Case Reports in Emergency Medicine The latest articles from Hindawi Publishing Corporation © 2016 , Hindawi Publishing Corporation . All rights reserved. Ischemic Left Ventricular Perforation Covered by a Thrombus in a Patient Presenting with Cerebral Ischemia: Importance of Time-Sensitive Performance and Adequate Interpretation of Bedside Transthoracic Echography Thu, 04 Feb 2016 06:45:29 +0000 If myocardial infarction remains silent, only clinical signs of complications may unveil its presence. Life-threatening complications include myocardial rupture, thrombus formation, or arterial embolization. In the presented case, a 76-year-old patient was admitted with left-sided hemiparesis. In duplex sonography, a critical stenosis of the right internal carotid artery was identified and initially but retrospectively incorrectly judged as the potential cause for ischemia. During operative thromboendarterectomy, arterial embolism of the right leg occurred coincidentally, more likely pointing towards a cardioembolic origin. Percutaneous interventions remained unsuccessful and local fibrinolysis was applied. Delayed bedside echocardiography by an experienced cardiologist demonstrated a discontinuity of the normal myocardial texture of the left ventricular apex together with an echodense, partly floating structure merely attached by a thin bridge not completely sealing the myocardial defect, accompanied by pericardial effusion. The patient was immediately transferred to emergency cardiac surgery with extirpation of the thrombus, aortocoronary bypass graft placement, and aneurysmectomy. This didactic case reveals decisive structural shortcomings in patient’s admission and triage processes and underlines, if performed timely and correctly, the value of transthoracic echocardiography as a noninvasive and cost-effective tool allowing immediate decision-making, which, in this case, led to the correct but almost fatally delayed diagnosis. A. J. Fischer, P. Lebiedz, M. Wiaderek, M. Lichtenberg, D. Böse, S. Martens, and F. Breuckmann Copyright © 2016 A. J. Fischer et al. All rights reserved. An Unusual Case of Spontaneous Esophageal Rupture after Swallowing a Boneless Chicken Nugget Tue, 02 Feb 2016 07:21:42 +0000 A 25-year-old previously healthy man presented to our Emergency Department with shortness of breath and epigastric pain after swallowing a boneless chicken nugget one hour prior to presentation. Physical examination revealed epigastric rigidity and tenderness. Serology was normal except for mildly elevated bilirubin and amylase. Computed tomography (CT) scan of the chest revealed a distal esophageal rupture with accompanying pneumomediastinum and left-sided pleural effusion. Treatment was initiated with administration of intravenous fluids and broad-spectrum antibiotics. Subsequently, an esophageal stent was inserted endoscopically in addition to VATS (Video-Assisted Thoracoscopic Surgery) drainage of the left-sided pleural space. This case illustrates an unusual presentation of Boerhaave’s syndrome: a rare and life-threatening form of noniatrogenic esophageal rupture most often preceded by forceful vomiting. Our case demonstrates that physicians should maintain an index of suspicion for spontaneous esophageal rupture in patients presenting with shortness of breath and epigastric pain even in the absence of preceding vomiting, cough, or seizure. Additionally, ingestion of boneless, shell-less foods may be sufficient to cause rupture in individuals without underlying esophageal pathology. CT scan of the thorax and upper abdomen should be performed in these patients to rule out this rare and life-threatening diagnosis. Zeenia Aga, Jackie Avelino, Gail E. Darling, and Jo Jo Leung Copyright © 2016 Zeenia Aga et al. All rights reserved. A Tuboovarian Abscess Associated with a Ruptured Spleen Sun, 24 Jan 2016 14:04:58 +0000 We report the first case of a tuboovarian abscess complicated by a ruptured spleen. Our patient was a 27-year-old female with human immunodeficiency virus (HIV) who presented to the emergency department (ED) with complaints of urinary symptoms and diarrhea. After being diagnosed with a tuboovarian abscess (TOA), she received antibiotics and was admitted to the gynecology service. Shortly thereafter she developed hemorrhagic shock, necessitating a splenectomy and salpingooophorectomy from a ruptured spleen. Jennifer S. Li and Johnathan Michael Sheele Copyright © 2016 Jennifer S. Li and Johnathan Michael Sheele. All rights reserved. The Great Imitator Strikes Again: Syphilis Presenting as “Tongue Changing Colors” Wed, 20 Jan 2016 12:12:23 +0000 Syphilis is