A 64-year-old Caucasian male with a history of alcohol use disorder and tobacco use disorder presents with painless bilateral hand contractures that have been worsening for the past several months. He denies any recent trauma, fever, chills, or decreased sensation. The patient works as a construction worker.
Vitals: BP 143/83 ; HR 94; RR 18; T 98.6°F; O2 saturation 98% on room air
Musculoskeletal: He has bilateral palmar contractures proximal to the fourth digits. No tenderness to palpation along digits. Passive extension of the digits is limited bilaterally but does not elicit pain. When asked to place his palm flat on the table, there is notable contracture of the bilateral fourth metacarpophalangeal (MCP) joint (a positive Hueston’s tabletop test). No erythema or cellulitic changes are appreciated.
Dupuytren’s Contracture is a clinical diagnosis that most commonly presents as painless loss of extension of the fourth and fifth phalanx. Collagen deposition and subsequent fibrosis within the palmar fascia cause nodule formation along the flexor tendons near the distal palmar crease. Clinically this appears as puckering, tethering, and/or dimpling of the skin of the palm (as shown in the photograph). Accompanying joint rigidity and loss of full extension of the digit typically can take years to fully develop. Pain or inflammatory findings are not commonly seen unless there is an underlying tenosynovitis. Without signs of infection, outpatient management with Hand Surgery is the appropriate initial management.
Risk factors for the development of Dupuytren’s contracture include northern European descent, age greater than 50 years, and diabetes. The condition has been associated with tobacco use disorder, alcohol use disorder, jobs that require repetitive handling tasks or vibration, and localized fibrotic pathologies including Peyronie’s disease.
A 29-year-old female with a past medical history of migraine headaches presented to the emergency department (ED) for several hours of bilateral eye pain, redness, and decreased visual acuity. The patient is a contact lens wearer. The night prior to presentation at 18:00, the patient inserted her contacts that she had washed and soaked in a hydrogen peroxide (H2O2) cleaning solution. She removed the contacts five hours later at 23:00, at which time she noted her eyes to feel drier than normal but did not note significant pain with removal, significant trauma, or a partial contact removal. For the eye dryness and mild irritation, she rinsed her eyes with her contact solution. She woke up the following day at 6:00 with severe, bilateral eye pain, blurry vision, and difficulty opening her eyes due to pain. She again washed her eyes with contact solution which resulted in worsening pain while also noting a “fizzing” sensation in her eyes which prompted her presentation to the ED at 10:00. She denied any foreign body sensation, known trauma, or experiencing similar symptoms previously.
Eyes: Bilateral corneal injection with mild tearing. No foreign body on lid eversion. Uncorrected visual acuity of 20/200 in the right eye and 20/30 in the left eye. Extra-ocular movements intact. Right eye pressure measured 18 mmHg and left eye 17 mmHg. pH 7.0 in both eyes.
Fluorescein uptake represents defects in the cornea that allow for this dye to pool. For this case, this represents trauma caused by contact lens removal as the uptake covers the areas where contacts are placed.
Given the location and size of these defects, antibiotic drops should be promptly initiated, and prompt ophthalmologic evaluation should be obtained.
Cope JR, Collier SA, Rao MM, Chalmers R, Mitchell GL, Richdale K, Wagner H, Kinoshita BT, Lam DY, Sorbara L, Zimmerman A, Yoder JS, Beach MJ. Contact Lens Wearer Demographics and Risk Behaviors for Contact Lens-Related Eye Infections–United States, 2014. MMWR Morb Mortal Wkly Rep. 2015 Aug 21;64(32):865-70. doi: 10.15585/mmwr.mm6432a2. PMID: 26292204; PMCID: PMC5779588.
Stapleton F, Bakkar M, Carnt N, Chalmers R, Vijay AK, Marasini S, Ng A, Tan J, Wagner H, Woods C, Wolffsohn JS. CLEAR – Contact lens complications. Cont Lens Anterior Eye. 2021 Apr;44(2):330-367. doi: 10.1016/j.clae.2021.02.010. Epub 2021 Mar 25. PMID: 33775382.
U.S. Food and Drug Administration. (2022, August 16). Hydrogen Peroxide Solution. Hydrogen Peroxide Solution | FDA. Retrieved September 5, 2022, from https://www.fda.gov/medical-devices/contact-lenses/hydrogen-peroxide-solution
A 65-year-old male presented with chest and abdominal pain for three weeks. He endorsed a poor appetite and a weight loss of 16 kilograms in the last month. He denied fever, vomiting, diarrhea, and tarry stools and described having his usual bowel movements.
