About Jordan Spector, MD

Assistant Professor
Residency Program Director
Department of Emergency Medicine
Boston Medical Center

SAEM Clinical Images Series: Ptosis? A Don’t Miss Diagnosis!

ptosis

A 50-year-old female with no past medical history presented to the emergency department for a headache. She developed progressive dull, left-sided head pain with sinus pressure one week prior, associated with sleep disturbance. In addition, she described two days of left eyelid drooping. She had no fever, chills, cough, difficulty breathing, neck pain, jaw claudication, vision changes, dizziness, numbness, or recent weight loss. She also denied any recent trauma to the head or neck.

Additional Images

Physical Exam

Vitals: BP 119/59; PR 92; Temp 37°C; RR 16; SpO2 100% on RA

General: Well-appearing, no acute distress.

HEENT: EOMI, left eyelid ptosis with miosis of left pupil.

Cardiovascular: RRR, normal S1/S2, no murmur.

Neurologic: Alert and oriented x 3, normal strength and sensation bilateral upper and lower extremities, left ptosis and miosis, otherwise cranial nerves II-XII unremarkable.

Laboratory Data

WBC: 8.9

INR: 0.9

Case Question: What underlying syndrome is suggested by the findings in this image?

This patient presented with Horner Syndrome, a triad of ipsilateral anhidrosis, miosis, and ptosis, the latter two of which are evident in this clinical image. Horner Syndrome presents when a lesion or insult disturbs the three-order sympathetic pathway that innervates the head, neck, and ipsilateral eye. Physical examination findings may be variable and/or subtle in patients with carotid dissection. Interestingly, isolated Horner Syndrome is the only abnormal physical finding in up to 50% of patients with carotid dissection. Further, patients with carotid dissection may present with only a partial Horner’s, with anhidrosis limited to the ipsilateral eyebrow, which can be difficult to identify. Evaluation of a patient with a new Horner Syndrome in the emergency department should include CT brain, CXR, and, if there is concern for carotid artery dissection, CTA or MRA head/neck. Carotid artery dissection is a neurologic emergency with significant morbidity and mortality ranging between 25-46% if left untreated. Management requires emergent neurology consultation with activation of the stroke team, as the treatment may require systemic thrombolytics and/or mechanical thrombectomy. Patients who present outside the time-window for stroke care, or who demonstrate resolving symptoms should be treated with antiplatelet or anticoagulant therapy. Notably, for patients with intracranial dissection or dissection involving the aorta, the preferred treatment is antiplatelet therapy in conjunction with neurology consultation.

Case Question: What is the differential diagnosis and workup for patients with this syndrome?

Horner syndrome has a broad differential diagnosis including stroke, neoplastic disease (brain, neck or lung), vascular injury, demyelinating disease, lymphoma, and iatrogenic injuries. This patient’s Horner syndrome was attributable to a carotid artery dissection (the most common vascular cause of Horner’s). Carotid dissection may occur after blunt trauma to the neck, but also as a result of seemingly innocuous movements of the neck. For example, evidence suggests that yoga, massage, and roller coaster rides each may increase risk for carotid dissection.

Case Discussion

Take-Home Points

Horner syndrome is the triad of ipsilateral anhidrosis, miosis, and ptosis, although physical exam findings may be subtle.
The differential for Horner Syndrome includes several urgent and emergent underlying etiologies.
Carotid artery dissection is an important cause of Horner Syndrome to consider in the appropriate clinical context.

References

Hakimi R, Sivakumar S. Imaging of Carotid Dissection. Curr Pain Headache Rep. 2019 Jan 19;23(1):2. doi: 10.1007/s11916-019-0741-9. PMID: 30661121.
Keser Z, Chiang CC, Benson JC, Pezzini A, Lanzino G. Cervical Artery Dissections: Etiopathogenesis and Management. Vasc Health Risk Manag. 2022 Sep 2;18:685-700. doi: 10.2147/VHRM.S362844. PMID: 36082197; PMCID: PMC9447449.
Flaherty PM, Flynn JM. Horner syndrome due to carotid dissection. J Emerg Med. 2011 Jul;41(1):43-6. doi: 10.1016/j.jemermed.2008.01.017. Epub 2008 Sep 14. PMID: 18790590.
Maloney WF, Younge BR, Moyer NJ. Evaluation of the causes and accuracy of pharmacologic localization in Horner’s syndrome. Am J Ophthalmol. 1980 Sep;90(3):394-402. doi: 10.1016/s0002-9394(14)74924-4. PMID: 7425056.
Stein DM, Boswell S, Sliker CW, Lui FY, Scalea TM. Blunt cerebrovascular injuries: does treatment always matter? J Trauma. 2009 Jan;66(1):132-43; discussion 143-4. doi: 10.1097/ TA.0b013e318142d146. PMID: 19131816.

