SAEM Clinical Images Series: Purple Finger

bruising

A 30-year-old female with a past medical history of Crohn’s Disease presented to the ED for evaluation of an acutely bruised right 4th finger. She stated she was typing on a computer keyboard approximately 10 minutes prior to presentation and she noticed a sudden popping sensation at the base of her right ring finger. After the popping sensation, she noticed a cool sensation of the finger and numbness to the entire finger. Shortly after that, the finger turned purple, so she came to the Emergency Department for evaluation. She denied pain in the hand and has had no problems moving the finger. She denied trauma to the hand or finger. No other complaints or issues. She noted that she has had this once in the past, which self-resolved on its own in 10 days a few months ago in the same situation.

General: No acute distress

Right hand: Right 4th finger with diffuse ecchymosis across the palmar surface of the finger with swelling, no tenderness, ecchymosis does not extend to the palmar surface of the hand. FROM of all 5 digits at both the DIP and PIP joints. Sensation to the right 4th finger is decreased to light touch.

Left hand: Normal

Extremities: Normal other than the right ring finger

Pulses: Radial pulses 2+ bilaterally

Remainder of the physical exam is normal.

Non-contributory

Achenbach Syndrome, also known as paroxysmal finger hematomas, is a self-limited condition. It typically afflicts middle-aged women and presents as spontaneous subcutaneous bleeding of the palmar surface of the middle and index fingers of the hand. Patients usually present with pain, swelling, tingling, numbness, and ecchymosis. Many report a burning sensation to the finger. Diagnosis is based on presentation and exam. Laboratory testing and imaging do not show pathologic findings in this disorder. There is no known treatment and symptoms usually resolve on their own in a few days, but can last up to months. It has been shown to be recurrent, but without a known cause. Given the dramatic presentation of Achenbach Syndrome, it is important to be aware of this benign process to prevent unnecessary testing and workup, as it is a self-limited process.

Take-Home Points

  • Achenbach Syndrome is a benign, self-limited condition that does not require treatment
  • Relapses may occur.
  • No testing is indicated, but if sent will be normal including laboratory studies and arterial dopplers of the extremity.
  • Ahmed Z, Elmallah A, Elnagar M, Dowdall J, Barry M, Sheehan SJ. Painful Blue Finger-Achenbach’s Syndrome: Two Case Reports. EJVES Short Rep. 2018 Jun 27;40:1-2. doi: 10.1016/j.ejvssr.2018.05.008. PMID: 30094355; PMCID: PMC6070693.
  • van Twist DJL, Hermans W, Mostard GJM. Paroxysmal finger hematoma. Cleve Clin J Med. 2020 Apr;87(4):194. doi: 10.3949/ccjm.87a.19122. PMID: 32238371.

By |2024-03-16T21:44:45-07:00Mar 18, 2024|Orthopedic, SAEM Clinical Images|

SAEM Clinical Images Series: Workout Gone Wrong

hyphema

A 28-year-old male presented to the ED for evaluation of an injury to his right eye. While working out with an exercise band, it snapped back, hitting the patient in the right eye. He experienced blurry vision and excess eye tearing immediately after the incident occurred. The patient also developed gross blood over the front of the eye.

Vitals: Temp 98°F, HR 73, BP (135/77), RR 16, SpO2 99%

HEENT: Gross blood in the anterior portion of the right eye (grade I). The right pupil is dilated with minimal responsiveness to light. Visual Acuity: OD 20/70, OS 20/10, Both 20/10. Pressure: OD (21), OS (16). Decreased visual field on the right when compared to the left. Staining with tetracaine and fluorescein did not reveal any evidence of corneal abrasion or ulceration. Left eye is atraumatic in appearance.

Neurologic: Alert and oriented x3

Non-contributory

A Hyphema is a collection of blood in the anterior chamber of the eye due to the tearing of the iris root vessels.

The most common cause is blunt trauma to the eye. Spontaneous hyphemas can also occur and are often associated with sickle cell disease. It can be caused by ocular surgery and neoplastic disease, as well.

