurologic sequelae.

an 84 y.o. fell out of his wheelchair and had neck pain with a negative CT of the C spine

an 84 y.o. fell out of his wheelchair and had neck pain with a negative CT of the C spine

He returned with persistent pain and an odontoid fracture was seen on MRI requiring treatment.

He returned with persistent pain and an odontoid fracture was seen on MRI requiring treatment.

In a prospective study of 767 patients who had MRI because of persistent neck pain after a negative neck CT, the MRI was abnormal in 23.6% of patients  with injuries ranging from ligamentous injuries(16%), soft tissue swelling 4%, Disc injury 1.4%,  and dural hematomas in 1.3%.  11 patients underwent cervical spine surgery after the MRI results and five of those had no neurologic findings. Another prospective study of 10,765 patients found 2% of patients with neg CT and persistent neck pain had significant neck injuries requiring intervention. The teaching point is that a neg neck CT is not able to completely rule out significant neck injury.

Most of the patients with missed injuries on CT had degenerative spine disease: our patient had a large posterior osteophyte which pushed the clinicians to order an MRI. He was discharged with a collar and neurosurgical follow up.

 

 

Maung A, Johnson D, Barre K, et al. Cervical spine MRI in patients with negative CT: A prospective, multicenter study of the Research Consortium of New England Centers for Trauma (ReCONECT). 2017 J Trauma Acute Care Surg. Feb 82(2):263-269.

Inaba K, Byerly S, Buysh L, et al. Cervical spinal clearance: A prospective Western Trauma Association Multi-Institutional Trial. 2016 J Trauma Acute Care Surg, Dec:81(6):1122-1130.

Resnick S, et al. Clinical relevance of Magnetic resonance imaging in cervical spine clearance. 2014  JAMA Surgery , vol 149 (9) jan: p 934, doiP10.1001/jamasurg.2014.867.

Diaz J, et al. The early work-up for isolated ligamentous injury of the cervical spine: does CT-scan have a role?2004  The Journal of Trauma: Injury, Infection and Critical Care, vol 57(2):453.

 

A 58 y.o. presents with an expanding abdominal wall hematoma six days after having an "abscess" aspirated

needle aspiration of an “abscess” after appendectomy; only blood returns

needle aspiration of an “abscess” after appendectomy; only blood returns

she returns six days later with an expanding hematoma; What happened?

she returns six days later with an expanding hematoma; What happened?

Our patient developed a pseudoaneursym which is  a collection of blood between the two outer layers of an artery, the tunica media and the tunica adventitia.  The damage probably happened when the interventionalist tried to aspirate what they thought was an abscess. 

aneursym.JPG

A pseudoaneursym is a common complication after a cardiac cath and occurs in 0.8 to 8% of vascular interventional procedures.

Pseudoaneursyms can occur in association with inflammation. In pancreatitis they occur in the superior mesenteric, and   pancreaticoduodenal artery.  In the heart pseudoaneursyms most often occur in the lateral wall and true aneurysms occur in the apex.

pseudoheart.JPG

Doppler flow mapping establishes the diagnosis. Diagnostic criteria include: swirling color flow in a mass separate from the main artery and a typical to and fro pattern in the pseudoaeursym neck. Ultrasound compression has been useful in occluding the pseudoaneursym neck allowing the aneurysm neck to thrombose.  Stents, percutaneous thrombin, percutaneous fibrin adhesive, coiling and surgery are also used to repair pseudoaneursyms.

In our patient, the superficial circumflex iliac artery was feeding the pseudoaneursym and was embolized.

The following is a question from USMLE

a. septal rupture  b. left ventricular free wall rupture  c. right ventricular free wall rupture  d. mitral regurgitation  e. left ventricular aneursym

a. septal rupture

b. left ventricular free wall rupture

c. right ventricular free wall rupture

d. mitral regurgitation

e. left ventricular aneursym

The answer is E. A thin fibrous scar is seen in the myocardial tissue. The patient presented with CHF which is the most common cause of death in patients with ventricular aneursyms. CHF is caused by poor contractility of the scarred myocardium and dyskinesis (paradoxical ballooning of the aneurysm with contraction). A pseudoaneursym( where there is no endocardium in the aneurysm) is more likely to rupture since only fragile scar tissue prevents cardiac wall rupture.

