J Emerg Med
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Case Reports
Varicella Zoster Virus Meningoencephalitis With an Atypical Presentation of Chest Pain, Impaired Memory, and Seizure.
Neurologic complications of varicella zoster virus (VZV) reactivation can be associated with considerable mortality and morbidity. Aseptic meningitis associated with VZV infection is rare, occurring in 0.5% of immunocompetent individuals. One third of VZV-related neurologic disease occurs without the classic herpes zoster exanthema, making early recognition more difficult. ⋯ A 60-year-old man presented to the emergency department with chest pain and impaired memory that he attributed to a transient ischemic attack as suggested by an urgent care facility 1 day earlier. He suffered a seizure while in the emergency department and was admitted to the intensive care unit. A computed tomography scan of his head and a magnetic resonance imaging scan were both negative for acute findings. An abnormal electroencephalogram consistent with an encephalopathy together with his new-onset seizure triggered a lumbar puncture that was positive for VZV. He was placed on acyclovir and was discharged from the hospital 5 days after admission. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: The typical presentation of a VZV central nervous system infection occurs with a sudden onset of fever, headache, nuchal rigidity, and focal neurologic signs. Our patient's recent impaired memory and subsequent seizure were likely manifestations of the developing VZV meningoencephalitis, while his chest pain may have correlated with subsequent development of a vesicular rash. Seizures are encountered in 11% of patients with VZV central nervous system infection, and VZV has recently been associated with cerebral vasculopathy. Awareness of alternative presentations for herpes zoster and meningitis is important in cases without classic symptoms to enable diagnosis and prevent delays in treatment.
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Aortic aneurysm ruptures are associated with high fatality. The timely diagnosis of a ruptured aortic aneurysm can be challenging for the emergency physician when hoarseness of voice is the only presenting symptom. Ortner's syndrome was first reported in 1897 as a case of left recurrent laryngeal nerve paralysis secondary to mitral stenosis and left atrial enlargement. In this case report, we describe a unique association of aortic aneurysm rupture with dysphonia presenting as Ortner's syndrome. ⋯ An 81-year-old man presented to our emergency department (ED) with an acute hoarse voice. Physical examination of his cardiovascular and neurologic systems was normal. Further evaluation with a nasoendoscope revealed a left vocal cord palsy. Consideration of Ortner's syndrome prompted an early call for thoracic imaging. A computed tomogram of the aorta showed a contained aortic aneurysm rupture with an acute hyperdense periaortic hematoma at the aortic arch. As our patient was a poor surgical candidate in view of concurrent comorbidities, he was managed conservatively. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: We identified a unique presentation of a painless, ruptured aortic aneurysm. This is a fatal diagnosis that all emergency physicians struggle to make in a timely fashion. The imminent aortic aneurysm rupture, masked by the absence of pain in our patient, could have resulted in a potentially catastrophic event. In the evaluation of a patient with hoarse voice, early consideration of Ortner's syndrome could result in timely diagnosis of a ruptured aortic aneurysm.
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Case Reports
Elevated Methemoglobin Levels in a Patient Treated with Hydroxocobalamin After Suspected Cyanide Exposure.
Cyanide (CN) toxicity commonly occurs during enclosed-space fires. Historically, the first step in treating CN toxicity utilized amyl nitrite and sodium nitrite to induce methemoglobinemia, which can be dangerous in this population. Hydroxocobalamin (OHCob), which binds to CN to form the nontoxic metabolite cyanocobalamin, is now the first-line antidote for CN toxicity, and has the advantage of not inducing methemoglobinemia. ⋯ A 62-year-old man presented to the Emergency Department (ED) after a house fire. He was intubated for respiratory distress and hypoxia with an initial carboxyhemoglobin of 1.3%, methemoglobin 0.3%, and anion gap 19. Eleven hours after presentation, his serum lactic acid was 9 mmol/L. Given his continued deterioration, 14 h after arrival he received OHCob 5 g i.v. for presumed CN toxicity. Methemoglobin concentration 4 min prior to OHCob administration was 0.7%, and 2 h after administration was 4.2%. This subsequently increased to 14.3% (16 h after OHCob administration) and peaked at 16.3% (47 h after OHCob administration), at which time he was administered a dose of methylene blue 50 mg i.v., 60 h after ED arrival. His methemoglobin concentrations fluctuated until a consistent downward trend starting at 92 h from ED arrival. He continued to deteriorate and expired on hospital day 5 with a methemoglobin concentration of approximately 6.0%. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: CN toxicity requires immediate recognition and treatment. The antidote, OHCob, is believed to not induce methemoglobinemia. However, this potential side effect must be considered by emergency physicians when treating suspected CN toxicity, especially if the patient does not improve after antidotal therapy.
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Review Case Reports
Multisystem Inflammatory Syndrome in Children (MIS-C) in an Adolescent that Developed Coronary Aneurysms: A Case Report and Review of the Literature.
A small subset of pediatric patients develop a rare syndrome associated with Coronavirus Disease 2019 (COVID-19) infection called multisystem inflammatory syndrome in children (MIS-C). This syndrome shares characteristics with Kawasaki disease. ⋯ A 15-year-old girl presented to our Emergency Department (ED) with fevers and malaise. She was diagnosed on her initial visit with an acute viral syndrome and discharged with a COVID polymerase chain reaction test pending, which was subsequently negative. She returned 3 days later with persistent fever, conjunctivitis, and a symmetric targetoid rash over her palms. She had no adenopathy, but her erythrocyte sedimentation rate and C-reactive protein were both significantly elevated at 90 mm/h and 19.61 mg/dL, respectively. The patient was then transferred to the regional children's hospital due to a clinical suspicion for MIS-C, and subsequent COVID-19 immunoglobulin G testing was positive. She had been empirically started on intravenous immunoglobulin in addition to 81 mg aspirin daily. Initial echocardiograms showed mild dilatation of the left main coronary artery, and on repeat echocardiogram, a right coronary artery aneurysm was also identified. Oral prednisone therapy (5 mg) was initiated and the patient was discharged on a continued prednisone taper. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: We present a case of a 15-year-old girl who presented to the ED with MIS-C who developed coronary aneurysms despite early therapy, to increase awareness among emergency physicians of this emerging condition.