Take-Home Points

  • Hyphemas are an ocular emergency and should prompt immediate consultation with an ophthalmologist.
  • Patients should elevate the head of the bed to 45 degrees since layering of the blood is gravity-dependent.
  • Treatment usually involves the administration of steroidal and cycloplegic ophthalmic drops.
  • Cline, D., Ma, O. J., Meckler, G. D., Stapczynski, J. S., Thomas, S. H., Tintinalli, J. E., & Yealy, D. M. (2020). 241. In Tintinalli’s emergency medicine: A comprehensive study guide. essay, McGraw-Hill Education.
  • Traumatic Hyphema. Wikem. (2020, March 18). Retrieved January 11, 2023, from https://www.wikem.org/wiki/Main_Page

SAEM Clinical Images Series: Not Your Usual Irritated Eye

eye irritation

In July 2022, a 32-year-old male with a past medical history of HIV (on antiretroviral therapy, CD4 390, viral load undetectable) presented to the emergency department with constitutional symptoms and a rash for 4-5 days. His symptoms included malaise, body aches, subjective fevers, a sore throat, tender, swollen neck glands, body rash, and irritation of his left eye. He also noticed fluid-filled vesicles on his face, neck, trunk, and extremities. He denied travel outside the U.S. but reported a recent trip to New Orleans. He denied any new sexual partners or known exposure to individuals with similar symptoms.

Vitals: BP 135/83; Pulse 104; Temp 100.2 °F (37.9 °C); Resp 22; SpO2 99%

Constitutional: Alert, no acute distress

HEENT: 1×1 mm raised lesion to the left medial canthus/caruncle. No appreciated LAD. Oropharynx is clear and moist, and mucous membranes are normal.

Cardiovascular: Tachycardia, regular rhythm, and normal heart sounds.

Pulmonary: Breath sounds normal, unlabored respirations.

Abdominal: Soft. Non-tender.

Skin: Numerous 5-6 mm erythematous macules, bland fluid-filled vesicles, and umbilicated lesions throughout the face, neck, trunk, and extremities.

Complete Blood Count (CBC): WBC: 19.5 10^3/mcL, Hemoglobin: 15.2 gm/dL, Hematocrit: 43.6%, Platelet count: 325 10^3/mcL

Comprehensive Metabolic Panel (CMP): Within normal limits

RPR titer: Reactive, 1:4

Syphilis antibody IgG and IgM: Positive

Orthopoxvirus DNA: Pending

HIV RNA: Pending

The patient has Monkeypox with involvement of the caruncle of the left eye. The patient tested positive for non-variola orthopoxvirus DNA. Ophthalmology was consulted and did not find any other signs of compromise to the eye and recommended treatment with artificial tears. The patient received 14 days of Tpoxx. The patient’s eye lesion and symptoms resolved and he was discharged on hospital day eight.

Ocular lesions are a rare presentation of the monkeypox virus. There is limited literature documenting eye involvement and pictographic examples of its presentation. During the current outbreak, ocular involvement has been used as a criteria for hospital admission. The most commonly seen ophthalmologic lesions include a vesicular rash of the orbital and periorbital skin (25%), focal conjunctiva lesions, blepharitis, and conjunctivitis. Rarely, lesions can process to corneal ulcerations, keratitis, and vision loss. Given the late risk of vision loss in cases of ocular manifestations, clinicians should be aware of the varied presentation of ocular lesions associated with the monkeypox virus.

Take-Home Points

  • While rare, ocular involvement of Monkeypox is associated with vision loss, and should be promptly identified and addressed by a clinician.
  • If there is ocular involvement of primarily cutaneous pathology, a thorough eye exam is indicated in the initial assessment of the patient.
  • Abdelaal A, Serhan HA, Mahmoud MA, Rodriguez-Morales AJ, Sah R. Ophthalmic manifestations of monkeypox virus. Eye (Lond). 2023 Feb;37(3):383-385. doi: 10.1038/s41433-022-02195-z. Epub 2022 Jul 27. PMID: 35896700; PMCID: PMC9905463.
  • Kumar N, Acharya A, Gendelman HE, Byrareddy SN. The 2022 outbreak and the pathobiology of the monkeypox virus. J Autoimmun. 2022 Jul;131:102855. doi: 10.1016/j.jaut.2022.102855. Epub 2022 Jun 25. PMID: 35760647; PMCID: PMC9534147.
  • Thornhill, John P., et al. “Monkeypox virus infection in humans across 16 countries—April–June 2022.” N Engl J Med. 2022 Aug 25;387(8):679-691. doi: 10.1056/NEJMoa2207323. Epub 2022 Jul 21. PMID: 35866746.

