ACMT Toxicology Visual Pearl: Sleeping with the Fishes
What recreationally used substance has been dispensed in this fish-shaped dropper?
- Amyl nitrite
- Gamma-hydroxybutyrate (GHB)
- Heroin
- Ketamine
[Author’s own image]
SAEM Clinical Images Series: Modern Pirate
The patient is a 72-year-old male with multiple medical problems who presents to the Emergency Department complaining of dyspnea on exertion. The patient also complains of bruising that has developed on his right leg. He states that he previously had a similar episode for which she was admitted to the hospital and had warfarin discontinued due to thrombocytopenia. He also reports that he has been unable to eat or drink much lately due to gum swelling and tenderness, and states that when he begins chewing he feels as though his teeth are going to fall out. When asked about his usual diet, the patient states that he primarily eats raisin bran crunch and grits and that he does not really eat fruits or vegetables. He denies any chest pain, abdominal pain, nausea, vomiting, diarrhea, bloody stools, or any other complaints.
Vitals: All vital signs are normal.
General: Pleasantly interactive in no acute distress.
HEENT: Key findings are shown in the image provided.
Respiratory: Clear to auscultation, no increased work of breathing.
Extremities/Skin: Diffuse ecchymosis and petechiae are present. Bruising to the right foot and ankle as shown. Bilateral legs with significant petechiae diffusely. Hair as shown.
CBC: WBC 10.4 Hgb 7.8 Plt 98,000
RBC Morphology abnormal- Moderate Anisocytosis, Slight Poikilocytes
Moderate Polychromasia, Slight Elliptocytes, Slight Hyopchromia
CMP: Albumin 2.5, Total Protein 5.4
This patient has scurvy.
Vitamin C deficiency
Scurvy results in multiple symptoms including gingivitis with bleeding, periodontal disease, loss of dentition, mucocutaneous petechiae, ecchymosis, hyperkeratosis, and corkscrew hairs. Scurvy is due to Vitamin C deficiency and resultant impaired collagen biosynthesis. Petechiae, ecchymosis, follicular hyperkeratosis, perifollicular hemorrhages, corkscrew hairs, gingival bleeding, arthralgias, skin discoloration, impaired wound healing, koilonychias, and splinter hemorrhages may all be seen in patients with scurvy. These findings are primarily derived from inability to synthesize collagen due to lack of ascorbic acid, which is used as an electron donor to catalyze proline and lysine into hydroxyproline and hydroxylysine. Ascorbic acid also prevents epigenetic DNA hypermethylation, which is essential in the synthesis of certain collagen types.
Take-Home Points
- A thorough dietary history can help identify patients at risk for vitamin deficiencies and other diagnoses caused by malnutrition.
- Scurvy is caused by Vitamin C deficiency and results in impaired collagen synthesis, leading to multiple potential abnormal physical exam findings such as gingivitis with bleeding, severe periodontal disease, loss of dentition, mucocutaneous petechiae, ecchymosis, hyperkeratosis, and corkscrew hairs.
- Gandhi M, Elfeky O, Ertugrul H, Chela HK, Daglilar E. Scurvy: Rediscovering a Forgotten Disease. Diseases. 2023 May 26;11(2):78. doi: 10.3390/diseases11020078. PMID: 37366866; PMCID: PMC10296835.
- Léger D. Scurvy: reemergence of nutritional deficiencies. Can Fam Physician. 2008 Oct;54(10):1403-6. PMID: 18854467; PMCID: PMC2567249.
SAEM Clinical Images Series: A Mucous Membrane Mystery
The patient is a healthy 14-year-old male without past medical history who presents to the Emergency Department with oral lesions, eye swelling, intermittent fevers, and pain with urination. Over the past 10 days he has been seen by his PCP and at an outside ED for a cough, sore throat, fevers, and oral pain. Three days ago he was seen by his PCP, had a positive rapid strep test, and was started on amoxicillin. His oral lesions and lip swelling have been progressively worsening over the past 2 days. Monospot testing was also performed yesterday and is negative. Today he was seen again by his PCP for new pain with urination and was sent to the ED for concern for Kawasaki disease. The patient has had decreased oral intact due to his pain, but otherwise has no other complaints.
