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SAEM Clinical Images Series: Snorkeling Gone Wrong!

sting

The patient is a 30-year-old female who presents to the Emergency Department with severe left foot pain after snorkeling in shallow water off the coast of Phuket, Thailand. She reports a sudden onset of pain as she was kicking her legs while swimming. She describes the pain as burning in nature across the top of her foot, which worsens with weight bearing, though she can bear weight. She also complaints of multiple discolorations on the dorsum of her left foot since the pain began.

Vitals: All vital signs are normal.

General: Awake and alert in some distress from pain.

Respiratory: Clear to auscultation.

Extremities: As shown in the image provided. Sensation is intact to light touch. There is a full range of motion about the ankle. Flexion and extension are preserved in the toes. The dorsalis pedis pulse is bounding and there is no significant bleeding.

Sea urchin envenomation.

Warm water immersion to neutralize the toxin.

This patient has suffered a sea urchin envenomation after accidental contact with its spines. Sea urchins are capable of causing envenomation when accidentally stepped on or bumped into by divers and marine workers alike, especially in shallow and rocky waters where sea urchins tend to dwell. Their hollow spines, which contain toxins, easily embed in the soft tissues. They can cause significant local inflammation, including tenosynovitis and granuloma formation, or systemic effects such as nausea, vomiting, fatigue, syncope, and respiratory distress. Diving gear may offer some protection, but sharp spines may still penetrate protective gear such as flippers or water shoes. Sea urchin toxins are heat-labile, and warm water immersion (40-46°C) can rapidly reduce pain by neutralizing toxins. Other treatments, such as surgical debridement, antibiotics, and tetanus prophylaxis should be sought as necessary when returning to more resource-rich environments. Some species of sea urchins contain dye in their spines, which can give the appearance of retained spines, as seen in this case.

Take-Home Points

  • Beware sea urchin contact when diving, swimming, or snorkeling in shallow, rocky waters.
  • Significant pain relief can be achieved with hot water immersion in sea urchin stings, as the toxins are heat labile.

  • Gelman Y, Kong EL, Murphy-Lavoie HM. Sea Urchin Toxicity. [Updated 2023 Aug 7]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/sites/books/NBK536934/
  • Zafren K, Thurman R, Jones ID. Sea Urchin Envenomation. In: Knoop KJ, Stack LB, Storrow AB, Thurman R. eds. The Atlas of Emergency Medicine, 5e. McGraw-Hill; 2021. Accessed December 27, 2024. https://accessemergencymedicine.mhmedical.com/content.aspx?bookid=2969&sectionid=250461114

Copyright

Images and cases from the Society of Academic Emergency Medicine (SAEM) Clinical Images Exhibit at the 2025 SAEM Annual Meeting | Copyrighted by SAEM 2025 – all rights reserved. View other cases from this Clinical Image Series on ALiEM.

By |2025-11-10T14:40:56-08:00Dec 1, 2025|Environmental, SAEM Clinical Images|
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SAEM Clinical Images Series: Caught by the Cuff

cuff

A 74-year-old male with a history of hypertension and moderate alcohol use presented to the Emergency Department with generalized weakness. He was started on low dose furosemide once a day for mild ankle swelling 3 days prior. He reported good oral intake but noted that he had been urinating more than usual. He denied any fever, chest pain, shortness of breath, or any other problems but due to worsening weakness he came in for evaluation.

 

Vitals: BP 185/94; HR 90; R 18; T 97.4°F; O2 sat 98% room air.

General: Well appearing, no acute distress.

Respiratory: Clear to auscultation.

Cardiovascular: Regular rate and rhythm, no murmur.

Extremities: Mild trace pedal edema bilaterally. While resting, the patient suddenly called out to the nurse for arm pain. Image 1 was taken at this time, during which his blood pressure was being measured.

