Case Reports in Emergency Medicine The latest articles from Hindawi Publishing Corporation © 2015 , Hindawi Publishing Corporation . All rights reserved. Body Packing: From Seizures to Laparotomy Thu, 26 Mar 2015 12:21:33 +0000 Body packing is a common method for illegal drug trafficking. Complications associated with body packing can be severe and even lead to rapid death. Thus, a timely diagnosis is warranted. As most body packers initially do not show any symptoms, making a correct diagnosis can be rather challenging. We describe a case of a 41-year-old male, who was admitted with an epileptic seizure and who turned out to be a cocaine intoxicated body packer. Due to neurological and cardiovascular deterioration an emergency surgery was performed. Four bags of cocaine could be removed. We discuss the current management regimen in symptomatic and asymptomatic body packers and highlight pearls and pitfalls with diagnosis and treatment. Joanna M. Janczak, Ulrich Beutner, and Karin Hasler Copyright © 2015 Joanna M. Janczak et al. All rights reserved. An Atypical Case of Methemoglobinemia due to Self-Administered Benzocaine Thu, 19 Mar 2015 12:31:40 +0000 Acquired methemoglobinemia is an uncommon hemoglobinopathy that results from exposure to oxidizing agents, such as chemicals or medications. Although, as reported in the adult population, it happens most often due to prescribed medication or procedural anesthesia and not due to easily accessed over-the-counter medications, the authors will describe an otherwise healthy male adult with no known medical history and no prescribed medications, who presented to the emergency department reporting generalized weakness, shortness of breath, headache, dizziness, and pale gray skin. In addition, the patient reported that he also had a severe toothache for several days, which he had been self-treating with an over-the-counter oral benzocaine gel. Ultimately, the diagnosis of methemoglobinemia was made by clinical history, physical examination, and the appearance of chocolate-colored blood and arterial blood gas (ABG) with cooximetry. After 2 mg/kg of intravenous methylene blue was administered, the patient had complete resolution of all signs and symptoms. This case illustrates that emergency physicians should be keenly aware of the potential of toxic hemoglobinopathy secondary to over-the-counter, nonprescribed medications. Discussion with patients regarding the dangers of inappropriate use of these medicines is imperative, as such warnings are typically not evident on product labels. Thomas M. Nappe, Anthony M. Pacelli, and Kenneth Katz Copyright © 2015 Thomas M. Nappe et al. All rights reserved. P-Chloroaniline Poisoning Causing Methemoglobinemia: A Case Report and Review of the Literature Thu, 12 Mar 2015 13:42:29 +0000 Background. Methemoglobin (MetHb) most commonly results from exposure to an oxidizing chemical but may also arise from genetic, dietary, or even idiopathic etiologies. P-chloroaniline (PCA) was one of the first substances described in the context of acquired methemoglobinemia. Case Report. We report the case of a cyanotic chemistry worker who presented to our emergency department (ED) after working with PCA. His peripheral oxygen saturation (SpO2) measured by pulse oximetry was at 81% and remained on that level despite oxygen administration (100% oxygenation via nonrebreather mask). His MetHb level was measured at 42.8% in arterial blood gas analysis. After treatment with intravenous methylene blue cyanosis resolved and the patient was discharged after 36 hours of observation. Conclusion. Acquired methemoglobinemia is a treatable condition, which may cause significant morbidity and mortality. The knowledge about the most common causes, fast diagnostic, and proper treatment is crucial. Anna Sarah Messmer, Christian Hans Nickel, and Dirk Bareiss Copyright © 2015 Anna Sarah Messmer et al. All rights reserved. Herbal Weight Loss Pill Overdose: Sibutramine Hidden in Pepper Pill Wed, 11 Mar 2015 13:07:40 +0000 Supposedly herbal weight loss pills are sold online and are widely used in the world. Some of these products are found to contain sibutramine by FDA and their sale is prohibited. We report a case of a female patient who presented to the emergency department after taking slimming pills. 