known as the great imitator, making its diagnosis in the emergency department difficult. A 29-year-old male presented with the chief complaint of “my tongue is changing colors.” A syphilis rapid plasma reagin (RPR) test resulted as positive. In primary syphilis, the chancre is the characteristic lesion. While chancres are frequently found on the external genitalia or anus, extragenital chancres arise in 2% of patients. With oral involvement, the chancre is commonly found on the lip or tongue. The patient was treated for secondary syphilis with 2.4 million units of long acting penicillin intramuscularly. On follow-up a month later, the patient’s symptoms had resolved. Jessica Swanson and Janna Welch Copyright © 2016 Jessica Swanson and Janna Welch. All rights reserved. Pentobarbital Toxicity after Self-Administration of Euthasol Veterinary Euthanasia Medication Sun, 03 Jan 2016 13:07:55 +0000 Suicide attempt via sodium pentobarbital is uncommon. A 48-year-old woman with a history of depression and prior suicide attempt was found unresponsive by her veterinarian spouse near a syringe containing pink solution. Upon EMS’ arrival, the patient was experiencing apnea, hypoxemia, and miotic pupils; her blood glucose level measured 73 mg/dL. She was bradycardic and administered atropine with transient improvement in heart rate and transported to an emergency department; 2 mg of intravenous naloxone was administered without effect. She was endotracheally intubated via rapid sequence intubation. Rapid urine drug screening detected both benzodiazepines and barbiturates. The patient was transferred to an intensive care unit where she demonstrated a nearly absent radial pulse. Emergent fasciotomy to the left forearm and carpal tunnel was performed for acute compartment syndrome; “Euthasol” had been self-administered into the antecubital fossa. Expanded toxicological analysis via liquid chromatography/mass spectroscopy detected caffeine, atropine, 7-aminoclonazepam, phenytoin, citalopram, and naproxen. The patient’s coma resolved over 48 hours and she was successfully extubated without complication. Emergency physicians must closely monitor patients exposed to veterinary euthanasia agents who develop central nervous system and respiratory depression, hypothermia, bradycardia, hypotension, or skin injury. Consultation with a regional poison center and medical toxicologist is recommended. Steven Jason Crellin and Kenneth D. Katz Copyright © 2016 Steven Jason Crellin and Kenneth D. Katz. All rights reserved. Life-Threatening Retropharyngeal Hemorrhage Secondary to Rupture of the Inferior Thyroid Artery Thu, 24 Dec 2015 11:15:01 +0000 Inferior thyroid artery (ITA) rupture is rare and may progress to life-threatening conditions. We present a patient who visited the emergency department after an episode of syncope and dizziness in which he had a mechanical fall that resulted in abrasions and a hematoma to his left forehead. The patient presented with dysphagia and anterior neck swelling that progressed rapidly into airway compromise requiring endotracheal intubation. Emergent computed tomography revealed a large retropharyngeal hematoma, with active arterial extravasation that was thought to be arising from the thyrocervical trunk on the left. The hematoma measured approximately 6.7 cm transversely and 3.2 cm anteroposteriorly and extended from the level of the lower nasopharynx, down the neck into the retropharyngeal and danger space and into the mediastinum posterior to the esophagus, overall approximately 25 cm. The larynx was deviated anteriorly and there was esophageal compression. An emergent arteriogram and catheterization confirmed bleeding from branches of the ITA, and successful embolization was performed. It is important to recognize the ITA rupture as a potential etiology of an acute airway compromise. In emergent situations, while securing an airway is a priority, rapidly initiating diagnostic testing to confirm the diagnosis and arranging for arterial embolization can be life-saving. Cristina G. Calogero, Andrew C. Miller, and Marna Rayl Greenberg Copyright © 2015 Cristina G. Calogero et al. All rights reserved. Not Just Painless Bleeding: Meckel’s Diverticulum as a Cause of Small Bowel Obstruction in Children—Two Cases and a Review of the Literature Wed, 16 Dec 2015 12:37:04 +0000 Physicians are educated with the classical teaching that symptomatic patients with Meckel’s diverticulum (MD) most often present with painless rectal bleeding. However, a review of the literature reveals that young patients with MD will most commonly present with signs of intestinal