Insulin edema: An untypical etiology of anasarca in a 19-year old female presenting to a pediatric emergency department.

Pulmonary edema and anasarca are both common findings in patients presenting to emergency departments (ED). The differential diagnosis for these conditions is very wide and requires an initially broad approach that considers multiple organ systems. Insulin edema has been previously described in multiple case reports as a likely cause of acutely developing edema in mostly type I diabetics either initiating or increasing the intensity of their insulin regimens. This case report describes a 19-year-old female with history of type I diabetes mellitus recently admitted to the hospital for diabetic ketoacidosis (DKA) presenting to a pediatric emergency department (ED) with dyspnea and weight gain. The patient had been reportedly poorly compliant on her insulin therapy before her last admission for DKA and had strictly begun to adhere to her insulin therapy in the interim. Her clinical presentation was notable for hypoxia requiring supplemental oxygen, bilateral lower extremity pitting edema, weight gain of 30 kg since discharge 9 days ago, a chest Xray displaying bilateral pulmonary edema and a work-up otherwise unrevealing for cardiac, renal, or liver etiologies. She was then admitted to the Pediatric Intensive Care Unit (PICU) on supplemental oxygen where through further evaluation she was determined to have insulin edema. This case details an unlikely etiology of anasarca and pulmonary edema, however diagnosing this condition highlights the broad diagnostic process that must be considered for any patient without known significant cardiac, renal, or liver history presenting with respiratory distress and anasarca especially on initial presentation to an emergency department.

Subarachnoid hemorrhage diagnosed by lumbar puncture after negative computed tomography angiography head.

Acute headache is a common emergency department (ED) chief complaint that usually has a benign course. Rare etiologies such as subarachnoid hemorrhage (SAH) can lead to extensive disability or even death. If suspected, SAH requires an intricate and intensive diagnostic investigation. Classic teaching recommends computed tomography head imaging without contrast which, if negative, is followed by lumbar puncture (LP) to rule out SAH. With improvements in computed tomography (CT), practice patterns have begun to adjust to allow computed tomography angiography (CTA) to rule out SAH. This case report describes a 23-year-old woman presenting with headache, neck, and back pain. Her initial CT head and CTA head imaging was negative for SAH. However, 3 days later upon re-presentation to the ED with the same symptoms, an LP was positive for increasing red blood cell count in subsequent tubes. She was transferred to a facility with interventional neurology capabilities where digital subtraction angiography showed a left anterior choroidal saccular aneurysm for which she underwent coiling. Given recent changes in SAH clinical practice guidelines, this case highlights the importance of understanding the current limitations of CT imaging, understanding the risks and benefits of both CT and LP, and always maintaining a high suspicion for especially lethal and disabling conditions such as SAH.