17-year-old female patient presented to the emergency room with palpitations, dizziness, anxiety, and insomnia. She stated that she had taken 3 pills named La Jiao Shou Shen for slimming purposes during the day. Her vital signs revealed tachycardia. On her physical examination, she was restless, her oropharynx was dry, her pupils were mydriatic, and no other pathological findings were found. Sibutramine intoxication was suspected. She was given 5 mg IV diazepam for restlessness. After supportive therapy and observation in emergency department for 12 hours there were no complications and the patient was discharged home. Some herbal pills that are sold online for weight loss have sibutramine hidden as an active ingredient, and their sale is prohibited for this reason. For people who use herbal weight loss drugs, sibutramine excessive intake should be kept in mind at all times. Gul Pamukcu Gunaydin, Nurettin Ozgur Dogan, Sevcan Levent, and Gulhan Kurtoglu Celik Copyright © 2015 Gul Pamukcu Gunaydin et al. All rights reserved. An Unusual Cause of Pulmonary Nodules in the Emergency Department Mon, 23 Feb 2015 09:37:36 +0000 We report a 51-year-old woman who presented to the emergency department with left-sided pleuritic chest pain 2 weeks after subtotal hysterectomy and bilateral salpingo-oophorectomy for a leiomyomatous uterus. Computed tomography scan of the chest revealed bilateral pulmonary nodules. Biopsy showed cytologically bland spindle cells without overt malignant features. Immunohistochemistry confirmed smooth muscle phenotype, in keeping with a clinicopathologic diagnosis of benign metastasizing leiomyoma (BML). BML does not frequently come to the attention of the emergency physician because it is rare and usually asymptomatic. When symptomatic, its clinical presentation depends on the site(s) of metastasis, number, and size of the smooth muscle tumors. Emergent presentations of BML are reviewed. Ryan Yu and Melanie Ferri Copyright © 2015 Ryan Yu and Melanie Ferri. All rights reserved. Unusual Presentation of Meckel’s Diverticulum: Gangrene due to Axial Torsion Sun, 22 Feb 2015 09:29:04 +0000 Meckel’s diverticulum is the most common congenital anomaly of the small bowel. The majority of cases are asymptomatic; however, life-threatening complications can also take place. We present a case of a 37-year-old male who was admitted with symptoms of acute, severe abdominal pain in the right iliac fossa. The patient was operated on with the preoperative diagnosis of acute appendicitis but the operative findings were consistent with torted Meckel’s diverticulum due to presence of mesodiverticular band and he was treated successfully with surgical resection. Ahmet Rencuzogullari, Kubilay Dalci, and Orcun Yalav Copyright © 2015 Ahmet Rencuzogullari et al. All rights reserved. Ovarian Hyperstimulation Syndrome, the Master of Disguise? Sun, 22 Feb 2015 08:29:21 +0000 The use of IVF has risen dramatically over the past 10 years and with this the complications of such treatments have also risen. One such complication is ovarian hyperstimulation syndrome with which patients can present acutely to hospital with shortness of breath. On admission, a series of blood tests are routinely performed, including the d-dimer. We present a case of a 41-year-old lady who had recently undergone IVF and presented with chest pain and dyspnoea. In the emergency department, a d-dimer returned as mildly elevated. Consequential admission onto MAU initiated several avoidable investigations for venous thromboembolism. Careful examination elicited a mild ascites and a thorough drug history gave recent low molecular weight heparin usage. Ultrasound scan of the abdomen subsequently confirmed the diagnosis of severe OHSS. The d-dimer should therefore be used to negate and not to substantiate a diagnosis of VTE. This case report aims to highlight the importance of OHSS as an uncommon cause of dyspnoea but whose prevalence is likely to increase in the forthcoming years. We discuss the complications of the misdiagnosis of OHSS, the physiology behind raised d-dimers, and the potential harm from incorrect treatment or inappropriate imaging. Emily Charlotte Ironside and Andrew James Hotchen Copyright © 2015 Emily Charlotte Ironside and Andrew James Hotchen. All rights reserved. STEMI Associated with Overuse of Energy Drinks Thu, 19 Feb 2015 09:31:01 +0000 Coronary artery disease (CAD) and ST-elevation myocardial infarction (STEMI) are predominantly diseases of middle-aged and older adults and when found in younger adults are usually associated with a strong family history. However, this report details the case of a nonobese 26-year-old Hispanic male who presented with an acute STEMI despite having no family history or other apparent risk factors for CAD or STEMI beyond a two pack-year smoking history and