CBC and BMP normal

Ca:8.4

Mg: 1.2

Trousseau’s sign of latent tetany (carpopedal spasm)

Hypomagnesemia

Trousseau’s sign is an involuntary, inducible carpopedal spasm that occurs when circumferential compression is applied to the limb, inhibiting blood flow (such as done by an inflated blood pressure cuff). Classically described, the metacarpophalangeal joints are flexed, the interphalangeal joints of the fingers and thumb are extended, and the thumb adopts a posture of opposition as seen in Image 1. Image 2 was taken with the blood pressure cuff deflated. Trousseau’s sign is primarily seen with hypocalcemia and hypomagnesemia, with hypocalcemia being the more common cause. Trousseau’s sign is seen most frequently in patients with disease states causing hypocalcemia and/or hypomagnesemia such as hypoparathyroidism, vitamin D deficiency, pancreatitis, renal disease, metabolic alkalosis, alcohol use disorders, and restrictive diets. The likely cause in this case is hypomagnesemia caused by furosemide diuresis and increased excretion of magnesium.

Take-Home Points

  • Trousseau’s sign is most commonly caused by hypocalcemia, but may also be less commonly associated with hypomagnesemia.

  • Trousseau’s sign of latent tetany resolves when the underlying electrolyte abnormality is corrected.

  • Trousseau A. Lectures on clinical medicine, delivered at the Hôtel-Dieu, Paris. 3rd ed [Translated by Cormack Sir John.]. London (UK): New Sydenham Society; 1872
  • Rehman HU, Wunder S. Trousseau sign in hypocalcemia. CMAJ. 2011 May 17;183(8):E498. doi: 10.1503/cmaj.100613. Epub 2011 Feb 28. PMID: 21398222; PMCID: PMC3091937.
  • Jesus JE, Landry A. Images in clinical medicine. Chvostek’s and Trousseau’s signs. N Engl J Med. 2012 Sep 13;367(11):e15. doi: 10.1056/NEJMicm1110569. Erratum in: N Engl J Med. 2012 Dec 6;367(23):2262. PMID: 22970971.

Copyright

Images and cases from the Society of Academic Emergency Medicine (SAEM) Clinical Images Exhibit at the 2025 SAEM Annual Meeting | Copyrighted by SAEM 2025 – all rights reserved. View other cases from this Clinical Image Series on ALiEM.



By |2025-11-17T01:53:05-08:00Nov 21, 2025|Endocrine-Metabolic, SAEM Clinical Images|
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SAEM Clinical Images Series: Mind the Gap

scapholunate

A 25-year-old right-handed female with a longstanding history of right wrist pain presents with wrist pain. Her chronic pain had worsened over the past 2-3 weeks. She did not recall a specific recent injury, but did recall that she had a painful injury to the same wrist in the past when she fell on her outstretched hand. She was seen several weeks prior for the injury, but did not seek follow-up care after her initial evaluation. She had pain with any movement and complained of tenderness around the wrist, but denied any fever, redness, swelling, or any other complaints.

 

Vitals: All vital signs are normal.

General: No acute distress.

Musculoskeletal: Right upper extremity: Normal shoulder and elbow range of motion without tenderness. The right wrist is tender over the proximal carpal row and thenar eminence, with mild snuffbox tenderness. Radial and ulnar pulses are intact. Radial, median, and ulnar nerve motor and sensory function intact. The patient can fully flex and extend at the wrist, but has pain with motion. There is no obvious visual deformity and no ecchymosis. Capillary refill in all digits <2 seconds. Can flex and extend all digits without difficulty. There is no warmth or erythema over the joint.

Non-contributory

Terry Thomas sign (widening of the scapholunate space)

The scapholunate ligament is disrupted.

Scapholunate advanced collapse (SLAC)

A fall on an outstretched hand (FOOSH) injury can result in not only fractures, but also ligamentous disruptions. Scapholunate Advanced Collapse (SLAC) injury is a progressive form of degenerative osteoarthritis of the wrist, often resulting from untreated disruption of the scapholunate ligament (SLL). SLAC is the most common form of post-traumatic osteoarthritis of the wrist. Injury to the SLL may be identified by intra-articular space widening between the scaphoid and lunate bones of the proximal row of the carpal bones on radiographs. This classic x-ray finding is also known as the “Terry Thomas” sign, referring to the famous gap in the upper dental incisors of the late British comedian. The SLL is responsible for stabilizing the scapholunate joint, and this x-ray finding indicates disruption of the ligament. Patients with this degree of joint space widening will often require surgical repair to ensure best functional outcome, and in the short term the injury is managed with NSAIDS, splinting, and orthopedic hand referral.