 

Lenartoya, M, Tak T. Iatrogenic pseudoaneursym of femoral artery: case report and literature review. Clin Med Res 2003 Jul;1(3):243-247.

Hamraoui K, Ernst S, et al. Efficacy and safety of percutaneous treatment of iatrogenic femoral artery pseudoaneursym by biodegradable collagen injection. J Am Coll Cardiol. 2002;39:1297-1304.

Messina L, Brothers T, Wakefield T, Zelenock G, et al. Clinical characteristics and surgical management of vascular complications in patients undergoing cardiac catheterization: interventional versus diagnostic procedures. J Vasc Surg. 1991;13:593-600.

A 30 y.o. male with no medical history presents for memory loss. He reports his short term memory has been gone for two weeks.

What could be wrong?

Increased T2 signal is seen in subcortical areas of the frontal lobes on MRI

Increased T2 signal is seen in subcortical areas of the frontal lobes on MRI

Our patient had encephalitis. This inflammation of the brain or meninges has many causes including viral and autoimmune. Viral causes include mosquito-borne illness as well as tick borne. RMSF is comon in Missouri but that was not the cause of our patients disease.

Rocky Mountain spotted fever

Rocky Mountain spotted fever

VIRAL ENCEPHALITIS

Varicella-zoster, Epstein-Barr virus,  CMV, measles, mumps.  Can present with  rash, lyphadenopathy, hepatosplenomegaly or parotid enlargement.

St. Louis encephalitis( mosquito borne) can present with movement disorders, dysuria and pyuria.

West Nile encephalitis( mosquito borne) can present with extreme lethargy or flaccid paralysis.

Tick borne encephalitis is an important infectious disease in Europe, the former Soviet Union and Asia. Powassan virus causes tick borne encephalitis in the US.

Rabies, Zika,  HIV, and enteroviruses also can cause encephalitis.

Any viral encephalitis can present with behavioral changes, SIADH, memory disturbance or seizures

Powassan encephalitis is also tick borne and not the cause of our patients disease..

Powassan encephalitis is also tick borne and not the cause of our patients disease..

AUTOIMMUNE ENCEPHALITIS

NMDA receptor encephalitis-40% are associated with ovarian teratomas

Leucine-rich glioma inactivated 1 and contactin-associated protein 2.

Anti-aquaporin-4 is associated with neuromyelitis optica.

HIV.

 

Different parts of the brain can be affected by encephalitis.  Limbic system involvement may result in psychosis.  Brainstem involvement may result in cranial nerve findings. Neuromyelitis optica may result in blindness. Our patient had primarily frontal lobe involvement with his encephalitis and therefore executive function; calculation and memory were affected.

Our patient had encephalitis caused by HIV.  He had a CD4 count of 90 and was started on bicegravir-emtricitabine-tenofovir and Bactrim. His JC virus in csf was negative .  The current diagnosis is HIV encephalopathy since infectious studies were negative.  

Remember West Nile as a possible cause of encephalitis

Remember West Nile as a possible cause of encephalitis

Davidson M, Williams H, Macleod J.  Louping ill in man: a forgotten disease. Journal of Infection 1991;23(30:241-49.

Ebel G. Update on Powassan virus: emergency of North American  tick-borne flavivirus . Annual Review of Entomology.  2010;55:95-110.

DubeyD, Pittock S, Kelly C, et al. Autoimmune encephalitis epidemiology and a comparison to infectious encephalitis. Ann Neurol. 2018;83(1):166-177.

 

A 39 y.o. woman persents with peritonitis, she has a history of a peritoneal inclusion cyst which has been drained by IR.

Her cyst is shown from 3/19 and her CT from 6.5 prior to the IR drain placement

cyst seen on US 3/19

cyst seen on US 3/19

CT prior to cyst drainage.

CT prior to cyst drainage.

The cyst was drained on 6/5 and alcohol was instilled. They were unable to replace a drained after several tries because the cyst had collapsed. When she returned with peritonitis the cyst was no longer visible on CT , there was no free air and no perforation noted with oral contrast on CT. She was taken to the OR by general surgery . What did they find?

