ACMT Toxicology Visual Pearl – Master of Deceit
What venomous marine animal is pictured?
- Fire coral
- Lionfish
- Sea urchin
- Stonefish
[Image from Rapheal Duprat via Wikimedia]
SAEM Clinical Images Series: Connect the Dots
The patient is a 39-year-old female with past medical history of polysubstance use disorder and seizures who presents to the Emergency Department complaining of bilateral leg pain, primarily in her joints. She states that she was seen by her PCP today and was given a shot of Toradol, but she reports that her pain has continued to worsen to the point that she has difficulty ambulating. She states that two days ago she developed pruritic blisters on her feet and her feet began to swell. She reports the blisters have worsened and have spread to her hands and forearms as well as her calves and thighs. She denies ever having similar symptoms in the past. She reports some subjective fevers and chills as well as cough and congestion, but denies sore throat, chest pain, abdominal pain, vomiting, diarrhea, dysuria, vaginal bleeding, or vaginal discharge. She denies any recent travel and denies any animal exposure other than her mother’s dog but there are no fleas that she knows of. She denies any recent insect bites. She states that she has been sexually active with one male partner over the last six months and that she has tested negative for STIs in the last two months. She has no other complaints at this time.
Vitals: BP 121/77; HR 107; R 22; T 100.8°F; O2 sat 98% room air.
General: Appears mildly uncomfortable but no acute distress.
HEENT: Normal, no signs of pharyngitis.
Respiratory: Clear to auscultation bilaterally.
Cardiovascular: Tachycardia without murmur.
Abdomen: Non-tender, no masses.
Extremities: There are no signs of trauma. Full range of motion but complaints of joint pain with moving her legs and with walking.
Skin: Relevant findings as shown. Discrete, tender, erythematous macules and vesicles on the bilateral feet, calves, forearms and a singular vesicle of the right1st digit
Urinalysis: Small amount of bacteria
This patient has disseminated gonococcal infection.
Disseminated gonococcal infection (DGI) is a serious complication of untreated gonorrhea, potentially leading to severe complications such as septic arthritis, pustular skin lesions, tenosynovitis, and in rare cases, endocarditis or meningitis. DGI is characterized by fevers, polyarticular joint pain, and skin lesions. The diagnosis of disseminated gonorrhea should be considered in any patient presenting with polyarticular joint pain or swelling in the setting of petechial or pustular skin lesions, especially in high risk populations. The skin lesions of disseminated gonorrhea most commonly appear on the distal extremities, and may involve the palms and soles. Patients may also present with acute septic arthritis without an obvious source. Patients with gonoccocal bacteremia may show signs of perihepatitis, meningitis, endocarditis, or osteomyelitis. Disseminated gonococcal infection results from the hematogenous spread of N gonorrhoeae, and typically develops within 3 weeks of primary mucosal infection. Patients with disseminated gonoccocal infection should be admitted for intravenous antibiotics (ceftriaxone). Any sexual partners should be treated as well.
Take-Home Points
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Consider disseminated gonorrhea when you have a patient with polyarticular joint pain/swelling with pustular skin lesions.
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Complications of DGI may be severe; admission and aggressive treatment with intravenous antibiotics is warranted.
- Tang et al. Characterizing the rise of disseminated gonococcal infections in California, July 2020-July 2021. Clin Infect Dis. January 2023;76(2):194-200.
- Wang CH, Lu CW. Images of the month 2: Disseminated gonococcal infection presenting as the arthritis-dermatitis syndrome. Clin Med (Lond). 2019 Jul;19(4):340-341. doi: 10.7861/clinmedicine.19-4-340. PMID: 31308120; PMCID: PMC6752240.
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: 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
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Molar pregnancy can be diagnosed with excessively high β-hcg levels and an ultrasound that shows a classic “snowstorm” or “bunches of grapes” finding.
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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
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Dermoid cysts are benign ovarian germ cell tumors that may grow large, cause significant pain, and often contain teeth and hair.
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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.
SAEM Clinical Images Series: Pain, Paralysis, and Rash
The patient is an 81-year-old female with a history of asthma and hypertension who presents to the Emergency Department with right-sided abdominal swelling for five days. Five days ago, the right side of her abdomen appeared to protrude more than the left. This protrusion then increased over the next 2-3 days. The patient was diagnosed with shingles to the right lower abdomen earlier that month, but her rash has now nearly resolved. She continues to have “electric” pain in the region of the prior shingles infection. She denies any fevers, abdominal trauma, vomiting, or changes in bowel or bladder habits. She has never had anything like this before.
Vitals: All vital signs are normal.
Abdomen: See image provided. There is a firm unilateral distention of the right lower abdomen without shifting dullness or fluid wave. No palpable masses are present. There is moderate tenderness over the protruding region but no rebound or guarding. Bowel sounds are present.
Skin: See image provided. Moderate tenderness to palpation over region.
CBC and CMP are unremarkable.
CT scan of the abdomen and pelvis: No evidence of acute abnormality. Normal appendix. Moderate stool burden.
This patient has a Zoster pseudohernia.
Varicella-Zoster Virus (Shingles).
Zoster pseudohernia (ZP) occurs when the zoster infection infiltrates a posterior thoracic dermatome, affecting the spinal nerve roots responsible for the motor function of the abdominal wall. ZP typically presents with a rapidly progressive unilateral outpouching of the abdomen, giving a hernia-like appearance, but with intact abdominal wall musculature. In most cases, the classic Herpes Zoster rash precedes ZP, however in up to 10% of patients ZP may be the first presenting sign of zoster. Although uncommon, the symptoms are often distressing to patients, with many presenting to emergency departments or surgical offices for initial evaluation. The diagnosis is clinical and is based on a history of zoster infection or classic zoster symptoms and lack of findings suggesting alternate pathology. Abdominal CT or other imaging is recommended to exclude tumors, true hernias, free fluid, or other possible causes of abdominal distention. Electromyography (EMG) can be used to support diagnosis and will typically be abnormal due to the dysfunction of the abdominal wall musculature. Complete recovery occurs in 70-80% of patients within about 4-5 months.
Take-Home Points
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Zoster Pseudohernia is a rare presentation of herpes zoster infection resulting in dysfunction of the abdominal wall musculature.
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There is no specific treatment with most cases fully resolving within several months to one year.
- Chernev I, Dado D. Segmental zoster abdominal paresis (zoster pseudohernia): a review of the literature. PM R. 2013 Sep;5(9):786-90. doi: 10.1016/j.pmrj.2013.05.013. PMID: 24054853.
- Yoo J, Koo T, Park E, Jo M, Kim MS, Jue MS. Abdominal pseudohernia caused by herpes zoster: 3 case reports and a review of the literature. JAAD Case Rep. 2019 Aug 5;5(8):729-732. doi: 10.1016/j.jdcr.2019.06.019. PMID: 31440570; PMCID: PMC6698640.