SAEM Clinical Images Series: Two Pupils for the Price of One

pupil

A 24-year-old female with no pertinent PMHx presents to the ED with a chief complaint of eye pain. She reported a 10-day history of worsening right eye pain following being punched in that eye. She had been managing her pain with ice and had not taken any OTC medications. Her mom convinced her to go to the ED and she first went to an outside hospital, but was referred to come to our institution. She endorsed photophobia and blurry vision but denied double vision. She further noted occasional left-sided headaches.

Vitals: Within normal limits

General: The patient is alert and conversant. No apparent distress.

HEENT: NC, AT. Mucous membranes moist. Neck supple. Minimal pain with EOM. No double vision in right eye. Right eye discoloration at superior portion. Divided abnormal pupil. Mild superior periorbital swelling. Visual acuity: Right – 20/400, Left – 20/25

CV: Regular rate and rhythm.

Resp: Clear to auscultation bilaterally.

Abd: Soft, non-tender, non-distended.

Neuro: Alert. Motor and sensation grossly intact.

MSK: Moves all extremities, no joint pain or tenderness.

Skin: No obvious rashes or skin lesions.

Non-contributory

This is traumatic iridodialysis. It is typically related to significant blunt trauma to the eye that pulls the iris away from the ciliary body at the scleral spur [1]. That is what causes the split appearance or “two pupil” phenomenon.

Take-Home Points

  • Whenever you have a two-pupil phenomenon consistent with traumatic iridodialysis, the differential should always include penetrating injury to the globe, globe rupture, scleral rupture, hyphema, and lens dislocation. These additional findings may warrant urgent surgical repair or close monitoring of IOP. [2]
  • Consider bedside ultrasound to rule out posterior pathology (retinal detachment, vitreous hemorrhage, etc.).
  • Always refer to Ophthalmology, more urgently if the trauma was recent vs multiple days out (as in this case).
  • Knoop KJ, Palma JK. Iridodialysis. In: Knoop KJ, Stack LB, Storrow AB, Thurman R. eds. The Atlas of Emergency Medicine, 5e. McGraw Hill; 2021. https://accessmedicine.mhmedical.com/content.aspx?bookid=2969&sectionid=250455915
  • Gurwood AS. Cut at the root. Review of Optometry. https://www.reviewofoptometry.com/article/cut-at-the-root. Published November 19, 2012. Accessed January 2023.

By |2024-02-25T20:54:51-08:00Mar 1, 2024|Ophthalmology, SAEM Clinical Images|

SAEM Clinical Images Series: Neonatal Rash

An 18-day-old male presented for a rash on his face for two days. The patient was born via spontaneous vaginal delivery full term without complications to a mom who has a history of genital HSV but without active lesions at delivery and on acyclovir. The patient presented with a vesicular rash on his face including around his eyes. He had conjunctival discharge noted by mom. Otherwise, he was well-appearing, acting normally, and eating/voiding/stooling normally.

General: Well appearing, acting appropriately for age

HEENT: Scalp normal. Anterior fontanelle soft and flat. Vesicular appearing rash with erythematous base in clusters noted around eyes, cheek, and chin. Fluorescein staining with corneal abrasion noted at 4 o’clock region on right eye, no dendritic pattern. Scant yellow discharge noted from left eye. TM normal bilaterally. Oropharynx clear.

Neuro: Normal tone, moving all extremities

Skin: Flaky skin, no rash noted elsewhere except as listed above (Photos taken after fluorescein)

CBC: Normal

LFTs: Normal

BMP: Unremarkable

CRP: Negative

Lab results for HSV were negative:

HSV 1 and 2 (chin): negative

HSV 1 and 2 (near eye): negative

HSV 1 and 2 (nose, mouth, rectum): negative

HSV 1 blood Igg: negative

HSV 2 blood Igg: positive (reflective of maternal antibody status)

What was once called “neonatal acne” now known as neonatal cephalic pustulosis is usually seen in the first three weeks of life. Usually, it appears as pustulo-papules on the face, around the eyes, on the cheeks, and chin. Some studies have suggested that neonatal cephalic pustulosis is caused by Malassezia species. As the rash is self-limiting, treatment is not necessary.