excessive energy drink consumption. The patient reported consuming between eight and ten 473 mL cans per day. Cardiac catheterization subsequently confirmed total occlusion of his left circumflex coronary artery. Daniel Solomin, Stephen W. Borron, and Susan H. Watts Copyright © 2015 Daniel Solomin et al. All rights reserved. An Unusual Presentation of a Massive Pulmonary Embolism with Misleading Investigation Results Treated with Tenecteplase Thu, 19 Feb 2015 06:23:42 +0000 Background. There is no foolproof strategy to identify a pulmonary embolism (PE) in the emergency department, and atypical presentations are common. Negative test results may mislead physicians away from the diagnosis of PE. Objectives. The current report aims to raise awareness of an unusual presentation of massive PE and its diagnosis and management, in the face of limited evidence in the scientific literature. Case Reports. We report the case of a patient with a negative D-Dimer and a negative Computed Tomography contrast angiography of the chest who was diagnosed twenty-seven hours later with a massive PE, as suggested by a bedside echocardiography. The patient was successfully treated with tenecteplase (TNK). Conclusions/Summary. Pulmonary embolism frequently presents atypically and is often a diagnostic challenge. There is limited literature about the treatment of massive PE. Further research on bedside echocardiography for diagnosing PE in unstable patients is warranted. In addition, further study into new thrombolytic agents like tenecteplase in the context of massive and submassive PE is warranted. David Migneault, Zachary Levine, and François de Champlain Copyright © 2015 David Migneault et al. All rights reserved. A Rare and Unexpected Side-Effect of Cannabis Use: Abdominal Pain due to Acute Pancreatitis Wed, 11 Feb 2015 12:47:07 +0000 Acute pancreatitis is a frequently encountered disorder in patients presenting to emergency units. Biliary system disorders, alcohol consumption, infections, and drugs are among the causes of acute pancreatitis. However, it is sometimes difficult to determine the etiology of this disorder, particularly if the patient does not wish to disclose his consumption of cannabis, the use of which is illegal. Mehmet Husamettin Akkucuk and Mustafa Erbayrak Copyright © 2015 Mehmet Husamettin Akkucuk and Mustafa Erbayrak. All rights reserved. Acute Headache at Emergency Department: Reversible Cerebral Vasoconstriction Syndrome Complicated by Subarachnoid Haemorrhage and Cerebral Infarction Tue, 10 Feb 2015 09:57:08 +0000 Introduction. Reversible cerebral vasoconstriction syndrome is becoming widely accepted as a rare cause of both ischemic and haemorrhagic stroke and should be evocated in case of thunderclap headaches associated with stroke. We present the case of a patient with ischemic stroke associated with cortical subarachnoid haemorrhage (cSAH) and reversible diffuse arteries narrowing, leading to the diagnosis of reversible vasoconstriction syndrome. Case Report. A 48-year-old woman came to the emergency department because of an unusual thunderclap headache. The computed tomography of the brain completed by CT-angiography was unremarkable. Eleven days later, she was readmitted because of a left hemianopsia. One day after her admission, she developed a sudden left hemiparesis. The brain MRI showed ischemic lesions in the right frontal and occipital lobe and diffuse cSAH. The angiography showed vasoconstriction of the right anterior cerebral artery and stenosis of both middle cerebral arteries. Nimodipine treatment was initiated and vasoconstriction completely regressed on day 16 after the first headache. Conclusion. Our case shows a severe reversible cerebral vasoconstriction syndrome where both haemorrhagic and ischemic complications were present at the same time. The history we reported shows that reversible cerebral vasoconstriction syndrome is still underrecognized, in particular in general emergency departments. M. Yger, C. Zavanone, L. Abdennour, W. Koubaa, F. Clarençon, S. Dupont, and Y. Samson Copyright © 2015 M. Yger et al. All rights reserved. Detecting Foreign Bodies in a Head Laceration Sat, 31 Jan 2015 07:17:38 +0000 Open wounds represent a potential area of medicolegal risk if foreign bodies are not identified prior to wound closure. The importance of imaging of lacerations was underscored by a recent case where a 20-year-old male collided with a friend’s mouth on a trampoline sustaining a simple, superficial scalp laceration. The wound was evaluated in typical fashion including irrigation