ACMT Visual Pearl: Basal Ganglia Hemorrhage
Which toxic alcohol can cause a basal ganglia hemorrhage?
- Ethanol
- Isopropanol
- Methanol
- Propylene glycol
[Left image from Wikimedia Commons]
SAEM Clinical Images Series: Mind the Gap
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.
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.
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.
SAEM Clinical Images Series: Leg Rash
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.
ACMT Visual Pearl: Necrosis in the Name of Anticoagulation
What anticoagulant medication can cause these skin changes?
- Apixaban
- Heparin
- Rivaroxaban
- Warfarin
[Image courtesy of Herbert Fred, MD and Hendrik van Dijk via Wikimedia Commons]
ALiEM AIR Series | OBGYN Module (2025)
Welcome to the AIR OBGYN Module! After carefully reviewing all relevant posts in the past 12 months from the top 50 sites of the Digital Impact Factor [1], the ALiEM AIR Team is proud to present the highest quality online content related to related to OBGYN emergencies in the Emergency Department. 3 blog posts met our standard of online excellence and were approved for residency training by the AIR Series Board. More specifically, we identified 1 AIR and 2 Honorable Mentions. We recommend programs give 1.5 hours of III credit for this module.
AIR Stamp of Approval and Honorable Mentions
In an effort to truly emphasize the highest quality posts, we have 2 subsets of recommended resources. The AIR stamp of approval is awarded only to posts scoring above a strict scoring cut-off of ≥30 points (out of 35 total), based on our scoring instrument. The other subset is for “Honorable Mention” posts. These posts have been flagged by and agreed upon by AIR Board members as worthwhile, accurate, unbiased, and appropriately referenced despite an average score.
Want asynchronous Individualized Interactive Instruction (III) credit?
Take the AIR quiz at ALiEMU. Free, 1-time login required.
Highlighted Quality Posts: OBGYN 2025
| Site | Article | Author | Date | Label |
|---|---|---|---|---|
| EMDocs | Tachyarrhythmias in Pregnancy | Dr. Derick Tompkins, Dr. Jordan Boggs, Dr. Patrick Grace | May 20, 2024 | AIR |
| EMCrit | Pulmonary and cardiac complications of pregnancy | Dr. Josh Farkas | March 5, 2024 | HR |
| EMDocs | EM@3AM: Amniotic Fluid Embolism | Dr. Kyle Smiley, Dr. Brit Long | June 22, 2024 | HR |
(AIR = Approved Instructional Resource; HM = Honorable Mention)
If you have any questions or comments on the AIR series, or this AIR module, please contact us!
Reference
- Lin M, Phipps M, Chan TM, et al. Digital Impact Factor: A Quality Index for Educational Blogs and Podcasts in Emergency Medicine and Critical Care. Ann Emerg Med. 2023;82(1):55-65. doi:10.1016/j.annemergmed.2023.02.011, PMID 36967275
SAEM Clinical Images Series: Tangled in the Toilet
An otherwise healthy 46-year-old male presented to the Emergency Department with 18 months of diarrhea and intermittent abdominal cramping that has acutely worsened in the past week. On the morning of presentation, he noticed a worm-like object in his stool, which he brought to the ED (See images), prompting his visit. Throughout these 18 months, he experienced 4-10 loose bowel movements per day. He tried dietary modifications, including the removal of dairy, gluten, and soy, all without relief. The patient frequently travels for work, mainly to the US, Europe, and intermittently to Asia. His diet includes all forms of meat, fish, and shellfish. He denied fevers, chills, headaches, chest pain, shortness of breath, unexpected weight loss or gain, nausea, vomiting, or changes in his urinary habits. His stool has been non- greasy and has not contained any blood or mucous.
Vitals: BP 136/85; HR 70; R 18; T 98.2°F; O2 sat; 97% room air.
General: Well appearing, no acute distress.
Abdomen: There is mild tenderness to palpation in bilateral lower quadrants. Bowel sounds present in all quadrants. No rebound tenderness or guarding. No organomegaly.
Lymph: No lymphadenopathy present.
Skin: No rashes.
WBC: 5.4
Hgb: 14.4
Dibothriocephalus (Diphyllobothrium) latus: a tapeworm.
Stool ova and parasites.
This patient is infected with Dibothriocephalus (Diphyllobothrium) latus, a tapeworm distinctive for its proglottids with central hyperpigmented reproductive organs, as shown in the images. Patients rarely visualize the tapeworm in their stool, so diagnosis is usually made with a stool ova and parasite study. Diphyllobothrium latus infection is commonly caused by eating raw, undercooked, or lightly pickled seafood contaminated with tapeworm eggs. Tapeworm eggs are also occasionally used as weight loss supplements. The market for these supplements is not regulated; thus, the eggs may be from other parasites, leading to more severe manifestations of infection in different body areas, such as the brain, lungs, or muscles. Diphyllobothrium latus infection can cause pernicious anemia, as 80% of Vitamin B12 intake may be absorbed by the worm. Treatment for Diphyllobothrium latus is a single dose of praziquantel. Due to fecal-oral transmission, patients who engage in high risk transmission-prone behaviors should consider having their partners tested and treated as well.
Take-Home Points
Diphyllobothrium latus infection may cause Vitamin B12 deficiency and resultant anemia as the worm may absorb up to 80% of B12 intake.
A single dose of praziquantel is generally sufficient to eradicate tapeworm infection.
- Schantz, P. M. (1996). Tapeworms (cestodiasis). Gastroenterology Clinics of North America., 25(3), 637–653. https://doi.org/10.1016/s0889-8553(05)70267-3
- Craig P, Ito A. Intestinal cestodes. Curr Opin Infect Dis. 2007 Oct;20(5):524-32. doi: 10.1097/QCO.0b013e3282ef579e. PMID: 17762788
- Scholz T, Garcia HH, Kuchta R, Wicht B. Update on the human broad tapeworm (genus Diphyllobothrium), including clinical relevance. Clin Microbiol Rev. 2009; 22:146–160