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SAEM Clinical Images Series: A Rare Cause of Recurrent UTI

bulge

A 52-year-old male presents to the Emergency Department with a chief complaint of right lower abdominal pain with urinary frequency and urgency over the past week. The pain radiates from his right groin with 10/10 severity at times. He reports multiple diagnoses of urinary tract infections over the last year requiring oral antibiotics. He claims intermittent constipation, denies any trauma, and is a truck driver by trade.

Vitals: T 97.7 °C; BP 138/75; HR 75; RR 16; O2 sat 96%

General: WDWN obese male, A/O x4, in mild distress

Abdomen: Soft, nondistended, normoactive bowel sounds, no organomegaly. A 5 cm moderately tender soft tissue bulge suggestive of a direct hernia is palpated in the right inguinal area and is reduceable.

Complete blood count (CBC): Within normal limits

Complete metabolic panel (CMP): Within normal limits

Urinalysis (UA):

  • Color: Cloudy, yellow
  • Blood: Trace
  • Leukocyte esterase: Positive
  • Nitrite: Positive
  • WBCs: 15-30 hpf
  • RBCs: 3-5 hpf
  • Bacteria: Moderate

This patient’s CT scans demonstrate an inguinal herniation of the urinary bladder, which occurs in less than 4% of all inguinal hernias. The clinical finding of a soft tissue mass in the groin in the setting of recurrent urinary tract infections should include urinary bladder herniation in the differential diagnosis.

Oral or parenteral antibiotics based on clinical presentation and prevalent sensitivities should be given to address urinary tract infections. Emergent or non-emergent (if reduceable) surgical consultation, usually by a urologist, is standard. Surgical reduction and repair techniques that utilize mesh versus non-mesh have been associated with a better prognosis with less recurrence.

Take-Home Points

  • Although rare, an inguinal herniation of the urinary bladder should be considered in males over 50 years old who have a herniation on physical exam and urinary complaints.
  • Risk factors include obesity, BPH, and male sex. This condition is diagnosed in very few women.
  • Computerized tomography is the usual imaging modality to diagnose a urinary bladder herniation.
  • Patients may be asymptomatic or have symptoms that may include inguinal pain or swelling, urinary retention, and acute renal failure.
  • Manual compression of hernia to void is pathognomonic for a urinary bladder herniation.

  • Branchu B, Renard Y, Larre S, Leon P. Diagnosis and treatment of inguinal hernia of the bladder: a systematic review of the past 10 years. Turk J Urol. 2018 Sep;44(5):384-388. doi: 10.5152/tud.2018.46417. Epub 2018 Sep 1. PMID: 30487042; PMCID: PMC6134980.
  • Papatheofani V, Beaumont K, Nuessler NC. Inguinal hernia with complete urinary bladder herniation: a case report and review of the literature. J Surg Case Rep. 2020 Jan 2;2020(1):rjz321. doi: 10.1093/jscr/rjz321. PMID: 31911827; PMCID: PMC6939942.

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 |2023-10-06T13:25:23-07:00Oct 6, 2023|Genitourinary, SAEM Clinical Images|
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SAEM Clinical Images Series: Unusual Scalp Lesions

scalp

A 6-year-old male presented to the pediatric emergency department (PED) for scalp lesions. He was seen by his pediatrician 2 weeks prior and prescribed antibiotics and a delousing shampoo for suspected cellulitis versus lice infestation. Symptoms did not improve despite completion of treatment. An outpatient ultrasound was performed showing “multiple scalp echogenic nodular lesions measuring from 0.5 cm to 1.2 cm in the long axis diameter.” The following differential diagnosis was entertained: lymphadenitis, benign avascular mass, epidermal inclusion cyst, or pilomatricoma, and the patient was started on clindamycin. Due to concern for an oncologic process, a surgery consultation was placed to arrange for a biopsy. Four days after the ultrasound and before the biopsy could be performed, the patient and his mother presented to the PED due to worsening symptoms. Multiple new lesions developed across the patient’s scalp which bled when pressure was applied. The patient denied fever and reported intermittent pruritus and pain over the lesion sites. The mother reported a history of travel to Ecuador one month prior to symptom onset.

