ACMT Toxicology Visual Pearls: On the Mark
What potential terrorism agent could be treated with the pictured antidote?
- Anthrax
- Botulism
- Dioxin
- Ricin
- Soman
SAEM Clinical Images Series: Unusual Scalp Lesions
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.
SAEM Clinical Images Series: Only a Flesh Wound
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.
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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.
ACMT Toxicology Visual Pearls: Mushroom Mishap
What well-known adverse reaction results from ingestion of the pictured mushroom?
- Acute hepatitis
- Disulfiram-like reaction with ethanol consumption
- Pneumonitis from inhalation of spores
- Seizures from glutamate agonist activity
[Image from Canstockphoto]
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.
SAEM Clinical Images Series: Insidiously Contracted Hand
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.
SAEM Clinical Images Series: Contact Your Nearest Ophthalmologist
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.