obstruction, an etiology not frequency considered in patients presenting to the emergency department with obstruction. We present two cases of intestinal obstruction diagnosed in our emergency department, with Meckel’s diverticulum being the etiology. Khalida Itriyeva, Matthew Harris, Joshua Rocker, and Robert Gochman Copyright © 2015 Khalida Itriyeva et al. All rights reserved. Isolated Proximal Tibiofibular Dislocation during Soccer Wed, 02 Dec 2015 09:03:36 +0000 Proximal tibiofibular dislocations are rarely encountered in the Emergency Department (ED). We present a case involving a man presenting to the ED with left knee pain after making a sharp left turn on the soccer field. His physical exam was only remarkable for tenderness over the lateral fibular head. His X-rays showed subtle abnormalities of the tibiofibular joint. The dislocation was reduced and the patient was discharged from the ED with orthopedic follow-up. Casey Chiu and Johnathan Michael Sheele Copyright © 2015 Casey Chiu and Johnathan Michael Sheele. All rights reserved. Death after Sexual Intercourse Tue, 01 Dec 2015 06:24:27 +0000 Sexuality is an essential aspect of quality of life. Nevertheless, sexual intercourse is physically challenging and leads to distinct changes in blood pressure, heart, and respiratory rate that may lead to vital complications. We present a case report of a 22-year-old female suffering from subarachnoid hemorrhage after sexual intercourse. The patient was immediately transported to hospital by emergency medical services and, after diagnosis, transferred to a tertiary hospital with neurosurgical expertise but died within 24 hours. After postcoital headaches, subarachnoid hemorrhage is the second most common cause of neurological complications of sexual intercourse and therefore patients admitted to an emergency department with headache after sexual intercourse should always be carefully evaluated by cerebral imaging. Christian T. Braun, Meret E. Ricklin, Andreina Pauli, Daniel Ott, Aristomenis K. Exadaktylos, and Carmen A. Pfortmueller Copyright © 2015 Christian T. Braun et al. All rights reserved. Subdural Hematoma as a Consequence of Epidural Anesthesia Mon, 30 Nov 2015 11:46:19 +0000 Regional spinal and epidural anesthesia are used commonly in operative procedures. While the most frequent complication, postdural puncture headache (PDPH), is a clinically diagnosed positional headache that is usually self-limited, subdural hemorrhage (SDH) is a potentially fatal complication that cannot be missed. We report a case of an otherwise healthy female who presented with persistent positional headache and was ultimately found to have a large subdural hematoma with midline shift requiring surgical evacuation. Tracy M. Bishop, Kareem S. Elsayed, and Kathleen E. Kane Copyright © 2015 Tracy M. Bishop et al. All rights reserved. Low-Intensity Repetitive Exercise Induced Rhabdomyolysis Thu, 26 Nov 2015 11:55:01 +0000 Rhabdomyolysis is a rare condition caused by the proteins of damaged muscle cells entering the bloodstream and damaging the kidneys. Common symptoms of rhabdomyolysis are muscle pain and fatigue in conjunction with dark urine; kidney damage is a common symptom among these patients. We present a case of a 23-year-old woman who displayed myalgia in the upper extremities caused by low-intensity and high-repetition exercise. She was successfully diagnosed and treated for exertional rhabdomyolysis. This patient had no significant medical history that would induce this condition. We urge the emergency medical community to observe and monitor patients that complain of myalgia to ensure they are not suffering from rhabdomyolysis even in atypical cases. Mina Tran, Nicholas Hayden, Brandon Garcia, and Veronica Tucci Copyright © 2015 Mina Tran et al. All rights reserved. Double Bolus Thrombolysis for Suspected Massive Pulmonary Embolism during Cardiac Arrest Tue, 17 Nov 2015 11:09:53 +0000 More than 70% of cardiac arrest cases are caused by acute myocardial infarction (AMI) or pulmonary embolism (PE). Although thrombolytic therapy is a recognised therapy for both AMI and PE, its indiscriminate use is not routinely recommended during cardiopulmonary resuscitation (CPR). We present a case describing the successful use of double dose thrombolysis during cardiac arrest caused by pulmonary embolism. Notwithstanding the relative lack of high-level evidence, this case suggests a scenario in which recombinant tissue Plasminogen Activator (rtPA) may be beneficial in cardiac arrest. In addition to the strong clinical suspicion of pulmonary embolism as the causative agent of the patient’s