Copyright

Images and cases from the Society of Academic Emergency Medicine (SAEM) Clinical Images Exhibit at the 2023 SAEM Annual Meeting | Copyrighted by SAEM 2023 – all rights reserved. View other cases from this Clinical Image Series on ALiEM.

By Jordan Spector, MD|2025-04-03T09:22:20-07:00Apr 4, 2025|Neurology, SAEM Clinical Images|

SAEM Clinical Images Series: A Serious Pain in the Neck

lemierre

An otherwise healthy 34-year-old male presented to the Emergency Department with two weeks of anterior neck pain. Symptoms began with several days of pain in his mandibular molars, progressing to pain and swelling in the neck. In the last several days, the patient developed warmth and redness in the chest wall associated with subjective fever and chills. Additionally, the patient reports difficulty swallowing solid foods secondary to odynophagia associated with intermittent globus sensation. He has no history of immunocompromise and denies any drug or alcohol use. Of note, he has not seen a dentist in many years.

Additional Images

Physical Exam

Vitals: BP 115/80; HR 120; T 101°F; RR 16; O2 sat 97%

General: Well appearing in no acute distress

HEENT: Poor dentition, mild trismus. No gingival inflammation or swelling or induration to suggest abscess. The floor of the mouth is unremarkable.

Skin: The neck and upper chest demonstrate erythema and tenderness with an enlarged area of fluctuance on the superior aspect of the left breast (Figure 1).

Laboratory Data

White blood cell (WBC) count: 6.3 k/uL

Lactate: 1.6 mmol/L

Glucose: 95 mg/dL

Creatinine: 0.72 mg/dL

Case Question: What is the diagnosis?

Lemierre Syndrome, also known as septic thrombophlebitis of the internal jugular vein, is a rare condition with an incidence of 3-15 cases per million people. This condition occurs when an oropharyngeal or odontogenic infection spreads locally from pharyngeal tissue to the internal jugular vein. The pathogens classically arise from normal oral flora, most commonly Fusobacterium necrophorum. The presentation may be associated with trismus and/or dysphagia. Subsequent complications, including localized abscess formation and bacteremia, stem from a combination of surrounding tissue invasion and systemic septic embolization.

Case Question: What are the initial priorities for management?

Given the potential for regional lymphatic spread and septic embolization, patients may present with both local and systemic findings. Skin exam may reveal regionalized cellulitic or infectious changes overlying the neck or chest (Figure 1).

Respiratory signs and symptoms may suggest the presence of pulmonary septic emboli or mediastinitis.

Constitutional symptoms including fever, chills, and fatigue are common though nonspecific. The differential is broad and includes a number of infectious, lymphatic, endocrine, and neoplastic conditions.

It is essential for the clinician to consider the alternative diagnosis of Ludwig’s Angina through careful evaluation of the oral floor.

Given the potential for oropharyngeal and respiratory compromise, emergency clinicians must maintain a high index of suspicion for this condition. Diagnostics should include laboratory studies with blood cultures, as well as CT imaging of the neck and chest to evaluate for filling defects of the internal jugular vein.

When entertaining the diagnosis, early antibiosis is prudent. Treatment should include both an extended course of antibiotic therapy as well as surgical source control of abscesses. Given the propensity for thrombus development (Figure 2), anticoagulation may be considered, but its indication here remains controversial. Patients with Lemierre Syndrome will require surgical consultation and hospital admission.

Case Discussion

Take-Home Points

Lemierre Syndrome is a septic thrombophlebitis of the internal jugular vein most commonly occurring via direct spread from the oral cavity. Distinction from Ludwig’s Angina is imperative.
Given the proximity to critical structures and the potential for systemic organ dysfunction from septic emboli, emergency physicians need to maintain a high clinical suspicion for this rare diagnosis.
Treatment includes parenteral antibiotics and prompt consultation of medical and surgical subspecialists to identify the infectious source as well as mitigate against systemic spread and/or thrombus propagation.

References

Kuppalli K, Livorsi D, Talati NJ, Osborn M. Lemierre’s syndrome due to Fusobacterium necrophorum. Lancet Infect Dis. 2012 Oct;12(10):808-15. doi: 10.1016/S1473-3099(12)70089-0. Epub 2012 May 25. PMID: 22633566.

