Case Reports in Emergency Medicine The latest articles from Hindawi Publishing Corporation © 2015 , Hindawi Publishing Corporation . 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. A Rare Entity: Bilateral First Rib Fractures Accompanying Bilateral Scapular Fractures Sun, 14 Jun 2015 11:27:05 +0000 First rib fractures are scarce due to their well-protected anatomic locations. Bilateral first rib fractures accompanying bilateral scapular fractures are very rare, although they may be together with scapular and clavicular fractures. According to our knowledge, no case of bilateral first rib fractures accompanying bilateral scapular fractures has been reported, so we herein discussed the diagnosis, treatment, and complications of bone fractures due to thoracic trauma in bias of this rare entity. Gultekin Gulbahar, Tevfik Kaplan, Hasan Bozkurt Turker, Ahmet Gokhan Gundogdu, and Serdar Han Copyright © 2015 Gultekin Gulbahar et al. All rights reserved. A Woman with Unilateral Rash and Fever: Cellulitis in the Setting of Lymphedema Thu, 11 Jun 2015 16:52:33 +0000 Cellulitis in the setting of lymphedema is an uncommon but clinically important presentation to the emergency department. Stagnant lymph is an ideal medium for bacterial growth and progression can be rapid due to decreased ability to fight infection in the affected area. Infections are commonly caused by gram-positive cocci, though blood cultures are often negative. Treatment should be aimed at rapid initiation of antibiotics targeting these species. There may be a role for antibiotic prophylaxis in recurrent cases. Melissa Joseph, Marissa Camilon, and Tarina Kang Copyright © 2015 Melissa Joseph et al. All rights reserved. Bilateral Wallerian Degeneration of the Pontocerebellar Tracts Wed, 10 Jun 2015 13:42:17 +0000 Wallerian degeneration is the process of progressive demyelination and disintegration of the distal axonal segment following the transection of the axon or damage to the neuron. We report a case of a patient with Wallerian degeneration of the pontocerebellar tracts. She had a history of a pontine infarction 3 months ago. Wallerian degeneration of pontocerebellar tracts is seen bilaterally and symmetrically and is more visible in the middle cerebellar peduncles. Along the middle cerebellar peduncles hyperintense signal was detected on T2 weighted images. Wallerian degeneration of pontocerebellar tracts is a rare entity. It can occur bilaterally after a large pontine infarction. Magnetic resonance imaging seems to be the most effective technique for detection of Wallerian degeneration. In this report we want to mention this rare entity and to prevent wrong diagnosis. Azad Hekimoglu, Ihsaniye Suer Dogan, Aynur Turan, Mehmet Fevzi Oztekin, and Baki Hekimoglu Copyright © 2015 Azad Hekimoglu et al. All rights reserved. A Bullet Entered through the Open Mouth and Ended Up in the Parapharyngeal Space and Skull Base Sun, 07 Jun 2015 12:01:35 +0000 Shot from a revolver from a close range, a bullet pierced the chest of a policeman and entered through the open mouth of a young male person standing behind. The entry wound was found in the cheek mucosa adjacent to the left lower third molar. After hitting and fracturing the body and the ramus of the mandible, the bullet was deflected and was finally lodged in the parapharyngeal space and skull base, anterolateral to the transverse process of the atlas. The great vessels of the neck were not injured. The patient’s condition was very critical but his life could be saved. The bullet was approached through a modified Blair’s incision and was found to be lying over the carotid sheath. It was removed safely and the patient recovered completely. Saileswar Goswami and Choitali Goswami Copyright © 2015 Saileswar Goswami and Choitali Goswami. All rights reserved. Phencyclidine Induced Oculogyric Crisis Responding Well to Conventional Treatment Tue, 26 May 2015 06:58:50 +0000 Background. Oculogyric crisis is a form of acute dystonic reaction characterized by involuntary upward deviation of eye ball. Its causes are broad with antipsychotics and antiemetics as the most common causes. Case Presentation. A 25-year-old man with the past medical history of marijuana use presented to ED with involuntary upward deviation of eye 1 day after using phencyclidine (PCP) for the first time. He did not have any other symptoms and was hemodynamically