cardiac arrest, the extremely low end-tidal CO2 suggested a massive PE. The absence of dilatation of the right heart on subxiphoid ultrasound argued against the diagnosis of PE, but not conclusively so. In the context of the circulatory collapse induced by cardiac arrest, this aspect was relegated in terms of importance. The second dose of rtPA utilised in this case resulted in return of spontaneous circulation (ROSC) and did not result in haemorrhage or an adverse effect. Gerard O’Connor, Gareth Fitzpatrick, Ayman El-Gammal, and Peadar Gilligan Copyright © 2015 Gerard O’Connor et al. All rights reserved. Concurrent Spontaneous Sublingual and Intramural Small Bowel Hematoma due to Warfarin Use Mon, 16 Nov 2015 11:47:17 +0000 Introduction. We present a case of concurrent spontaneous sublingual and intramural small bowel hematoma due to warfarin anticoagulation. Case. A 71-year-old man presented to the emergency department complaining of a swollen, painful tongue. He was on warfarin therapy. Physical examination revealed sublingual hematoma. His international normalized ratio was 11.9. The computed tomography scan of the neck demonstrated sublingual hematoma. He was admitted to emergency department observation unit, monitored closely; anticoagulation was reversed with fresh frozen plasma and vitamin K. 26 hours after his arrival to the emergency department, his abdominal pain and melena started. His abdomen tomography demonstrated intestinal submucosal hemorrhage in the ileum. He was admitted to surgical floor, monitored closely, and discharged on day 4. Conclusion. Since the patient did not have airway compromise holding anticoagulant, reversing anticoagulation, close monitoring and observation were enough for management of both sublingual and spontaneous intramural small bowel hematoma. Gül Pamukçu Günaydın, Hatice Duygu Çiftçi Sivri, Serkan Sivri, Yavuz Otal, Ayhan Özhasenekler, and Gülhan Kurtoğlu Çelik Copyright © 2015 Gül Pamukçu Günaydın et al. All rights reserved. Incidental Finding of Inferior Vena Cava Atresia Presenting with Deep Venous Thrombosis following Physical Exertion Tue, 10 Nov 2015 11:10:29 +0000 Inferior vena cava atresia (IVCA) is a rare but well described vascular anomaly. It is a rare risk factor for deep venous thrombosis (DVT), found in approximately 5% of cases of unprovoked lower extremity (LE) DVT in patients <30 years of age. Affected population is in the early thirties, predominantly male, often with a history of major physical exertion and presents with extensive or bilateral DVTs. Patients with IVC anomalies usually develop compensatory circulation through the collateral veins with enlarged azygous/hemizygous veins. Despite the compensatory circulation, the venous drainage of the lower limbs is often insufficient leading to venous stasis and thrombosis. We describe a case of extensive and bilateral deep venous thrombosis following physical exertion in a thirty-six-year-old male patient with incidental finding of IVCA on imaging. Shalini Koppisetty, Alton G. Smith, and Ravneet K. Dhillon Copyright © 2015 Shalini Koppisetty et al. All rights reserved. Elevated Intracranial Pressure Diagnosis with Emergency Department Bedside Ocular Ultrasound Mon, 26 Oct 2015 11:36:36 +0000 Bedside sonographic measurement of optic nerve sheath diameter can aid in the diagnosis of elevated intracranial pressure in the emergency department. This case report describes a 21-year-old female presenting with 4 months of mild headache and 2 weeks of recurrent, transient binocular vision loss. Though limited by patient discomfort, fundoscopic examination suggested the presence of blurred optic disc margins. Bedside ocular ultrasound (BOUS) revealed wide optic nerve sheath diameters and bulging optic discs bilaterally. Lumbar puncture demonstrated a cerebrospinal fluid (CSF) opening pressure of 54 cm H2O supporting the suspected diagnosis of idiopathic intracranial hypertension. Accurate fundoscopy can be vital to the appropriate diagnosis and treatment of patients with suspected elevated intracranial pressure, but it is often technically difficult or poorly tolerated by the photophobic patient. BOUS is a quick and easily learned tool to supplement the emergency physician’s fundoscopic examination and help identify patients with elevated intracranial pressure. D. Amin, T. McCormick, and T. Mailhot Copyright © 2015 D. Amin et al. All rights reserved. Disabling Orthostatic Headache after Penetrating Stonemason Pencil Injury to the Sacral Region Mon, 26 Oct 2015 08:21:24 +0000 Penetrating injuries to the spine, although less common than motor vehicle accidents