Our patient was found to have a 10 cm tubovarian abscess on the L. It was not diagnosed on CT scan possibly because of abnormalities from the collapsed inclusion cyst and possibly because CT is poor for defining pelvic structures. It is not clear if the cyst drainage caused inadvertent puncture of bowel or the cyst causing peritonitis.

peritoneal inclusion cysts caused by adhesions to the ovary.

peritoneal inclusion cysts caused by adhesions to the ovary.

A peritoneal inclusion cyst is usually caused by accumulation of ovarian fluid that is trapped by adhesions to the ovary caused by previous inflammation. Previous inflammation thickens the peritoneum and makes it more difficult to absorb fluid.  Because the source of the fluid is ovarian, cysts are rare in males but have been reported in Crohn’s disease where there is chronic inflammation.

Conservative treatment of a peritoneal inclusion cyst is recommended because after surgical resection 30-50% recur. Oral contraceptives can be used to suppress ovulation, thus decreasing the formation of ovarian fluid trapped by adhesion and aspiration of the cysts can often be done transvaginally..

Our patient underwent a a L salpingo-oophorectomy and received doxy and flagyl .  Her pain improved and she was discharged.

Jain, K.  Imaging of peritoneal inclusion cysts. American Journal of Roentgenology. 2000 June Vol 174(6).

Ross M, Welch W, Scully R. Multilocular peritoneal inclusion cysts . Cancer 1989;64:1336-1364.

Sohaey R, Gardner T, Woodward P, Peterson C. Sonographic diagnosis of peritoneal inclusion cyst. J Ultrasound Med 1995;14:913-17.

Spriggs D, Melamed A, Weier L, Safdar N. A 24 y.o. woman with a pelvic mass. Case 18-2019. NEJM 2019

380:2361-9.

THE DIFFERENTIAL OF A PELVIC MASS INCLUDES:

Pregnancy and physiologic masses-endometriomas, cysts

Infections-diverticulitis, appendicitis, tuberculosis

Benign tumors-cystadenomas of the ovary or ovarian epithelial tumors

Cancer-familial tumors (BRCA or Lynch syndrome), high grade serous tumors and endometroid tumors(associated with CA-124), germ cell tumors.

A 51 y.o. presents for a swelling in the buttock

AVM presenting as a mass in the buttock

What is it?

What is it?

Our patient had an AVM of the pelvis which eroded through an ulcer in the skin. The AVM was from multiple feedings arteries from the profunda femoris and the internal iliac draining into the L common femoral vein. In the ED she initially stopped bleeding and IR was scheduled to embolize the next day but then she began to have a massive arterial hemorrhage and developed hemorrhagic shock in the ED. She was taken to IR after the massive tranfusion protocol was initiated and the BP remained 70 in spite of blood and pressors. Only 20 per cent of the AVM could be embolized but the bleeding was stopped by embolization and suturing the skin closed. She developed ATN with a creatinine was 6.0. Further definitive treatment was postponed until her kidneys recover. A REBOA was considered but general surgery felt the bleeding could be managed better with direct pressure.

AVMs are abnormal connections between arteries and veins causing high flow in the venous limb. They can occur in the brain, neck, spine, arms, legs and liver. The incidence of AVM is one in 10,000 individuals. If you have an AVM there is a 4% risk of bleeding per year.

Uterine AVM presenting with vaginal bleeding and diagnosed with US. While US is the first modality for diagnosis, MRA is often used as well.

Uterine AVM presenting with vaginal bleeding and diagnosed with US. While US is the first modality for diagnosis, MRA is often used as well.

AVMs can be congenital or acquired with the congenital form having more feeding vessels and being more difficult to embolize. Ischemia of the distal extremity and thrombosis are known complications of AVMs. One of the more common forms of acquired AVMs are uterine AVMs which occur after abortion or childbirth and cause life threatening vaginal bleeding.

Greene A, Orbach D. Management of AV malformations. 2011 Clin Plastic Surg;38(1):95-106.

Belfort M. Postpartum hemorrhage: Medical and minimally invasive management.

Sridhar D, Vogelsang R. Diagnosis and treatment of uterine and pelvic AVM: a review of etiology, clinical presentation and imaging findings, and treatment options, 2018 Endovascular Today, Jan

Yazawa H, Soeda S, Hiraiwa T, el al. Prospective evaluation of the incidence of uterine vascular malformation developing after abortion or delivery. Minimally Invasive Gynecology 2013;20:360-67.