Take-Home Points

  • Scapholunate ligament disruption can lead to long term arthritis and impaired wrist function. Early identification and treatment helps improve outcomes.

  • MRI may be needed to identify disruption of the scapholunate ligament. X-ray is approximately 63% sensitive in identifying the injury by demonstrating scapholunate space widening.

  • Kompoliti E, Prodromou M, Karantanas AH. SLAC and SNAC Wrist: The Top Five Things That General Radiologists Need to Know. Tomography. 2021 Sep 23;7(4):488-503. doi: 10.3390/tomography7040042. PMID: 34698283; PMCID: PMC8544666.
  • Wessel LE, Wolfe SW. Scapholunate Instability: Diagnosis and Management – Anatomy, Kinematics, and Clinical Assessment – Part I. J Hand Surg Am. 2023 Nov;48(11):1139-1149. doi: 10.1016/j.jhsa.2023.05.013. Epub 2023 Jul 14. PMID: 37452815.

Copyright

Images and cases from the Society of Academic Emergency Medicine (SAEM) Clinical Images Exhibit at the 2025 SAEM Annual Meeting | Copyrighted by SAEM 2025 – all rights reserved. View other cases from this Clinical Image Series on ALiEM.



By |2025-11-17T01:47:19-08:00Nov 17, 2025|Orthopedic, SAEM Clinical Images|
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SAEM Clinical Images Series: Strawberry Tongue

A 7-year-old male with no significant past medical history presented to the Emergency Department complaining of a sore throat. The parents stated that he had been running fevers for two days along with a worsening sore throat. The patient had been able to swallow, but had decreased oral intake secondary to pain. There are no other complaints at the time.

 

strawberry tongue

Vitals: BP 110/70; HR 111; R 17; T 101°F; O2 sat: 99% on room air.

General: Well appearing, no acute distress, normal voice.

HEENT: There is no sign of conjunctivitis. Oropharyngeal exam is remarkable for exudative pharyngitis with tonsillar swelling. There is no sign of peritonsillar abscess or airway compromise. Uvula midline and normal. Tongue as shown. Anterior cervical lymphadenopathy is present.

Respiratory: Clear to auscultation bilaterally.

Cardiovascular: Tachycardia without murmur.

Abdomen: Non-tender, no organomegaly.

Skin: Relevant findings as shown.

Non-contributory

Strawberry tongue and sandpaper rash.

Scarlet fever

Scarlet fever is caused by Group A Streptococcus (S. pyogenes), and most commonly occurs in children aged 5-15 years. The illness typically begins with a prodrome of fever, sore throat, headache, and abdominal pain, followed 1-2 days later by a distinctive coarse rash with a texture that resembles sandpaper. Exudative pharyngitis is usually present. The tongue may initially have a white coating which fades by day 4-5, revealing a bright red, “strawberry tongue” as seen in this case. The rash usually starts on the neck, axillae, and groin, and then spreads to the trunk and extremities. Pastia lines, which are linear petechial eruptions, may be present in the antecubital and axillary folds. Facial flushing with a pale area around the mouth is also common. Desquamation of the skin may occur about two weeks after the rash appears. A rapid strep test can quickly confirm the diagnosis. If scarlet fever is left untreated, it can lead to serious complications such as rheumatic fever or post-streptococcal glomerulonephritis. Early diagnosis and treatment with antibiotics, usually penicillin or amoxicillin, are effective in preventing sequelae.

Take-Home Points

  • Scarlet fever is characterized by strawberry tongue, sandpaper rash, and exudative pharyngitis. The cause is Group A Streptococcus.

  • Early diagnosis and antibiotic treatment are crucial to prevent the serious potential complications of untreated scarlet fever, such as rheumatic fever and post-streptococcal glomerulonephritis.

  • The Sanford Guide to Antimicrobial Therapy. Dallas, TX :Antimicrobial Therapy, Inc., 1995.

Copyright

Images and cases from the Society of Academic Emergency Medicine (SAEM) Clinical Images Exhibit at the 2025 SAEM Annual Meeting | Copyrighted by SAEM 2025 – all rights reserved. View other cases from this Clinical Image Series on ALiEM.