stable. All laboratory investigations were normal except urine drug screen which was positive for PCP. Patient was treated with IV diphenhydramine which improved his symptoms. Conclusion. Illicit drug abuse is a growing problem in our society with increasingly more patients presenting to ED with its complications. The differential diagnosis of acute dystonic reactions should be extended to include illicit drugs as the potential cause of reversible acute dystonias especially in high risk patients. Hassan Tahir and Vistasp Daruwalla Copyright © 2015 Hassan Tahir and Vistasp Daruwalla. All rights reserved. A Rare and Serious Syndrome That Requires Attention in Emergency Service: Traumatic Asphyxia Sun, 24 May 2015 08:48:53 +0000 Traumatic asphyxia is a rare syndrome caused by blunt thoracoabdominal trauma and characterized by cyanosis, edema, and subconjunctival and petechial hemorrhage on the face, neck, upper extremities, and the upper parts of the thorax. Traumatic asphyxia is usually diagnosed by history and inspection; however, the patient should be monitored more closely due to probable complications of thoracoabdominal injuries. Treatment is conservative, but the prognosis depends on the severity of the associated injuries. Herein we present a traumatic asphyxia due to an elevator accident in a 32-year-old male patient and discuss the diagnosis, treatment, and prognosis by reviewing the relevant literature. Gultekin Gulbahar, Tevfik Kaplan, Ahmet Gokhan Gundogdu, Hatice Nurdan Baran, Burak Kazanci, Bulent Kocer, and Serdar Han Copyright © 2015 Gultekin Gulbahar et al. All rights reserved. Food Particle Aspiration Associated with Hemorrhagic Shock: A Diagnostic Dilemma Tue, 19 May 2015 06:28:23 +0000 The hemodynamic compromise caused by a large aspirated food particle in the airway can become the focus of medical attention and a distraction from rare but fatal Heimlich maneuver related injuries after an incident of food aspiration. We herein present a case of an 84-year-old man who was brought to the emergency department after an episode of choking at a restaurant followed by several failed Heimlich maneuver attempts. Despite relieving the airway obstruction by extracting a large piece of steak from the airway, the patient remained hypotensive and required continued hemodynamic support. Repeated laboratory tests within 24 hrs of aspiration showed a significant decline in the hemoglobin level. A computed tomography (CT) scan of the abdomen and pelvis showed a lacerated liver with a large subcapsular hematoma draining into the pelvis. Conclusion. Hepatic rupture is a rare complication of Heimlich maneuver; this paper represents the second case report in the literature. It emphasizes the necessity of early identification and surveillance of fatal Heimlich maneuver complications in a high risk population. Basheer Tashtoush, Jonathan Schroeder, Roya Memarpour, Eduardo Oliveira, Michael Medina, Anas Hadeh, Jose Ramirez, and Laurence Smolley Copyright © 2015 Basheer Tashtoush et al. All rights reserved. Intravenous Lipid Emulsion Therapy for Acute Synthetic Cannabinoid Intoxication: Clinical Experience in Four Cases Mon, 11 May 2015 11:40:14 +0000 There is no specific antidote for intoxication with synthetic cannabinoids. In this case series, we considered the efficiency of intravenous lipid emulsion therapy in four cases, who presented to emergency department with synthetic cannabinoid (bonzai) intoxication. The first patient had a GCS of 3 and a left bundle branch block on electrocardiography. The electrocardiography revealed sinus rhythm with normal QRS width after the treatment. The second patient had bradycardia, hypotension, and a GCS of 14. After intravenous lipid emulsion therapy, the bradycardia resolved, and the patient’s GCS improved to 15. The third patient presented with a GCS of 8, and had hypotension and bradycardia. After the treatment, not only did the bradycardia resolve, but also the GCS improved to 15. The fourth patient, whose electrocardiography revealed accelerated junctional rhythm, had a GCS of 13. The patient’s rhythm was sinus after the treatment. Cardiovascular recovery was seen in all four cases, and neurological recovery was also seen in three of them. Based on the fact that intravenous lipid emulsion is beneficial in patients intoxicated with lipophilic drugs, unstable patients presenting to the emergency