and local exploration and was prepared for closure. The friend was then evaluated and noted to have multiple extensive dental fractures. An increased index of suspicion generated further evaluation of the first patient’s wound. Plain radiography obtained of the first patient’s skull was noted to have bony foreign bodies consistent with teeth, which were then removed after further exploration. Superficial wounds are common and complications arising from retained foreign bodies are a potential source of substantial morbidity and consequently medical litigation. This case serves as a reminder to be vigilant and maintain a high index of suspicion regarding the potential for foreign body. Thomas R. Fowler, Steven J. Crellin, and Marna Rayl Greenberg Copyright © 2015 Thomas R. Fowler et al. All rights reserved. Profound Hypoglycemia with Ecstasy Intoxication Tue, 27 Jan 2015 06:34:26 +0000 Background. 3,4-Methylenedioxymethamphetamine (MDMA) or ecstasy is a synthetic drug that is commonly abused for its stimulant and euphoric effects. Adverse MDMA effects include hyperthermia, psychomotor agitation, hemodynamic compromise, renal failure, hyponatremia, and coma. However, endogenous hyperinsulinemia with severe persistent hypoglycemia has not been reported with MDMA use. Case Report. We report the case of a 29-year-old woman who remained severely hypoglycemic requiring continuous intravenous infusion of high-dose dextrose solutions for more than 24 hours after MDMA intoxication. Serum insulin and C-peptide levels confirmed marked endogenous hyperinsulinemia as the cause of the severe hypoglycemia. Why Should an Emergency Physician Be Aware of This? Immediate and frequent monitoring of blood glucose should be instituted in patients presenting with MDMA ingestion particularly if found to be initially hypoglycemic. Early recognition can help prevent the deleterious effects of untreated hypoglycemia that can add to the morbidity from MDMA use. Clinicians need to be aware of this side effect of MDMA so they can carefully monitor and treat it, especially in patients presenting with altered mental status. Perliveh Carrera and Vivek N. Iyer Copyright © 2015 Perliveh Carrera and Vivek N. Iyer. All rights reserved. Diagnosis of Mondor’s Disease in the Emergency Department with Bedside Ultrasound Sun, 18 Jan 2015 07:41:10 +0000 Mondor’s disease is a rare condition characterized by a superficial thrombophlebitis that can occur in the thoracoabdominal and genital areas. Findings with ultrasound in penile Mondor’s disease are readily measurable: a noncompressible penile vein without flow and absence of tears of the corpus cavernosum or tunica albuginea, hematoma, or evidence of fracture of the penis. We present a case of Mondor’s disease, diagnosed with bedside ultrasound, in the emergency department. Ultrasonography is readily available within the emergency department, and we suggest its use in aiding diagnosis of genitourinary disorders such as Mondor’s disease. J. Michael O’Neal, Erik Castleberg, and Vi Am Dinh Copyright © 2015 J. Michael O’Neal et al. All rights reserved. Methamphetamine Ingestion Misdiagnosed as Centruroides sculpturatus Envenomation Wed, 14 Jan 2015 09:26:04 +0000 The authors present a case report of a 17-month-old female child who ingested a large amount of methamphetamine that looked very similar clinically to a scorpion envenomation specific to the southwestern United States by the species Centruroides sculpturatus. The child was initially treated with 3 vials of antivenom specific for that scorpion species and showed a transient, though clinically relevant neurologic improvement. Her clinical course of sympathomimetic toxicity resumed and she was treated with intravenous fluids and benzodiazepines after blood analysis showed significant levels of d-methamphetamine. This case report is to specifically underline the clinical confusion in discerning between these two conditions and the realization of limited and/or expensive resources that may be used in the process. Joshua Strommen and Farshad Shirazi Copyright © 2015 Joshua Strommen and Farshad Shirazi. All rights reserved. Recurrent Coagulopathy after Rattlesnake Bite Requiring Continuous Intravenous Dosing of Antivenom Mon, 12 Jan 2015 13:18:45 +0000 Context. Snakebite envenomation is common and may result in systemic coagulopathy. Antivenom can correct resulting laboratory abnormalities; however, despite antivenom use, coagulopathy may recur, persist, or result in death after a latency period. Case Details. A 50-year-old previously healthy man