A 60 y.o male with altered mental staus is found wandering; you notice something in his chest.

what happened to him?

what happened to him?

Our patient had an implantable loop recorder that eroded through the skin. The device is covered by Medicare and can stay implanted for three years. The European College of Cardiology recommends implantation in the early stages of a syncope evaluation so they may be seen more frequently in the ED.

placement of a loop event monitor

placement of a loop event monitor

Kaoru Tanno’s article reviews the studies which have been done comparing implantable loop event monitors with conventional syncope evaluations which include 2-4 weeks of external heart monitoring, electrophysiological studies and tilt table testing. The implantable monitor was more successful in making a diagnosis than conventional testing. There have been no studies showing that making the diagnosis improves quality of life or length of life.

2.JPG

The complications of the implantable loop event monitor include infection of the pocket and misdiagnosis since it has difficulty distinguishing at times between VT and SVT. The complications occur in 1-5% of patients.

Our patient had his event monitor removed in the ED.

Krahn A, Klein G. et al. The high cost of syncope: cost implications of a new insertable loop recorder in the investigation of recurrent syncope. Am Heart 1999. may, 137(5)870-87

Tanno K. Use of implantable and external loop recorders in syncope with unknown causes. Arrhythm 2017 v33(6) . This reference includes the RAST study comparing external recording x 2-4 wks, with EP testing and tilt table vs 1 yr of an implantable recorder.

Onuki T, Ito H. Ochi A. Single center experience in Japanese patients with syncope. J Cardio 2015;66:395-402.

Ruwald M, Zereba W. ECG monitoring in Syncope. Prog Cardiovas Dis. 2013. 56:203-210.

A 23 y.o. female involved in a head on MVC, is awake and alert. She is taken to the OR and post op does not wake up.

A chest Ct looking for PE is neg for PE but shows the findings below.

patchy ground glass infiltrates are seen HInt: she had a leg fracture

patchy ground glass infiltrates are seen HInt: she had a leg fracture

What could be wrong?

our patient had fat emboli from a femur fracture

our patient had fat emboli from a femur fracture

Our patient had a fat emboli syndrome. Fat emboli occur in nearly   all patients that have fractures of the long bones but in a small percentage this results in fat emboli syndrome (FES). This occurs in 3-10% of ortho trauma patients  and the mortality is 10-20%. Manifectations occure 24-72 hours after injury  Embolized fat is degraded into free fatty acids, which cause toxic injury and inflammation causing edema. 

mini infarct in the brain on her T2 weighted images.

mini infarct in the brain on her T2 weighted images.

The classic triad involves lung, brain and skin. It was first described by Zenker in 1862. The pulmonary manifestations are the most common with hypoxia as the main presentation.  The neuroabnormalities include confusion, focal deficits and seizures.  There is a petechial rash in 20 per cent of cases often on the head and neck.  Lipiduria may also be present.  Fat globules can be seen in bronchoalveolar lavage specimens.

fat globues with Oil red O stain in macrophages on bronchoalveolar lavage.

fat globues with Oil red O stain in macrophages on bronchoalveolar lavage.

In the correct clinical setting, as in our patient the diagnosis can be made.  Other forms of trauma have been associated with fat embolism syndrome including liposuction and CPR.  There are also rare cases of nontrauma-related FES including sickle cell anemia, pancreatitis and lipid infusions.

 

Albumin has been recommended for treatment since it binds fatty acids. It is not clear if steroids are effective.

Our patient was unable to speak after surgery secondary to cerebral fat emboli and mini strokes.  She has gradually improved and now is able to speak although she is very slow to respond to questions and will be discharged to rehab.

petechiae in fat embolism

petechiae in fat embolism

Shaikh N, Emergency management of fat embolism syndrome. 2009 J Emerg Trauma Shock. Jan-April 2(1);19-33.

Fourme T, Viellard-Baron. Et al. Early fat embolism after liposuction. Anaesthesiology 1998 ;89:782-4.

Verdrinne J, Guillauma C, Gagnieu M. et al. Bronchoalveolar lavage in trauma patients for diagnosis of fat embolism syndrom. Chest 1992;102:1323-7.

Gangaraju R, Reddy V, Marques M. Fat embolism syndrome secondary to bone marrow necrosis in patients with hemoglobinopathies. South Med 2016;109-549.