and falls, are important causes of injury to the spinal cord. They are essentially of two varieties: gunshot or stab wounds. Gunshot injuries to the spine are more commonly described. Stab wounds are usually inflicted by knife or other sharp objects. Rarer objects causing incidental spinal injuries include glass fragments, wood pieces, chopsticks, nailguns, and injection needles. Just few cases of penetrating vertebral injuries caused by pencil are described. The current case concerns a 42-year-old man with an accidental penetrating stonemason pencil injury into the vertebral canal without neurological deficit. After the self-removal of the foreign object the patient complained of a disabling orthostatic headache. The early identification and treatment of the intracranial hypotension due to the posttraumatic cerebrospinal fluid (CSF) sacral fistulae were mandatory to avoid further neurological complications. In the current literature acute pattern of intracranial hypotension immediately after a penetrating injury of the vertebral column has never been reported. Carlo Brembilla, Luigi Andrea Lanterna, Paolo Gritti, Emanuele Costi, Gianluigi Dorelli, Elena Moretti, and Claudio Bernucci Copyright © 2015 Carlo Brembilla et al. All rights reserved. A Case of Palytoxin Poisoning in a Home Aquarium Enthusiast and His Family Mon, 26 Oct 2015 06:34:38 +0000 Inhalational exposure to palytoxin is an extremely rare cause of respiratory distress. This little-known marine toxin has the potential to cause significant morbidity and mortality. Toxicity has been best documented in cases of ingestion but has also been seen in cases of dermal exposure and inhalation of vapors. Palytoxin has been found in several coral species, some of which are favored by home aquarium enthusiasts and are commercially available. We report a case of a family who were exposed to the aerosolized toxin following the cleaning of a coral in their home aquarium. It is important that clinicians be aware of this source of toxic exposure to provide necessary care to these patients. Christine Hall, David Levy, and Steven Sattler Copyright © 2015 Christine Hall et al. All rights reserved. Acetabular Liner Dissociation following Total Hip Arthroplasty: A Rare but Serious Complication That May Be Easily Misinterpreted in the Emergency Department Mon, 12 Oct 2015 08:12:40 +0000 Acetabular liner dissociation is a rare complication of Total Hip Arthroplasty (THA) which requires urgent revision surgery. A case is presented in which the correct diagnosis was not appreciated on two separate Emergency Department attendances. The typical symptoms, signs, and radiological features are outlined and the importance of considering a rare complication following a commonly performed procedure is highlighted. Christopher K. J. O’Neill, Richard J. Napier, Owen J. Diamond, Seamus O’Brien, and David E. Beverland Copyright © 2015 Christopher K. J. O’Neill et al. All rights reserved. Damage Control Surgery for Hepatocellular Cancer Rupture in an Elderly Patient: Survival and Quality of Life Sun, 04 Oct 2015 15:17:32 +0000 Spontaneous rupture of hepatocellular carcinoma (HCC) is a rare emergency condition with high mortality rate. Successful management depends on patients’ hemodynamic condition upon presentation and comorbidities, correct diagnosis, HCC status, liver function, and future liver remnant, as well as available sources. There is still a debate in the literature concerning the best approach in this devastating complication. Nevertheless, the primary goal should be a definitive bleeding arrest. In most cases, patients with spontaneous rupture of HCC present with hemodynamic instability, due to hemoperitoneum, necessitating an emergency treatment modality. In such cases, transcatheter arterial embolization (TAE) should be the treatment of choice. Emergency liver resection is an option when TAE fails or in cases with preserved liver function and limited tumors. Otherwise, damage control strategies, as in liver trauma, are a reasonable alternative. We report a case of an elderly patient with hemoperitoneum and hypovolemic shock from spontaneous rupture of undiagnosed HCC, who was treated successfully by emergency surgery and damage control approach. Konstantinos Bouliaris, Grigorios Christodoulidis, Dimitrios Symeonidis, Alexandros Diamantis, and Konstantinos Tepetes Copyright © 2015 Konstantinos Bouliaris et al. All rights reserved. A Missed Case of Occult Bilateral Temporomandibular Dislocation Mistaken for Dystonia Mon, 07 Sep 2015 05:57:22 +0000 A 24-year-old male with a history of psychiatric disorder and no prior