presented to the emergency department after a rattlesnake bite to his right upper extremity. His presentation was complicated by significant glossal and oropharyngeal edema requiring emergent cricothyrotomy. His clinical course rapidly improved with the administration of snake antivenom (FabAV); the oropharyngeal and upper extremity edema resolved within several days. However, over the subsequent two weeks, he continued to have refractory coagulopathy requiring multiple units of antivenom. The coagulopathy finally resolved after starting a continuous antivenom infusion. Discussion. Envenomation may result in latent venom release from soft tissue depots that can last for two weeks. This case report illustrates the importance of close hemodynamic and laboratory monitoring after snakebites and describes the administration of continuous antivenom infusion, instead of multidose bolus, to neutralize latent venom release and correct residual coagulopathy. Charles W. Hwang and F. Eike Flach Copyright © 2015 Charles W. Hwang and F. Eike Flach. All rights reserved. Development of ST Elevation Myocardial Infarction and Atrial Fibrillation after an Electrical Injury Thu, 08 Jan 2015 08:50:54 +0000 Electrical energy is a type of energy that is commonly used in daily life. Ventricular premature beats, ventricular tachycardia, ventricular fibrillation, atrial tachycardia, atrial fibrillation, bundle branch blocks, and AV block are arrhythmic complications that are encountered in case of electric shocks. Myocardial infarction is one of the rarely seen complications of electric shocks yet it has fatal outcomes. Coronary arteries were detected to be normal in most of the patients who had myocardial infarction following an electric shock. So, etiology of myocardial infarction is thought to be unrelated to coronary atherosclerosis in these cases. Coronary artery vasospasm is thought to be the primary etiological cause. In our case report, we presented a patient who developed ST elevation MI with atrial fibrillation after an electric shock. Erdal Gursul, Serdar Bayata, Ercan Aksit, and Basak Ugurlu Copyright © 2015 Erdal Gursul et al. All rights reserved. Atypical Presentation of Traumatic Aortic Injury Tue, 30 Dec 2014 07:11:52 +0000 Background. Blunt thoracic aorta injury (BAI) is second only to head injury as cause of mortality in blunt trauma. While most patients do not survive till arrival at the hospital, for the remainder, prompt diagnosis and treatment greatly improve outcomes. We report an atypical presentation of BAI, highlighting the diagnostic challenges of this condition in the emergency department. Case Presentation. A previously well 25-year-old male presented 15 hours after injury hemodynamically stable with delirium. There were no signs or symptoms suggestive of BAI. Sonography showed small bilateral pleural effusions. Chest radiograph showed a normal mediastinum. Eventually, CT demonstrated a contained distal aortic arch disruption. The patient underwent percutaneous endovascular thoracic aortic repair and recovered well. Conclusion. This catastrophic lesion may present with few reliable signs and symptoms; hence, a high index of suspicion is crucial for early diagnosis and definitive surgical management. This paper discusses the diagnostic utility of clinical features, injury mechanism, and radiographic modalities. Consideration of mechanism of injury, clinical features, and chest radiograph findings should prompt advanced chest imaging. Andrew Fu Wah Ho, Tallie Wei-Lin Chua, Puneet Seth, Kenneth Boon Kiat Tan, and Sohil Pothiawala Copyright © 2014 Andrew Fu Wah Ho et al. All rights reserved. Retrograde Gastrojejunostomy Tube Migration Mon, 29 Dec 2014 07:53:59 +0000 Percutaneous enteral feeding tubes are placed about 250,000 times each year in the United States. Although they are relatively safe, their placement may be complicated by perforation, infection, bleeding, vomiting, dislodgment, and obstruction. There have been numerous reports of antegrade migration of gastrojejunostomy (G-J) tubes. We report a case of G-J tube regurgitation following protracted vomiting and discuss the management of this very rare entity. Adeleke Adesina, Guhan Rammohan, and Rebecca Jeanmonod Copyright © 2014 Adeleke Adesina et al. All rights reserved. Acute Renal Infarction Presenting with Acute Abdominal Pain Secondary to Newly Discovered Atrial Fibrillation: A Case Report and Literature Review Mon, 29 Dec 2014 07:25:04 +0000 We report an 85-year-old female with known history of recurrent diverticulitis presented with abdominal