Take-Home Points

  • When a vesicular rash is in a neonate < 1 month and all over the face, consider benign neonatal pustular lesions such as neonatal cephalic pustulosis.

  • Antoniou C, Dessinioti C, Stratigos AJ, Katsambas AD. Clinical and therapeutic approach to childhood acne: an update. Pediatr Dermatol. 2009 Jul-Aug;26(4):373-80. doi: 10.1111/j.1525-1470.2009.00932.x. PMID: 19689511.
  • Ghosh S. Neonatal pustular dermatosis: an overview. Indian J Dermatol. 2015 Mar-Apr;60(2):211. doi: 10.4103/0019-5154.152558. PMID: 25814724; PMCID: PMC4372928.

By |2024-02-25T20:47:08-08:00Feb 26, 2024|Dermatology, Pediatrics, SAEM Clinical Images|

SAEM Clinical Images Series: An Ultrasonographic Rabbit Hole

hole

An 86-year-old man with a past medical history of coronary artery disease, hypertension, hyperlipidemia, chronic kidney disease, COPD, choledocholithiasis requiring ERCP and sphincterotomy 2 years ago presented with five days of feeling unwell. History was limited due to cognitive impairment. His daughter had reported to staff he had been feeling unwell for five days, intermittently having nausea and generalized abdominal pain, subjective fevers, chest pain, and shortness of breath. His daughter also reported a history of intermittent lower abdominal cramping which was chronic for him. He denied changes to urination or bowel movements.

Vitals: BP 106/67, Temp 36.2°C, Pulse 115, Resp 20, SpO2 95%

General: Nontoxic appearing, no distress

Heart: Regular, no murmurs

Lungs: Clear bilaterally, normal work of breathing

Abdomen: Diffusely tender, greatest in left upper quadrant

CBC with differential: WBC 14.1, Neutrophil 12% (high)

Comprehensive metabolic panel (CMP): Total bilirubin 2.7 (high), AlkP 328 (high), AST/ALT normal

Lipase: Normal

Troponin x2: Negative

Chest x-ray: No acute abnormality

This patient has sonographic evidence of perforated gangrenous cholecystitis which was confirmed on subsequent CT scan. Gallbladder perforation is a complication of cholecystitis and has a reported incidence of 5-10%. It has been reported as early as two days after the onset of symptoms to as late as several weeks afterward. The most common site of perforation is the fundus due to relatively poor blood supply. In this case, the culprit perforation was in the proximal body adjacent to the stone which is suspected to have eroded through the wall.

Figure 1 depicts a minimally thickened gallbladder wall measured at 3.5 mm with a large shadowing stone-in-neck and associated perihepatic fluid collection (arrow) with a subtle intraluminal membrane and wall irregularity consistent with gangrenous cholecystitis. Figure 2 doppler images show no flow within the fluid collection and a suspiciously thin gallbladder wall (arrow). Figure 3 again highlights an irregular wall with small “hole sign” (arrow) signifying perforation of the gallbladder into the adjacent fluid collection. This patient was admitted to the hospital’s general surgical service and treated with IV broad-spectrum antibiotics and a percutaneous cholecystostomy tube placed by interventional radiology.

Take-Home Points

  • Look out for “hole signs” with adjacent fluid collection on your gallbladder ultrasounds which would suggest perforation.
  • Intraluminal membranes or wall irregularities suggest gangrenous cholecystitis.
  • Initial treatment includes broad-spectrum antibiotics and cholecystostomy tube decompression.

  • Indiran, V., Prabakaran, N. & Kannan, K. “Hole sign” of the gallbladder. Indian J Gastroenterol 36, 66–67 (2017). https://doi.org/10.1007/s12664-016-0723-3
  • Jeffrey RB, Laing FC, Wong W, Callen PW. Gangrenous cholecystitis: diagnosis by ultrasound. Radiology. 1983 Jul;148(1):219-21. doi: 10.1148/radiology.148.1.6856839. PMID: 6856839.
  • Sood, B.P., Kalra, N., Gupta, S., Sidhu, R., Gulati, M., Khandelwal, N. and Suri, S. (2002), Role of sonography in the diagnosis of gallbladder perforation. J. Clin. Ultrasound, 30: 270-274.