Vitals: BP 124/88 HR 112 R 28 T 100.2 F O2sat 94% room air.
HEENT: Relevant findings are shown in the images provided. Tonsillar exudate is present. No meningismus. Voice is normal.
Respiratory: Coarse breath sounds with diffuse wheezing.
Cardiovascular: Tachycardic, no murmurs, no rubs.
Skin: No rash. Negative Nikolsky sign. No palmar desquamation.
Lymph: Cervical lymphadenopathy is present
Genitourinary: See image provided.
CBC, CMP, Urinalysis: negative
COVID/Flu/RSV: negative
Mycoplasma NAAT: positive.
CRP: 13.5 mg/L
ESR: 48 mm/Hr
This child has RIME (reactive infections mucocutaneous eruption), a rare post-infectious cause of mucositis in children and adolescents.
Mycoplasma pneumoniae
Prolonged fevers and illnesses are frequent reasons for pediatric ED visits. Children and adolescents can be more prone than adults to a variety of immune-mediated and other inflammatory reactions such as Kawasaki disease, serum sickness like reactions, erythema or urticaria multiforme, SJS/TEN, MISC, among others. RIME is a relatively recently described post-infectious condition characterized by mucositis in at least two mucus membranes, with or without an area of cutaneous eruption. It was previously called mycoplasma-induced rash and mucositis (MIRM), and mycoplasma is the most common trigger, though the designation RIME implies that other common infectious agents (covid, influenza, and other viral and bacterial pathogens) have been identified as causal agents. Management is supportive, including treatment of the underlying illness (in this case, treatment of mycoplasma). Corticosteroids and other immunomodulatory agents may be used in more severe cases.
Take-Home Points
- RIME is a reaction primarily involving mucosal surfaces that is often associated with Mycoplasma pneumoniae infections in pediatric populations.
- Treatment of RIME involves treating Mycoplasma pneumoniae with azithromycin and supportive care including hydration and appropriate consultations for wound management as needed.
- Lofgren D, Lenkeit C. Mycoplasma Pneumoniae-Induced Rash and Mucositis: A Systematic Review of the Literature. Spartan Med Res J. 2021 Aug 30;6(2):25284. doi: 10.51894/001c.25284. PMID: 34532621; PMCID: PMC8405277.
- Meyer Sauteur PM, Theiler M, Buettcher M, Seiler M, Weibel L, Berger C. Frequency and Clinical Presentation of Mucocutaneous Disease Due to Mycoplasma pneumoniae Infection in Children With Community-Acquired Pneumonia. JAMA Dermatol. 2020 Feb 1;156(2):144-150. doi: 10.1001/jamadermatol.2019.3602. PMID: 31851288; PMCID: PMC6990853.
- Rehmus, W. E., Phillips, J., & Flegel, L. (2023). In Pediatric Dermatology (pp. 274–274). essay, UBC LIBRARY. Retrieved January 6, 2025,.
SAEM Clinical Images Series: An Unusual Appearing Umbilicus
The patient is a 70-year-old female with a remote history of breast cancer who presents to the Emergency Department with family due to frequent falls and disorientation. Her family reports that she previously walked independently. However, over the last several months, she has had worsening weakness and has become wheelchair-bound. Nonetheless, she frequently attempts to walk and loses her balance, leading her to falling. She is brought in today due to another fall along with worsening confusion over the past few weeks. The family does not believe the patient suffered any significant injury today, but brings here in due to her worsening condition. The patient has no complaints at this time.
SAEM Clinical Images Series: Bilateral Leg Swelling with a Uterine Twist
The patient is a 40-year-old female who presents to the Emergency Department with bilateral leg swelling. Her symptoms started six days prior and have progressively worsened. Her symptoms are associated with shortness of breath with no chest pain. The patient has taken an over-the-counter diuretic, which has helped with her symptoms. She also reports intermittent vaginal bleeding for the past two months, with a LMP that was two months prior. She is not currently on contraceptives, and does endorse unprotected intercourse over this time. The patient denies headache, blurry vision, nausea or vomiting, abdominal pain, urinary complaints, diarrhea or constipation. She has no other complaints at this time.
Vitals: BP 140/86; HR 97; R 14; T 99°F; O2 sat 99% on room air.
General: Well appearing, no acute distress.