department with acute synthetic cannabinoid intoxication may be candidates for intravenous lipid emulsion treatment. Gökhan Aksel, Özlem Güneysel, Tanju Taşyürek, Ergül Kozan, and Şebnem Eren Çevik Copyright © 2015 Gökhan Aksel et al. All rights reserved. Assessment of Musculoskeletal Injuries from Domestic Violence in the Emergency Department Thu, 07 May 2015 16:52:16 +0000 Domestic violence is one of the most common causes of nonfatal injury in women, with musculoskeletal injuries representing the second most prevalent manifestation of this form of violence. It is therefore of great importance that healthcare providers such as emergency department (ED) physicians and surgeons are able to recognize and assess these kinds of injuries. In this case report, a woman is described visiting an ED with injuries caused by a fall. Thanks to the knowledge and attention of the ED physician, the real cause of the injury was discovered. What appeared to be an unsuspicious accident was actually the result of intimate partner violence. Georgios F. Giannakopoulos and Udo J. L. Reijnders Copyright © 2015 Georgios F. Giannakopoulos and Udo J. L. Reijnders. All rights reserved. Temporoparietal Headache as the Initial Presenting Symptom of a Massive Aortic Dissection Wed, 06 May 2015 11:13:14 +0000 Aortic dissection is a life-threatening medical emergency often presenting with severe chest pain and acute hemodynamic compromise. The presentation of aortic dissection can sometimes be different thus leading to a challenge in prompt diagnosis and treatment as demonstrated by the following presentation and discussion. We present a case of a 71-year-old male who presented to the emergency department with complaints of left sided temporoparietal headache and was eventually diagnosed with a thoracic aortic dissection involving the ascending aorta and descending aorta, with an intramural hematoma in the descending aorta. This case illustrates the importance of keeping in mind aortic dissection as a differential diagnosis in patients with acute onset headaches in which any intracranial source of headache is not found. Manan Parikh, Abhinav Agrawal, Braghadheeswar Thyagarajan, Sayee Sundar Alagusundaramoorthy, and James Martin Copyright © 2015 Manan Parikh et al. All rights reserved. Noncardiogenic Pulmonary Edema after Amlodipine Overdose without Refractory Hypotension and Bradycardia Tue, 05 May 2015 12:06:51 +0000 Amlodipine overdose can be life-threatening when manifesting as noncardiogenic pulmonary edema. Treatment remains challenging. We describe a case of noncardiogenic pulmonary edema without refractory hypotension and bradycardia after ingestion of 500 milligram amlodipine with suicidal intent. Mechanical ventilation, dexamethasone, atrovent HFA (ipratropium), pulmicort inhalation, and antibiotic therapy were used for the management. Length of hospital stay was 11 days. The patient was discharged with full recovery. M. Hedaiaty, N. Eizadi-Mood, and A. M. Sabzghabaee Copyright © 2015 M. Hedaiaty et al. All rights reserved. A Broken Toothbrush in the Retropharyngeal Space in a Toddler of Sixteen Months Tue, 28 Apr 2015 09:36:33 +0000 A toddler of sixteen months fell while brushing his teeth and his mouth hit the ground. The toothbrush broke and one-third of it including the head got impacted in his throat. The attempt of his mother to remove it with her fingers further complicated the case and the toothbrush was ultimately lodged in the retropharyngeal space at the level from C1 to C5 vertebrae. It was strongly impacted due to the presence of the bristles. The broken end of the handle was just protruding into the nasopharynx and was very difficult to locate. The first attempt of its removal was unsuccessful. The toothbrush was removed safely in the second attempt without any complication. Saileswar Goswami and Choitali Goswami Copyright © 2015 Saileswar Goswami and Choitali Goswami. All rights reserved. Pitfalls in Suspected Acute Aortic Syndrome: Impact of Appropriate and If Required Repeated Imaging Mon, 27 Apr 2015 08:01:52 +0000 The incidence of acute aortic syndrome is low, but the spontaneous course is often life-threatening. Adequate ECG-gated imaging is fundamental within the diagnostic workup. We here report a case of a 53-year-old man presenting with atypical chest pain, slight increase of D dimers at admission, and extended diameter of the ascending