significant temporomandibular joint (TMJ) pathology presented to the emergency department for “lockjaw.” Plain film X-rays of the mandible were read as unremarkable by an attending radiologist, leading to the initial diagnosis of medication-induced dystonic reaction. Following unsuccessful medical treatment a maxillofacial computed tomography (CT) was ordered. CT confirmed bilateral dislocation, illustrating the importance of clinical judgment, and limitations of certain radiographic images. The authors believe this case to be the first reported case in the medical literature of bilateral anterior TMJ dislocation with a false negative X-ray. Evelyn Lee, Jan Shoenberger, and Jonathan Wagner Copyright © 2015 Evelyn Lee et al. All rights reserved. Speaking Tracheostomy Tube and Modified Mouthstick Stylus in a Ventilator-Dependent Patient with Spinal Cord Injury Thu, 27 Aug 2015 12:36:12 +0000 Communication is a serious problem for patients with ventilator-dependent tetraplegia. A 73-year-old man was presented at the emergency room in cardiopulmonary arrest after falling from a height of 2 m. After successful resuscitation, fractures of the cervical spine and cervical spinal cord injury were found. Due to paralysis of the respiratory muscles, a mechanical ventilator with a tracheostomy tube was required. First, a cuffed tracheostomy tube and a speaking tracheostomy tube were inserted, and humidified oxygen was introduced via the suction line. Using these tubes, the patient could produce speech sounds, but use was limited to 10 min due to discomfort. Second, a mouthstick stylus, fixed on a mouthpiece that fits over the maxillary teeth, was used. The patient used both a communication board and a touch screen device with this mouthstick stylus. The speaking tracheostomy tube and mouthstick stylus greatly improved his ability to communicate. Eiji Mitate, Kensuke Kubota, Kenji Ueki, Rumi Inoue, Ryosuke Inoue, Kenta Momii, Hiroshi Sugimori, Yoshihiko Maehara, and Seiji Nakamura Copyright © 2015 Eiji Mitate et al. All rights reserved. Late Onset Traumatic Diaphragmatic Herniation Leading to Intestinal Obstruction and Pancreatitis: Two Separate Cases Mon, 24 Aug 2015 13:44:18 +0000 Although diaphragmatic injuries caused by blunt or penetrating trauma are rare entities, they are the most commonly misdiagnosed injuries in trauma patients and occur in approximately 3–7% of all abdominal or thoracic traumas. Acute pancreatitis secondary to late presenting diaphragmatic hernia is very rare. Here we present two separate cases: one with acute bowel obstruction and the other with acute pancreatitis secondary to late onset traumatic diaphragmatic hernia (three and twenty-eight years after chest trauma, resp.). Tolga Dinc, Selami Ilgaz Kayilioglu, and Faruk Coskun Copyright © 2015 Tolga Dinc et al. All rights reserved. Scombrotoxinism: Protracted Illness following Misdiagnosis in the Emergency Department Wed, 19 Aug 2015 09:49:05 +0000 Background. Scombrotoxinism is an acute toxin-induced illness caused primarily by bacterial synthesis of histamine in decomposed fish. Case Report. Immediately after taking 2-3 bites of cooked salmon, a clerical worker developed oral burning, urticaria, and asthma. In the emergency department, she was diagnosed with “allergies”; scombrotoxinism was never considered. She then developed wide-ranging symptoms (e.g., chronic fatigue, asthma, anxiety, multiple chemical sensitivity, and paresthesiae) and saw many specialists (in pulmonology, otorhinolaryngology, allergy, toxicology, neurology, psychology, and immunology). During the next 500+ days, she had extensive testing (allergy screens, brain MRI, electroencephalogram, electromyogram, nerve conduction velocity, heavy metal screen, and blood chemistry) with essentially normal results. She filed a workers’ compensation claim since this injury occurred following a business meal. She was evaluated by a Qualified Medical Evaluator (GL) on day 504, who diagnosed scombrotoxinism. Comment. Scombrotoxinism should be considered in all patients presenting to the emergency department with “oral burning” or allergy symptoms following “fish consumption.” Initial attention to such history would have led to a correct diagnosis and averted this patient’s extended illness. Specialist referrals and tests should be ordered only if clinically indicated and not for diagnostic fishing expedition. Meticulous history is crucial in resolving clinical dilemmas. Ghan-Shyam Lohiya, Sapna Lohiya, Sunita Lohiya, and Vijay Krishna Copyright © 2015 Ghan-Shyam Lohiya et al. All rights reserved. Novel Therapies for Myocardial Irritability