By |2025-11-09T21:20:57-08:00Nov 14, 2025|Infectious Disease, Pediatrics, SAEM Clinical Images|
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SAEM Clinical Images Series: Leg Rash

ulcer

A 42-year-old male with no significant medical problems presented to the Emergency Department with a 5-week history of abdominal pain and bloody diarrhea. He also reported painful intraoral blisters and ulcerative lesions on the bilateral lower extremities and scrotum. The patient had been self-managing his symptoms with over-the-counter antidiarrheal medications and has unsuccessfully attempted to establish care with a gastroenterologist. He denied any history of intravenous drug use, cutaneous injections, or previous skin infections and has no other complaints at this time.

 

Vitals: BP 125/85; HR 97; R 22; T 99.2°F; O2 sat; 100% on room air

General: Overall well-appearing but uncomfortable.

HEENT: Dry mucous membranes, no lesions seen.

Respiratory: Clear to auscultation.

Cardiovascular: Regular rhythm without murmurs, rubs, or gallops.

Abdominal: Mild diffuse tenderness on palpation of abdomen without rebound or guarding. Bowel sounds mildly hyperactive.

Genitourinary: External purulent lesion on anus. Gross bright red blood on digital rectal exam.

Skin: Overall pallor, there are Scattered purulent ulcers on bilateral lower extremities and scrotum. Image 1 shows a lesion on the inner right thigh. Image 2 shows a second lesion on the right inner buttock. The right inner thigh lesion has been present longer.

WBC: 17.9

Hgb: 10.6

Plt: 654,000

ESR: 112

CRP: 21.8

Pyoderma gangrenosum

Ulcerative colitis

This rash is consistent with ulcerative pyoderma gangrenosum (PG), a rare inflammatory condition which may occur in isolation or in association with systemic diseases. PG typically manifests as an erythematous nodule or pustule that progresses to form a purulent or necrotic ulcerative base. The lower extremities are the most frequently affected sites. In this patient, the presence of abdominal pain, hematochezia, and elevated inflammatory markers raises suspicion for an underlying diagnosis of ulcerative colitis. Measurement of fecal calprotectin may provide additional diagnostic support. Management of mild flares in an outpatient setting may include rectal or oral mesalamine (5-ASA) in combination with oral prednisone. Severe exacerbations often require hospitalization for systemic glucocorticoid therapy and gastroenterology consultation. The patient was started on IV glucocorticoids and during his admission had resolution of his rectal bleeding and improvement in his rash. Colonoscopy results confirmed the underlying diagnosis of ulcerative colitis. The patient was discharged in stable condition with outpatient gastroenterology follow-up.

Take-Home Points

  • Pyoderma gangrenosum features erythematous nodules and pustules that progress to form a purulent or necrotic base, and is associated with inflammatory bowel diseases.

  • Severe cases of PG generally require glucocorticoid therapy.

  • Ruocco E, Sangiuliano S, Gravina AG, Miranda A, Nicoletti G. Pyoderma gangrenosum: an updated review. J Eur Acad Dermatol Venereol. 2009 Sep;23(9):1008-17. doi: 10.1111/j.1468-3083.2009.03199.x. Epub 2009 Mar 11. PMID: 19470075.
  • Ko CW, Singh S, Feuerstein JD, Falck-Ytter C, Falck-Ytter Y, Cross RK; American Gastroenterological Association Institute Clinical Guidelines Committee. AGA Clinical Practice Guidelines on the Management of Mild-to-Moderate Ulcerative Colitis. Gastroenterology. 2019 Feb;156(3):748-764. doi: 10.1053/j.gastro.2018.12.009. Epub 2018 Dec 18. PMID: 30576644; PMCID: PMC6858922.

Copyright

Images and cases from the Society of Academic Emergency Medicine (SAEM) Clinical Images Exhibit at the 2025 SAEM Annual Meeting | Copyrighted by SAEM 2025 – all rights reserved. View other cases from this Clinical Image Series on ALiEM.



By |2025-11-09T21:14:32-08:00Nov 10, 2025|Dermatology, Gastrointestinal, SAEM Clinical Images|
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