pain. It was believed that the patient again needed to be treated for another diverticulitis and was started on the routine treatment. The initial CT scan of abdomen showed renal infarcts bilaterally that were confirmed by a CT with and without intravenous contrast secondary to unknown cause. An ECG found accidentally that the patient was in atrial fibrillation, which was the attributed factor to the renal infarctions. Subsequently, the patient was started on the appropriate anticoagulation and discharged. Sherif Ali Eltawansy, Shil Patel, Mana Rao, Samaa Hassanien, and Mihir Maniar Copyright © 2014 Sherif Ali Eltawansy et al. All rights reserved. Acutely Onset Amiodarone-Induced Angioedema in a Patient with New Atrial Fibrillation Thu, 25 Dec 2014 10:07:23 +0000 A 50-year-old man was admitted to our emergency department due to new episode of palpitation. He had history of angioplasty of right coronary artery (RCA) with drug eluting stent 2 years ago. His electrocardiogram revealed atrial fibrillation (AF). Intravenous amiodarone 150 mg during 10 minutes and then 1 mg/min infusion were started to achieve rate control and pharmacologic conversion to sinus rhythm. After 60 minutes of starting amiodarone infusion, he developed swelling of the skin around his mouth and eyes, and also mucosa of the mouth, eyes and tongue. To conclude, angioedema should be considered a rare side effect of amiodarone which is used broadly in cardiovascular field. Hossein Vakili, Isa Khaheshi, Mehdi Memaryan, Habib Haybar, and Shooka Esmaeeli Copyright © 2014 Hossein Vakili et al. All rights reserved. A Vertebral Artery Dissection with Basilar Artery Occlusion in a Child Tue, 23 Dec 2014 00:10:10 +0000 This paper presents the case report of an 11-year-old boy with an acute dissection with thrombosis of the left vertebral artery and thrombosis of the basilar artery. The patient was treated with acute systemic thrombolysis, followed by intra-arterial thrombolysis, without any clinical improvement, showing left hemiplegia, bilateral clonus, hyperreflexia, and impaired consciousness. MRI indicated persistent thrombosis of the arteria basilaris with edema and ischemia of the right brainstem. Heparinization for 72 hours, followed by a two-week LMWH treatment and subsequent oral warfarin therapy, resulted in a lasting improvement of the symptoms. Vertebral artery dissection after minor trauma is rare in children. While acute basilar artery occlusion as a complication is even more infrequent, it is potentially fatal, which means that prompt diagnosis and treatment are imperative. The lack of class I recommendation guidelines for children regarding treatment of vertebral artery dissection and basilar artery occlusion means that initial and follow-up management both require a multidisciplinary approach to coordinate emergency, critical care, interventional radiology, and child neurology services. Katleen Devue, Annemie Van Ingelgem, Katrien De Keukeleire, and Marc De Leeuw Copyright © 2014 Katleen Devue et al. All rights reserved. Pediatric Stroke Presenting as a Seizure Mon, 22 Dec 2014 00:10:10 +0000 Background. Childhood arterial ischemic stroke (AIS) is rare and may be difficult to diagnose. Management of acute stroke in any age group is time sensitive, so awareness of the manifestations and appropriate diagnostic procedures for pediatric AIS is vital to establishing care. We present a pediatric case of arterial ischemic stroke that presented to the emergency department (ED) after two seizures. Case Report. A five-year-old female with an existing seizure disorder presented to a pediatric ED after having two seizures. Postictal upon arrival, she underwent a computed tomography (CT) scan of her head. Family reported that she had complained of a severe headache and vomited; her seizures were described as different from those she had experienced in the past. Loss of grey white matter differentiation on the CT warranted magnetic resonance imaging (MRI), which demonstrated a right-sided stroke. After a complicated course in the hospital, the patient was discharged to a rehabilitation hospital. Why Should an Emergency Physician Be Aware of This? It is important that emergency physicians recognize that a seizure may be the initial symptom of a pediatric stroke regardless of an established seizure history. Pediatric seizures are relatively common; however consideration of the diagnosis of pediatric stroke may prevent unnecessary delays in treatment. Katie L. Ahmadzadeh, Vartika Bhardwaj, Steven A. Johnson, and Kathleen E. Kane Copyright © 2014 Katie L. Ahmadzadeh et al. All rights reserved. Emergency Open Incarcerated Hernia Repair with a Biological Mesh in a Patient with Colorectal Liver Metastasis Receiving Chemotherapy and Bevacizumab Uncomplicated Wound Healing Sun, 21 Dec 2014 00:10:16 +0000 Bevacizumab is a humanized monoclonal antibody targeting vascular endothelial growth factor (VEGF), often used in combinational chemotherapy regimens for the treatment of patients with colorectal liver metastases. However adverse events have been attributed to the use of bevacizumab including gastrointestinal perforations, thrombotic events, hypertension, bleeding, and wound healing complications. 