Respiratory: Clear to auscultation.
Cardiovascular: Regular rate and rhythm, no murmur.
Abdomen: Soft, nondistended, nontender.
Extremities: Trace bilateral pitting edema. Normal range of motion, neurovascularly intact, equal pulses bilaterally.
Neurological: No focal neurological deficits.
Hgb: 9.6 (previously 13.3 two years prior)
Creatinine: Normal
BNP: 706 pg/mL
Serum ꞵ-HCG: 874,342 mIU/ml
This patient has a complete molar pregnancy.
Molar pregnancy is part of a spectrum of gestational trophoblastic tumors that include benign hydatidiform moles, locally invasive moles, and choriocarcinoma. Patients classically present with painless first or early second trimester vaginal bleeding with uterine size larger than expected gestational age and excessively high β-hcg levels. Some patients develop anemia, hyperemesis gravidarum, clinical hyperthyroidism, and signs of preeclampsia including hypertension, headaches, proteinuria and edema. Acute respiratory distress can occur due to embolization of trophoblastic tissue into the pulmonary vasculature, thyrotoxicosis, or simple fluid overload. Management involves removal of molar tissue through D&C or dilation and suction evacuation. Histopathologic examination of the products of conception is the gold standard for the diagnosis of a molar pregnancy. β-hcg levels are then monitored to ensure complete resolution and to detect any signs of persistent trophoblastic disease. In some cases, adjunct chemotherapy or even hysterectomy may be needed.
Take-Home Points
Molar pregnancy can be diagnosed with excessively high β-hcg levels and an ultrasound that shows a classic “snowstorm” or “bunches of grapes” finding.
Consider gestational trophoblastic disease in any patient with signs and symptoms of preeclampsia prior to 20 weeks gestation.
- Cavaliere A, Ermito S, Dinatale A, Pedata R. Management of molar pregnancy. J Prenat Med. 2009 Jan;3(1):15-7. PMID: 22439034; PMCID: PMC3279094.
- Soper, John T. MD. Gestational Trophoblastic Disease: Current Evaluation and Management. Obstetrics & Gynecology 137(2):p 355-370, February 2021. | DOI: 10.1097/AOG.0000000000004240
SAEM Clinical Images Series: A Curious Case of Abdominal Pain
The patient is a 22-year-old G0P0 female who presents to the Emergency Department with two days of left lower quadrant abdominal pain. The patient rates her pain as 10/10 in intensity, sharp in character, and states the pain radiates to her lower back. She notes similar intermittent pain over the past few months, but the pain became persistent over the past two days and has worsened. She also reports decreased appetite with nausea and vomiting. Her pain is exacerbated by movement. She began her menstrual period three days before presentation and denies being sexually active. She was previously prescribed oral contraception for treatment of menorrhagia, but discontinued it five months ago. She denies any fever, chills, chest pain, shortness of breath, urinary frequency, dysuria, vaginal discharge, bleeding, or vaginal pain.
Vitals: BP 132/84; HR 89; R 17; T 98.6°F; O2 sat 100% on room air
General: Appears uncomfortable due to pain.
Cardiovascular: Normal rate, regular rhythm.
Abdominal: Soft, non-distended, LLQ tenderness to palpation without rebound or guarding, bowel sounds present.
Genitourinary: No active bleeding or discharge, no signs of infection. No masses palpated.
WBC: 4.8
Hgb: 13.2
BMP: Normal
LFT’s: Normal
Urinalysis: Normal
Urine pregnancy test: Negative
This patient has a mature cystic teratoma (Dermoid Cyst).
Mature cystic teratomas (MCTs), also known as dermoid cysts, are benign ovarian germ cell tumors. While MCTs can occur in women of any age, they are found primarily in patients of reproductive age, with a median age of mid-30s. Patients may present asymptomatically, or with symptoms including nausea/vomiting, abdominal pain, and vaginal bleeding. Pelvic ultrasound or abdominal CT are first-line imaging studies, as well as laboratory testing to include ruling out pregnancy. In this patient with a negative UA and urine pregnancy test, abdominal CT was obtained and showed a large pelvic mass containing bony structures. Intraoperatively, the patient was found to have a large left ovarian dermoid cyst with evidence of torsion. The cyst contained multiple teeth and brown hair, and the diagnosis was confirmed with surgical pathology. Ovarian torsion is a serious complication of MCT and occurs in 3% to 21% of cases. If concomitant ovarian torsion is suspected, emergent gynecologic consultation is warranted.