Vitals: BP 98/61; Pulse 73; Temp 36.3°C (97.3°F) temporal; Resp 18; SpO2 99%, RA

Skin: Large, 3 x 3cm indurated, erythematous lesion located over the patient’s right temporal scalp (Image 1). Five additional lesions noted across the entirety of the scalp. No lesions identified below the neck. Lesions are mildly tender to palpation; no fluid able to be expressed. A small centrally located pore is noted on each lesion with appearance of pulsatile fluid level. No associated lymphadenopathy. A point-of-care ultrasound (POCUS) using a high-frequency, linear transducer was performed during the PED visit (Image 2).

Non-contributory

In short axis, there is an echogenic lesion with surrounding fluid (halo sign) suggesting a foreign body that also exhibits posterior acoustic shadowing. With the transducer held still, independent movement is visualized within the center of the lesion (Image 3).

Cutaneous furuncular myiasis due to Dermatobia hominis (botfly infestation).

Take-Home Points

  • Native to Central and South America, botfly infestation is facilitated through an infected female mosquito which deposits its eggs on the skin of a mammal on which it feeds.
  • Cutaneous furuncular myiasis is important to consider for unexplained head, neck, and extremity lesions when there is suspected travel to endemic areas and is unlikely to be recognized in the continental United States due to low prevalence.
  • Consider pertinent physical exam findings and utility of POCUS in confirming the diagnosis.

  • Harris AT, Bhatti I, Bajaj Y, Smelt GJ. An unusual cause of pre-auricular swelling. J Laryngol Otol. 2010 Mar;124(3):339-40. doi: 10.1017/S002221510999082X. Epub 2009 Aug 11. PMID: 19664319.
  • Minakova E, Doniger SJ. Botfly larva masquerading as periorbital cellulitis: identification by point-of-care ultrasonography. Pediatr Emerg Care. 2014 Jun;30(6):437-9. doi: 10.1097/PEC.0000000000000156. PMID: 24892687.

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 |2026-04-28T14:34:41-07:00Oct 2, 2023|Dermatology, Pediatrics, SAEM Clinical Images|
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SAEM Clinical Images Series: Only a Flesh Wound

flesh

A 49-year-old male was triaged to the Fast Track area with complaints of an abrasion to the neck following an assault. The patient was attending a party with his family when “someone started shooting.” The patient believes some stucco or stone fragment from a brick wall struck him in the neck during the initial incident, but his primary concern was for his more seriously wounded family members. He now presents requesting “Neosporin.” His tetanus status is out of date.

General: Well-appearing male in no distress

Neck: Hemostatic wound to his left neck. No significant pain, no hematoma, no bruits.

Neuro: Exam is non-focal

Non-contributory

This is a zone 2 injury to the neck. Despite the small size of the wound, a piece of metallic shrapnel from the splintered bullet is noted adjacent to the carotid on CT imaging. Penetrating wounds can be deceptively innocuous, and a high index of suspicion is required. In cases where the nature of the missile is known, plain films or POCUS may be a reasonable first step, but CT imaging would be definitive.

Development of hoarseness or a Horner syndrome on the affected side may indicate involvement of the carotid sheath, and an angiogram may be considered, though CTA compares favorably to angiography in penetrating as opposed to blunt arterial trauma.

Take-Home Points

  • “Superficial” wounds must be evaluated diligently for any signs of deeper extension, and advanced imaging obtained for any suspicious findings or concerning mechanism of injury.
  • CTA is likely to be adequate in most cases of penetrating trauma, but a role may still exist for angiography in the presence of compelling clinical findings.

  • Goodwin RB, Beery PR 2nd, Dorbish RJ, et al. Computed tomographic angiography versus conventional angiography for the diagnosis of blunt cerebrovascular injury in trauma patients. The Journal of Trauma. 2009 Nov;67(5):1046-1050. DOI: 10.1097/ta.0b013e3181b83b63. PMID: 19901666.
  • Múnera F, Soto JA, Palacio D, Velez SM, Medina E. Diagnosis of arterial injuries caused by penetrating trauma to the neck: comparison of helical CT angiography and conventional angiography. Radiology. 2000 Aug;216(2):356-62. doi: 10.1148/radiology.216.2.r00jl25356. PMID: 10924553.