following Extreme Hydroxychloroquine Toxicity Mon, 17 Aug 2015 08:48:35 +0000 Introduction. Hydroxychloroquine (HCQ) overdose is rare and potentially deadly when consumed in large doses. Management of severe HCQ toxicity is limited and infrequently reported. This report presents the case of a massive ingestion of HCQ. Case Report. A 23-year-old female presents following an intentional ingestion of approximately 40 g of HCQ. Within six hours after ingestion, she developed severe hemodynamic instability resulting from myocardial irritability with frequent ventricular ectopic activity leading to runs of polymorphic ventricular tachycardia (PMVT) and ventricular fibrillation (VF) requiring multiple defibrillations. Additional treatments included intravenous diazepam, epinephrine, norepinephrine, sodium bicarbonate, and magnesium sulfate. Despite the ongoing hemodynamic instability, the patient was also treated with Intralipid (ILE) and received hemodialysis. Improvements in her hemodynamics were observed after 18 hours. She survived her massive overdose of HCQ. Conclusion. HCQ poisoning is rare but serious because of its rapid progression to life-threatening symptoms. Hemodynamic support, gastric decontamination, electrolyte monitoring and replacement, and management of arrhythmias are the mainstays of treatment. The combined role of dialysis and ILE in the setting of massive HCQ overdose may improve outcomes. Paul B. McBeth, Perseus I. Missirlis, Harry Brar, and Vinay Dhingra Copyright © 2015 Paul B. McBeth et al. All rights reserved. Subclavian Artery Pseudoaneurysm Formation 3 Months after a Game of Rugby Union Mon, 17 Aug 2015 08:32:23 +0000 Pseudoaneurysms of the subclavian artery remain a rare complication after fracture of the clavicle. We report a case of delayed diagnosis of a subclavian artery pseudoaneurysm after a closed fracture of the clavicle in a 15-year-old patient, 3 months after the original injury while playing rugby union. Despite several attendances to the Emergency Department with vague symptoms, the final diagnosis was confirmed by duplex ultrasound and Computed Tomography of the thorax. Surgical repair was indicated due to acute limb ischaemia from distal embolisation from a large pseudoaneurysm, with the patient making a full recovery. This case highlights the need for clinical vigilance when assessing patients, particularly on repeated occasions when their recovery appears to be impaired. A thorough history and clinical examination can raise suspicion of even rare occurrences and aid prompt management. T. Evans, S. Roy, and M. Rocker Copyright © 2015 T. Evans et al. All rights reserved. A Case of Unrecognized Intrathoracic Placement of a Subclavian Central Venous Catheter in a Patient with Large Traumatic Hemothorax Tue, 11 Aug 2015 07:39:23 +0000 Traditional recommendations suggest placement of a subclavian central venous catheter (CVC) ipsilateral to a known pneumothorax to minimize risk of bilateral pneumothorax. We present the case of a 65-year-old male with a right hemopneumothorax who was found to have intrathoracic placement of his right subclavian CVC at thoracotomy despite successful aspiration of blood and transduction of central venous pressure (CVP). We thus recommend extreme caution with the interpretation of CVC placement by blood aspiration and CVP measurement alone in patients with large volume ipsilateral hemothorax. Dina Wallin, Alicia R. Privette, Andre R. Campbell, and Julin F. Tang Copyright © 2015 Dina Wallin et al. All rights reserved. Necrotizing Fasciitis Secondary to a Primary Suture for Anoperineal Trauma by Motorcycle Accident in a Healthy Adult Mon, 10 Aug 2015 14:07:21 +0000 A 41-year-old man experienced a swollen scrotum three days after a motorcycle accident and presented to our hospital. He had had a primary suture repair for anoperineal trauma in an outside hospital at the time of the injury. He presented to us with general fatigue, low grade fevers, and perineal pain. Abdominal computed tomography showed subcutaneous emphysema from the scrotum to the left chest. The sutured wound had foul-smelling discharge and white exudate. We made the diagnosis of necrotizing fasciitis and immediately opened the sutured wound and performed initial debridement and lavage with copious irrigation. We continued antibiotics and lavage of the wound until the infection was controlled. Fortunately, the necrotizing fasciitis did not worsen and he was discharged after 15 days. Our experience indicates that anoperineal injuries should not be closed without careful and intensive follow-up due to the potential of developing