Copyright

By Jordan Spector, MD|2023-10-15T21:15:48-07:00Oct 16, 2023|HEENT, Infectious Disease, SAEM Clinical Images|

SAEM Clinical Images Series: A Painful Swollen Digit

finger

A 50-year-old male with a history of polysubstance use disorder and poorly-controlled type 2 diabetes mellitus presents with left hand pain. One week ago, the patient sustained a macerating injury of the left distal middle digit. Since that time he has experienced worsening pain throughout the digit, now associated with diffuse swelling and discoloration. The patient also reports reduction in range of motion.

Additional Images

Physical Exam

Vitals: Temp 97.6°F (36.4°C); BP 134/89; HR 87; Resp 16

General: Uncomfortable appearing male.

Musculoskeletal: Left hand third digit with fusiform edema, diffuse erythema, and warmth. Held in passive flexion at rest. Skin breakdown noted at distal fingertip with scant serous drainage. Tender to palpation, most markedly over the volar surface of the PIP joint. Patient reports severe pain with passive extension at the MCP, PIP, and DIP joints.

Laboratory Data

Glucose: 296

White Blood Cell (WBC) Count: 8,000/μl

ESR: 54 mm/hr

Case Question: What is the diagnosis and what are the key history and exam findings that should rasie your clinical suspicion?

Infectious flexor tenosynovitis is an infection of the flexor tendon and synovial sheath with a significant risk of complications (e.g., tendon rupture, loss of function, amputation) if not promptly treated. Patients classically present 2-4 days after penetrating trauma to the hand (e.g., bite/scratch, puncture wound, laceration, injection).

This diagnosis is suggested clinically by four cardinal findings, the Kanavel signs:

1) diffuse “fusiform” swelling of the digit (most common)

2) digit held in passive flexion

3) tenderness to percussion over the flexor sheath

4) pain with passive extension

Case Question: What are the next best steps in management?

Although fundamentally a clinical diagnosis, the initial evaluation for infectious flexor tenosynovitis should include laboratory studies including complete blood count (CBC) and inflammatory markers (ESR/CRP). Radiographs may be performed to evaluate for occult traumatic injury or foreign body. Treatment includes emergent consultation of orthopedics or hand surgery, initiation of intravenous (IV) antibiotics, and hospital admission. Antibiotics should target gram-positive organisms (Staphylococcus, including MRSA, and Streptococcus). In immunocompromised patients, additional coverage against gram-negative organisms and anaerobes may be needed. Risk factors for poor outcomes include immunocompromise (HIV, diabetes, immunosuppression), intravenous drug use, peripheral vascular disease, and polymicrobial infection.

Case Discussion

Take-Home Points

Infectious flexor tenosynovitis is a surgical emergency that is diagnosed clinically by the presence of one or more of the four Kanavel signs on physical exam.
History of trauma or penetrating injury and immunocompromised status should raise suspicion for infectious flexor tenosynovitis; common pathogens include Staphylococcus and Streptococcus species.
Treatment includes emergent consultation with orthopedics or hand surgery as well as early initiation of IV antibiotics.

References

Ritter K, Fitch R. Tenosynovitis. In: Knoop KJ, Stack LB, Storrow AB, Thurman R. eds. The Atlas of Emergency Medicine, 5e. McGraw Hill; 2021. Accessed November 30, 2022. https://accessmedicine-mhmedical-com.ezproxy.bu.edu/content.aspx?bookid=2969&sectionid=250459435.
Hyatt MT, Bagg MR. Flexor Tenosynovitis. OrthopClin N Am 2017;48:217-27.
Pang HN, Teoh LC, Yam AKT, Lee JYL, Puhaindran ME, Tan ABH. Factors affecting the prognosis of pyogenic flexor tenosynovitis. Journal of Bone and Joint Surgery. 2007;89(8):1742-1748.

Copyright

Images and cases from the Society of Academic Emergency Medicine (SAEM) Clinical Images Exhibit at the 2021 SAEM Annual Meeting | Copyrighted by SAEM 2021 – all rights reserved. View other cases from this Clinical Image Series on ALiEM.

By Jordan Spector, MD|2023-08-14T14:28:46-07:00Aug 21, 2023|Infectious Disease, Orthopedic, SAEM Clinical Images|

5 Tips for Battling Academic Writer’s Block: Insights from the ALiEM Faculty Incubator

Academic writing is a core competency for any faculty member. As much as we hate to all admit it, professional advancement (and dissemination of your hard work) still heavily relies on academic publications – in a variety of formats original research, review papers, case reports, simulation cases, blog, and website writing. It is important to prioritize writing just as consistently as you do staying up-to-date with all the latest practice-changing evidence as a habit early in your health professions education career.

(more…)

By Jordan Spector, MD|2017-10-13T15:03:30-07:00Jun 8, 2016|Incubators, Medical Education, Professional Development|