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 |2023-09-14T13:12:37-07:00Sep 29, 2023|SAEM Clinical Images, Trauma|
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SAEM Clinical Images Series: Blue is Bad

66 year-old-male with a history of type 2 diabetes and hypertension presented as a transfer for rapid progression of lower extremity pain, swelling, and blue-purple discoloration of the entire limb with concern for a possible necrotizing infection. His symptoms began earlier in the day and progressed over just a few hours. He had no known thromboembolic risk factors.

MSK: Swollen, tender, and blue/purple-colored right lower extremity

Complete Blood Count (CBC): WBC 8.7; Hb 15; Hct 45; Plt 172

Glucose: 472

Severe venous thromboembolism (VTE), also known as Phlegmasia Cerulea Dolens, which means “painful blue inflammation”, is commonly seen with a unilateral exquisitely tender, swollen, and bluish/purple-colored lower extremity.

Phlegmasia Cerulea Dolens has a high amputation rate secondary to venous gangrene or compartment syndrome. If no pulse is noted on exam, a high suspicion for compartment syndrome must be maintained.

Take-Home Points

  • Phlegmasia Cerulea Dolens is a rare ischemic complication of massive venous thromboembolism with amputation and mortality rates as high as 50% and 40% respectively.
  • Phlegmasia Cerulea Dolens tends to affect the iliofemoral segment of the lower extremities and is commonly associated with malignancy.
  • The preferred imaging modality is doppler ultrasound. Management includes limb elevation, IV fluids, and either systemic anti-coagulation, catheter-directed thrombolysis, and/or thrombectomy.

  • Bazan HA, Reiner E, Sumpio B. Management of bilateral phlegmasia cerulea dolens in a patient with subacute splenic laceration. Ann Vasc Dis. 2008;1(1):45-8. doi: 10.3400/avd.AVDcr07002. Epub 2008 Feb 15. PMID: 23555338; PMCID: PMC3610218.
  • Chaochankit W, Akaraborworn O. Phlegmasia Cerulea Dolens with Compartment Syndrome. Ann Vasc Dis. 2018 Sep 25;11(3):355-357. doi: 10.3400/avd.cr.18-00030. PMID: 30402189; PMCID: PMC6200621.
  • Gardella L, Faulk J. Phlegmasia Alba And Cerulea Dolens. 2022 Oct 3. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan–. PMID: 33085284.
  • Said A, Sahlieh A, Sayed L. A comparative analysis of the efficacy and safety of therapeutic interventions in phlegmasia cerulea dolens. Phlebology. 2021 Jun;36(5):392-400. doi: 10.1177/0268355520975581. Epub 2020 Nov 25. PMID: 33236674.
  • Schroeder M, Shorette A, Singh S, Budhram G. Phelgmasia Cerulea Dolens Diagnosed by Point-of-Care Ultrasound. Clin Pract Cases Emerg Med. 2017 Mar 13;1(2):104-107. doi: 10.5811/cpcem.2016.12.32716. PMID: 29849409; PMCID: PMC5965407.

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 |2023-09-14T13:02:29-07:00Sep 25, 2023|Heme-Oncology, SAEM Clinical Images|
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SAEM Clinical Images Series: Insidiously Contracted Hand

contracture

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.

Non-contributory

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.

Take-Home Points

  • Dupuytren’s contracture presents as a painless palmar contraction (typically proximal to the 4th or 5th digit) that impedes finger extension.
  • A progressive condition, Dupuytren’s is best managed through Hand Surgery referral provided there is no evidence of superinfection.
  • Repetitive motion occupations, tobacco use, alcohol use, and diabetes are key risk factors.

  • Shih B, Bayat A. Scientific understanding and clinical management of Dupuytren disease. Nat Rev Rheumatol 2010; 6:715.   Trojian TH, Chu SM. Dupuytren’s disease: diagnosis and treatment. Am Fam Physician 2007; 76:86.

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 |2023-09-14T12:40:35-07:00Sep 15, 2023|Orthopedic, SAEM Clinical Images|
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