necrotizing fasciitis. Susumu Saigusa, Masaki Ohi, Hiroki Imaoka, Ryo Uratani, Minako Kobayashi, and Yasuhiro Inoue Copyright © 2015 Susumu Saigusa et al. All rights reserved. Subcutaneous Emphysema, Pneumomediastinum, and Pneumorrhachis after Cocaine Inhalation Wed, 08 Jul 2015 06:33:39 +0000 Introduction. The most prominent complications of cocaine use are adverse effects in the cardiovascular and central nervous systems. Free air in the mediastinum and subcutaneous tissue may be observed less frequently, whereas free air in the spinal canal (pneumorrhachis) is a very rare complication of cocaine abuse. In this report we present a case of pneumorrhachis that developed after cocaine use. Case. A 28-year-old male patient was admitted to the emergency department with shortness of breath, chest pain, and swelling in the neck and face which started four hours after he had sniffed cocaine. On physical examination, subcutaneous crepitations were felt with palpation of the jaw, neck, and upper chest area. Diffuse subcutaneous emphysema, pneumomediastinum, and pneumorrhachis were detected in the computed tomography imaging. The patient was treated conservatively and discharged uneventfully. Discussion. Complications such as pneumothorax, pneumomediastinum, and pneumoperitoneum that are associated with cocaine use may be seen due to increased intrathoracic pressure. The air then may flow into the spinal canal resulting in pneumorrhachis. Emergency physicians should know the possible complications of cocaine use and be prepared for rare complications such as pneumorrhachis. Tuğba Atmaca Temrel, Alp Şener, Ferhat İçme, Gül Pamukçu Günaydın, Şervan Gökhan, Yavuz Otal, Gülhan Kurtoğlu Çelik, and Ayhan Özhasenekler Copyright © 2015 Tuğba Atmaca Temrel et al. All rights reserved. Toxic Effects of Rhamnus alaternus: A Rare Case Report Wed, 01 Jul 2015 12:42:28 +0000 In Tunisia, there are about 478 species of plants commonly used in folk medicine. Medicinal plants and herbal remedies used are responsible for 2% of intoxications listed by Tunisian National Poison Center. Most cases are related to confusion between edible plants and toxic plants lookalikes or to an excessive consumption of therapeutic plants. We report the case of a 58-year-old man admitted to the Emergency Department of the Regional Hospital of Zaghouan (Tunisia), with renal failure and rhabdomyolysis. The patient reported having daily consumption of a homemade tea based on Mediterranean Buckthorn roots, during the last 6 months to treat type 2 diabetes. The aim of this work was to establish an association between the consumption of the herbal remedy and the occurrence of both renal failure and rhabdomyolysis. No similar cases have been reported in recent literature. H. Ben Ghezala, N. Chaouali, I. Gana, S. Snouda, A. Nouioui, I. Belwaer, J. Ouali, M. Kaddour, W. Masri, D. Ben Salah, D. Amira, H. Ghorbal, and A. Hedhili Copyright © 2015 H. Ben Ghezala et al. All rights reserved. A Case Report of Prilocaine-Induced Methemoglobinemia after Liposuction Procedure Tue, 23 Jun 2015 06:35:30 +0000 Prilocaine-induced methemoglobinemia is a rarely seen condition. In this paper, a case is presented with methemoglobinemia developed secondary to prilocaine use in a liposuction procedure, and the importance of this rarely seen condition is emphasized. A 20-year-old female patient presented with complaints of prostration, lassitude, shivering, shortness of breath, and cyanosis. It was learned that the patient underwent nearly 1000 mg prilocaine infiltration 8 hours priorly during a liposuction procedure. At admission, her blood pressure (130/80 mmHg), pulse rate (140 bpm), body temperature (36°C), and respiratory rate (40/min) were recorded. The patient had marked acrocyanosis. The arterial blood gas methemoglobin level was measured as 40%. The patient received oxygen therapy with a mask and was administered vitamin C in normal saline (500 mg tid), N-acetylcysteine (300 mg tid), and 50 mg 10% methylene blue in the intensive care unit of the internal medicine department. Methemoglobin level dropped down to 2% after her treatment with methylene blue and she was clinically cured and discharged 2 days later. Emergency service physicians should remember to consider methemoglobinemia when making a differential diagnosis between dyspnea and cyanosis developing after prilocaine infiltration performed for liposuctions in the adult age group. Birdal Yildirim, Ulku Karagoz, Ethem Acar, Halil Beydilli, Emine Nese Yeniceri, Ozgur Tanriverdi, Omer Dogan Alatas, and Şükrü Kasap Copyright © 2015 Birdal Yildirim et al. All rights reserved.