SAEM Clinical Images Series: One Month of Vaginal Bleeding

heterogenous uterus

A 28-year-old female G3P2002 presented to the emergency department for one month of vaginal bleeding. The patient was seen in the emergency department one month earlier for vaginal bleeding in the first trimester of pregnancy. Her estimated gestational age was six weeks by last menstrual period. At the time her beta-hCG was 7225 mlU/mL with no intrauterine pregnancy demonstrated on transvaginal ultrasound. Three days later, the patient had declining b-hCG and transvaginal ultrasound again with no intrauterine pregnancy. The patient was discharged home with a diagnosis of miscarriage. Since discharge, she endorsed an initial slowing of vaginal bleeding but over the last two weeks bleeding had become heavier and continuous; soaking up to eight pads a day. She endorsed worsening nausea and vomiting over the past two weeks. She has been sexually active since her last encounter. She denied abdominal pain, pelvic pain, cramping, dizziness, shortness of breath, or fevers.

Vitals: BP 136/70; Pulse 96; Temp 97.8°F; Resp 16; SpO2 100%

Constitutional: No distress

Cardiovascular: Normal rate, regular rhythm, normal heart sounds

Abdomen: Soft and non-tender; Gravid uterus approximately 10 weeks

Pelvic exam: Active vaginal bleeding of dark red blood originating from the cervical os. Cervical os is closed and otherwise normal in appearance. Multiple clots are seen in the vaginal canal and posterior fornix. Vaginal canal and external genitals are normal in appearance.

Beta-HCG: 91,401 mlU/mL

Hemoglobin: 12.8 g/dL

Our patient’s case is convoluted by reporting a miscarriage the month prior, with declining beta-HCG and transvaginal ultrasounds with no intrauterine pregnancy. While her symptoms never fully resolved she endorsed that her vaginal bleeding slowed and only started getting worse after resuming intercourse.

Her physical exam of a gravid uterus of approximately 10 weeks (despite reporting a miscarriage four weeks prior), persistent vaginal bleeding, and intractable nausea and vomiting are concerning for molar pregnancy [1]. Molar pregnancies typically present as abnormal uterine bleeding in the first or second trimester and are accompanied by symptoms of hyperemesis gravida secondary to the increase in beta-hCG [2]. The two main risk factors for gestational trophoblastic disease are the extremes of maternal age and prior molar pregnancy. However, there is an increased risk for molar pregnancy in patients with a history of prior spontaneous abortions and infertility [4]. Beta-hCG are typically greater than > 100,000 mlU/mL signifying excessive trophoblastic growth, however a value < 100,000 mlU/mL does not exclude the diagnosis of molar pregnancy as partial moles tend not to produce as much beta-HCG [3].

These images, taken by point of care ultrasound, show a heterogenic mass with mixed echogenicities within the uterine cavity consistent with gestational trophoblastic disease or molar pregnancy. Obstetrics and Gynecology was consulted for definitive management. The patient was taken to the operating room for dilation and curettage and was discharged the following day.

Take-Home Points

  • Physical exam findings of an enlarged uterus inconsistent with gestational age, vaginal bleeding, and intractable nausea and vomiting should clue you into a possible molar pregnancy.
  • Point-of-care ultrasound is an invaluable tool when assessing vaginal bleeding and will often help the clinician in the management or diagnostic pathway.
  • Beta-hCG < 100,000 mlU/mL does not rule out molar pregnancy. Obtain a good history, perform a thorough physical exam, and pick up your ultrasound probe.

  • Soper, John T. “Gestational Trophoblastic Disease.” Obstetrics & Gynecology, vol. 137, no. 2, 2021, pp. 355–370., https://doi.org/10.1097/aog.0000000000004240.
  • Cline, David, et al. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. McGraw-Hill Education, 2020.
  • Berkowitz, Ross S., and Donald P. Goldstein. “Molar Pregnancy.” New England Journal of Medicine, vol. 360, no. 16, 2009, pp. 1639–1645., https://doi.org/10.1056/nejmcp0900696.
  • Acaia, Barbara, et al. “Increased Frequency of Complete Hydatidiform Mole in Women with Repeated Abortion.” Gynecologic Oncology, vol. 31, no. 2, 1988, pp. 310–314., https://doi.org/10.1016/s0090-8258(88)80009-x.

By |2024-02-11T20:06:03-08:00Feb 12, 2024|Ob/Gyn, SAEM Clinical Images|
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