aorta accompanied by mild aortic regurgitation. Interpretation of an initial contrast-enhanced computed tomography was false negative due to inadequate gating and motion artifacts, thereby judging a tiny contrast signal in the left anterior quadrant of the ascending aorta as a pseudointimal flap. By hazard, cardiac magnetic resonance imaging demonstrated an ulcer-like lesion superior to the aortic root, leading to aortic surgery at the last moment. As sensitivity of imaging is not 100%, this example underlines that second imaging studies might be necessary if the first imaging is negative, but the clinical suspicion still remains high. C. Meier, M. Lichtenberg, P. Lebiedz, and F. Breuckmann Copyright © 2015 C. Meier et al. All rights reserved. The Unexpected Pitter Patter: New-Onset Atrial Fibrillation in Pregnancy Wed, 15 Apr 2015 09:16:50 +0000 Background. Atrial fibrillation is a relatively uncommon but dangerous complication of pregnancy. Emergency physicians must know how to treat both stable and unstable tachycardias in late pregnancy. In this case, a 40-year-old female with a cerclage due to incompetent cervix and previous preterm deliveries presents in new-onset atrial fibrillation. Case Report. A previously healthy 40-year-old African American G2 P1 female with a 23-week twin gestation complicated by an incompetent cervix requiring a cervical cerclage presented to the emergency department with intermittent palpitations and shortness of breath for the past two months. EMS noted the patient to have a tachydysrhythmia, atrial fibrillation with rapid ventricular response. She was placed on a diltiazem drip, which was titrated to 15 mg/hr without successful rate control. Her heart rate remained in the 130s and the rhythm continued to be atrial fibrillation with RVR. Digoxin was then added as a second agent, and discussions about the potential risks of cardioversion in pregnancy ensued. Fortunately, the patient converted to sinus rhythm before cardioversion became necessary. The digoxin was discontinued; the diltiazem was also discontinued after the patient subsequently developed hypotension. “Why Should Emergency Physicians Be Aware of This?” New-onset atrial fibrillation is rare in pregnancy but can increase the mortality and morbidity of the mother and fetus if not treated promptly. Sarah White, Janna Welch, and Lawrence H. Brown Copyright © 2015 Sarah White et al. All rights reserved. Rhabdomyolysis and Acute Renal Failure after Gardening Sun, 12 Apr 2015 07:48:14 +0000 Acute nontraumatic exertional rhabdomyolysis may arise when the energy supply to muscle is insufficient to meet demands, particularly in physically untrained individuals. We report on a psychiatric patient who developed large bruises and hemorrhagic blisters on both hands and arms, rhabdomyolysis of both forearm muscles with a moderate compartment syndrome, and consecutive acute renal failure following excessive work in the garden. Although specifically asked, the patient denied any hard physical work or gardening, and heteroanamnestic data were not available. The diagnosis of rhabdomyolysis was easy to establish, but until reliable anamnestic data were obtained, the etiology remained uncertain. Four days after arrival, the patient recalled working hard in the garden. The etiology of rhabdomyolysis was finally reached, and the importance of anamnestic data was once more confirmed. Zeljko Vucicevic Copyright © 2015 Zeljko Vucicevic. All rights reserved. Colonic Foreign Body Retrieval Using a Modified TAMIS Technique with Standard Instruments and Trocars Tue, 07 Apr 2015 08:48:32 +0000 Background. Reports of retained colorectal foreign bodies (CFBs) are no longer considered uncommon. We present a case where a retained CFB was retrieved using a modified TAMIS technique using standard instruments and trocars. Case Report. A 52-year-old man presented with a CFB. We report our technique of extraction with standard laparoscopic instruments without specialized access platforms. Conclusions. This modified TAMIS technique is well suited for resource poor environments because it requires no specialized equipment, platforms, or additional skill sets compared to conventional laparoscopy. Shamir O. Cawich, Fawwaz Mohammed, Richard Spence, Matthew Albert, and Vijay Naraynsingh Copyright © 2015 Shamir O. Cawich et al. 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.