Chen CE, Shih YC. Monomicrobial Klebsiella pneumoniae Necrotizing Fasciitis With Liver Abscess: A Case Report and Literature Review. Ann Plast Surg. 2017 Mar;78(3 Suppl 2):S28-S31. doi: 10.1097/SAP.0000000000001001. PMID: 28177973.
Cheng NC, Yu YC, Tai HC, Hsueh PR, Chang SC, Lai SY, Yi WC, Fang CT. Recent trend of necrotizing fasciitis in Taiwan: focus on monomicrobial Klebsiella pneumoniae necrotizing fasciitis. Clin Infect Dis. 2012 Oct;55(7):930-9. doi: 10.1093/cid/cis565. Epub 2012 Jun 19. PMID: 22715175.
A 44-year-old female presented to the emergency department with the complaint of a “stone under [her] tongue.” She reported that the “stone” had been present and painless for two years. The day prior, she began experiencing pain at this site while brushing her teeth. She squeezed the area in an attempt to expel it, but this action only increased her pain.
Sialolith in Wharton’s Duct. There was visual and tactile evidence of a calculus under the patient’s tongue. It had slowly grown and was associated with increased pain and swelling while brushing her teeth.
The majority of sialoliths can be managed conservatively with hydration, moist heat application, massaging of the gland, milking the duct, and advising the patient to suck on tart candies to promote salivation. Larger, more superficial sialoliths may benefit from excision in the emergency department. In the case above, local anesthetic was injected, and manual expulsion was attempted but was unsuccessful. The emergency physician made a single 1 cm incision over the calculus and a 0.5 cm x 0.75 cm sialolith was removed with minimal bleeding. The patient was discharged on a course of amoxicillin-clavulanic acid.
Dehydration, trauma, anticholinergics, and diuretics predispose to the formation of sialoliths, with 80-90% arising from the submandibular glands. As with our patient, the most common presentation is a single calculus within Wharton’s duct causing pain and swelling during periods of increased salivation.
Conservative treatment is the mainstay of sialolith management. Larger, more superficial sialoliths may require excision. Imaging and specialist referral should be considered in cases concerning for tumor, abscess, or treatment failure.
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.
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.
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
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.
A middle-aged man with a past medical history of hypertension and tobacco use disorder presented to the Emergency Department after evaluation by an ophthalmologist. He complained of ten days of a right-sided headache and three days of diplopia. He denied eye pain, pain with eye movements, photophobia, and vision loss.
Neuro: Ptosis, “down and out” deviation and pupil dilation of the right eye were noted. Extraocular movements were intact and pupils were reactive to light bilaterally. No other neurologic deficits were observed.
This patient has a partial cranial nerve (CN) III (oculomotor nerve) palsy. CN III is composed of: (a) internal somatic motor fibers that innervate the levator palpebrae superioris (which elevates the upper eyelid) and the medial recti, superior recti, inferior recti, and inferior oblique extraocular muscles, and (b) external parasympathetic fibers innervating the ciliary muscles (involved in accommodation) and sphincter pupillae (involved in pupillary constriction). The presentation of complete isolated CN III palsy generally involves ipsilateral ptosis (due to levator palpebrae paralysis) and “down and out” ocular deviation (due to preservation of superior oblique and lateral rectus function).
The most common etiology of CN III palsy is ischemia of the nerve fibers secondary to diabetes mellitus or hypertension, which preferentially affects the internal somatic fibers that surround the blood supply. This etiology classically results in a pupil-sparing palsy due to preserved function of the external parasympathetic fibers. However, the most feared etiology is an intracranial aneurysm, most commonly a posterior communicating artery aneurysm. This source of external compression classically affects both the internal somatic motor fibers and external parasympathetic fibers, resulting in asymmetric pupil dilation.
A 64-year-old female with a history of quadriplegia and bladder rupture secondary to a motor vehicle accident two years ago, complicated by chronic indwelling suprapubic foley, presents from her skilled nursing facility with fever, oliguria, tachycardia, low blood pressure, and a change in the color of her urine.
This is a case of Purple Urine Bag syndrome (PUBS), an uncommon subset of CAUTI that generally occurs in female patients with constipation and an indwelling foley. Although not fully understood, it is thought that the long stool transit time of constipation allows GI flora to break tryptophan down into indoles which travel to the liver via the portal system where they become indoxyl sulfate, which is excreted into the urine. Bacterial enzymes there catalyze this to indoxyl which oxidizes in alkaline urine to both indigo (blue) and indirubin (red), the combination of which, plus interaction with the plastic catheter tubing, causes the vivid purple discoloration. Risk factors include women, chronically catheterized, elderly, recurrent UTI, institutionalization, and chronic constipation.