53-year-old male, with a history of colorectal cancer with liver metastasis, receiving a combination of cytotoxic chemotherapy (FOLFIRI, irinotecan with fluorouracil and folinic acid) with bevacizumab presented as an emergency with an incarcerated incisional hernia. The last administration of chemotherapy and bevacizumab had taken place 2 weeks prior to this presentation. As the risk of strangulation of the bowel was increased, a decision was made to take the patient to theatre, although the hazard with respect to wound healing, haemorrhage, and infection risk was high due to the recent administration of chemotherapy with bevacizumab. The patient underwent an open repair of the incarcerated recurrent incisional hernia with placement of a biological mesh, and the postoperative recovery was uncomplicated with no wound healing or bleeding problems. Alexandros Giakoustidis, Dawn Morrison, Kyriakos Neofytou, Dimitrios Giakoustidis, and Satvinder Mudan Copyright © 2014 Alexandros Giakoustidis et al. All rights reserved. New Onset Refractory Status Epilepticus as an Unusual Presentation of a Suspected Organophosphate Poisoning Wed, 17 Dec 2014 11:26:10 +0000 New onset refractory status epilepticus (NORSE) is a new entity in medical literature. It has different infectious and noninfectious etiologies showing a devastating impact onto the clinical outcome of patients. Therapy with anaesthetic and antiepileptic agents often fails to improve the condition, unless the primary cause is rectified. Here is presented the case of a young female with a history of depression who after a recent bereavement came to the Emergency Department of Aga Khan University Hospital with complaints of drowsiness that lasted for few hours. Though she had no history of organophosphate poisoning, her physical examination and further investigations were suggestive of the diagnosis. During her hospital stay, she developed refractory status epilepticus. Her seizures did not respond to standard antiepileptic and intravenous anesthetic agents and subsided only after intravenous infusion of atropine for a few days. Organophosphate poisoning is a very common presentation in the developing world and the associated status epilepticus poses a devastating problem for emergency physicians. In patients with suspected organophosphate poisoning with favoring clinical exam findings, the continuation of atropine intravenous infusion can be a safe option to abate seizures. Shahan Waheed, Amber Sabeen, and Nadeem Ullah Khan Copyright © 2014 Shahan Waheed et al. All rights reserved. Histamine Poisoning from Ingestion of Fish or Scombroid Syndrome Sun, 07 Dec 2014 09:33:53 +0000 The scombroid poisoning is due to the ingestion of poorly preserved fish (especially tuna, sardines, and mackerel) out of the cold chain. Under the influence of the proliferation of gram negative bacteria that occurs for heating, the histidine content in the muscle of the fish is converted into histamine, by the action of the enzyme histidine decarboxylase. If the histamine is ingested in large quantities, it causes an anaphylactoid reaction with a variety of symptoms from moderate to severe to life-threating. We will describe two cases that came under our observation after consuming a meal of bluefin tuna. The diagnosis of scombroid syndrome was made on the basis of the anamnestic data and the clinical one. The rapid resolution of the signs and symptoms after treatment with histamines H1-H2 receptor blockers confirmed the suspected diagnosis. Vincenzo Tortorella, Peppino Masciari, Mario Pezzi, Assunta Mola, Simona Paola Tiburzi, Maria Concetta Zinzi, Annamaria Scozzafava, and Mario Verre Copyright © 2014 Vincenzo Tortorella et al. All rights reserved. What Lies behind the Ischemic Stroke: Aortic Dissection? Tue, 02 Dec 2014 11:01:41 +0000 Introduction. Some cases with aortic dissection (AD) could present with various complaints other than