Take-Home Points
Dermoid cysts are benign ovarian germ cell tumors that may grow large, cause significant pain, and often contain teeth and hair.
Ovarian torsion is an emergent potential complication of dermoid cysts and may require emergent consultation and surgical intervention.
- Cong L, Wang S, Yeung SY, et al. Mature Cystic Teratoma: An Integrated Review. Int J Mol Sci. 2023;24(7):6141. doi: 10.3390/ijms24076141. PMID: 37047114.
- Ahmed A, Lotfollahzadeh S. Cystic Teratoma. 2023. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024. PMID: 33231995.
SAEM Clinical Images Series: Quirky Quincke’s
The patient is a 38-year-old male with no past medical history who presents to the Emergency Department with chief complaint of “swollen uvula” that started 4 hours ago. The patient reports that he woke up this morning with pain in his throat and associated shortness of breath secondary to swelling. States he looked in his mouth in the mirror and saw that his uvula was swollen, prompting his visit to the ED. He states that he took Benadryl and Tylenol at onset of symptoms with no relief. The patient denies fever, cough, runny nose, nausea, vomiting, or drooling and has had no known sick contacts, changes in diet, or new medications. He denies smoking or any illicit drug use. He reports that this happened to him once before years ago when he was in his 20s, when he had similar presentation with edema of his uvula that was treated with Benadryl and a “shot” that he received 1 time in the emergency department with significant improvement and resolution of symptoms. He has no other complaints at this time.
Vitals: BP 115/69 HR 86 R 17 T 98.2 O2sat 100% room air.
General: Well appearing, no acute distress, normal voice.
HEENT: Relevant findings as shown. There is no drooling, pooling of secretions, muffled voice, lip swelling, or trismus. No signs of
peritonsillar abscess.
Neck: Non-tender to palpation. No swelling or adenopathy present.
Respiratory: Clear to auscultation bilaterally, breathing comfortably.
Influenza, COVID, Rapid Strep: negative
Quincke’s Disease (isolated angioedema of the uvula)
Quincke’s disease is an uncommon clinical diagnosis with unknown incidence; there are multiple causes reported in the literature. The most commonly reported cause is Type 1 hypersensitivity reaction. Other reported causes include hereditary angioedema, inhalation exposure, thermal injuries, and infections. In our particular case, we suspect hereditary angioedema given the patient’s prior history of the same issue. The ED management of uvular angioedema should include treatment with antihistamines, corticosteroids, NSAIDs and/or epinephrine in severe cases. Antibiotics are indicated if infection suspected. In cases of hereditary angioedema, patients may benefit from recombinant C1 esterase inhibitors. Patients with uvular angioedema should be closely monitored for signs of worsening respiratory compromise. If the patient worsens, admission for close observation should be considered or in severe cases, intubation for airway protection may be necessary. If the edema is not progressing, mild or uncomplicated, and/or resolved after treatment, patients can be safely discharged home. Our patient was monitored in the ED for over 2 hours without worsening and was discharged home with close follow up.
Take-Home Points
- Quincke’s disease is an uncommon phenomenon of isolated uvular edema with multiple possible etiologies.
- Airway patency is the primary concern when managing uvular angioedema.
- Gabriel Atan Sanchez, Madison Boot, Abdul Lathif, Quincke’s disease: an unusual pathology, Journal of Surgical Case Reports, Volume 2023, Issue 3, March 2023, rjad085, https://doi.org/10.1093/jscr/rjad085
- Mohammadi, Ladan1,; Miller, Anthony2; Ashurst, John V.3. Quincke’s disease. Journal of Family Medicine and Primary Care 5(3):p 677-679, Jul–Sep 2016. | DOI: 10.4103/2249-4863.197308
- Gonçalves FMF, Costa M, Campos AL, Cotter J. Quincke’s Disease Presenting After Cocaine Exposure. Cureus. 2022 Oct 21;14(10):e30536. doi: 10.7759/cureus.30536. PMID: 36415441; PMCID: PMC9675901.