pain, especially neurological and cardiovascular manifestations. AD involving the carotid arteries could be associated with many clinical presentations, ranging from stroke to nonspecific headache. Case Report. A 71-year-old woman was admitted to emergency department with vertigo which started within the previous one hour and progressed with deterioration of consciousness following speech disorder. On arrival, she was disoriented and uncooperative. Diffusion magnetic resonance imaging (MRI) of brain was consistent with acute ischemia in the cerebral hemisphere. Fibrinolytic treatment has been planned since symptoms started within two hours. Echocardiography has shown the dilatation of ascending aorta with a suspicion of flap. Computed tomography (CT) angiography has been applied and intimal flap has been detected which was consistent with aortic dissection, intramural hematoma of which was reaching from aortic arch to bilateral common carotid artery. Thereafter, treatment strategy has completely changed and surgical invention has been done. Conclusion. In patients who are admitted to the emergency department with the loss of consciousness and stroke, inadequacy of anamnesis and carotid artery involvement of aortic dissection should be kept in mind. Turgut Deniz, Ersel Dag, Murat Tulmac, Burcu Azapoglu, and Caglar Alp Copyright © 2014 Turgut Deniz et al. All rights reserved. The Management of Gas-Filled Eyes in the Emergency Department Wed, 26 Nov 2014 11:53:55 +0000 Background. Intraocular gas bubbles are commonly used in retinal surgery. There are specific management guidelines that need to be followed to ensure surgical success, and there are also unique ophthalmic and systemic complications that can occur in such patients. Objective. To educate emergency department personnel about important issues in the management of patients who have a gas-filled eye following retinal surgery. Case Report. A patient with a gas-filled eye developed several complications including pain, severe vision loss, high-grade atrioventricular (AV) block, and pneumocephalus. Conclusion. Awareness of potential problems that may arise in patients with gas-filled eyes who present to the emergency department may help minimize morbidity for such patients. Lik Thai Lim, Elliott Y. Ah-kee, Beve P. House, and Jonathan D. Walker Copyright © 2014 Lik Thai Lim et al. All rights reserved. Lazy Lips: Hyperkalemia and Acute Tetraparesis—A Case Report from an Urban Emergency Department Tue, 25 Nov 2014 16:31:58 +0000 A 58-year-old male patient was admitted to our emergency department at a large university hospital due to acute onset of general weakness. It was reported that the patient was bradycardic at 30/min and felt an increasing weakness of the limbs. At admission to the emergency department, the patient was not feeling any discomfort and denied dyspnoea or pain. The primary examination of the nervous system showed the cerebral nerves II–XII intact, muscle strength of the lower extremities was 4/5, and a minimal sensory loss of the left hemisphere was found. In addition, the patient complained about lazy lips. During ongoing examinations, the patient developed again symptomatic bradycardia, accompanied by complete tetraplegia. The following blood test showed severe hyperkalemia probably induced by use of aldosterone antagonists as the cause of the patient’s neurologic symptoms. Hyperkalemia is a rare but treatable cause of acute paralysis that requires immediate treatment. Late diagnosis can delay appropriate treatment leading to cardiac arrhythmias and arrest. Christian T. Braun, David S. Srivastava, Bianca Maria Engelhardt, Gregor Lindner, and Aristomenis K. Exadaktylos Copyright © 2014 Christian T. Braun et al. All rights reserved. An Uncommon, Life-Threatening, Traumatic Hematoma in the Neck Area Mon, 24 Nov 2014 08:31:07 +0000 It is well known that blunt neck trauma, when compared to a penetrating injury in the same anatomical area, is very rare. We report a case of an 81-year-old Caucasian woman with a blunt life-threatening neck trauma due to a bully goat. Although rare, direct evaluation should always be done in these cases because any misinterpretation may result in unfavorable outcomes. We have to highlight that close medical attention and prompt surgical treatment should be always considered in order to avoid dramatic consequences. Michalis Peroulis, Georgios D. Lianos, Vasilios Nousias, Zoi Anastasiadi, Aikaterini Lianou, Christos Katsios, and Miltiadis Matsagkas Copyright © 2014 Michalis Peroulis et al. All rights reserved.