Cryptococcal meningitis in an immunocompetent patient.

Cryptococcal meningitis is a fungal infection that is most commonly thought of as an opportunistic infection affecting immunocompromised patients, classically patients with Human Immunodeficiency (HIV) infection. It is associated with a variety of complications including disseminated disease as well as neurologic complications including intracranial hypertension, cerebral infarcts, vision loss and other neurologic deficits. It is diagnosed by lumbar puncture with CSF studies, including fungal culture and cryptococcal antigen testing. We present a case of cryptococcal meningitis and fungemia in a previously healthy male patient who presented after multiple emergency department visits with persistent headache. After multiple visits, he underwent a lumbar puncture consistent with cryptococcal infection, and he was admitted to the hospital for initiation of antifungal therapy. His workup revealed no known underlying condition leading to immune compromise.

Using the Retrobulbar Spot Sign to Assist in Diagnosis and Management of Central Retinal Artery Occlusions.

Point-of-care ultrasound has become an integral part of the evaluation of monocular vision loss. Most commonly, it has been used to evaluate retinal detachment, vitreous hemorrhage, and posterior vitreous detachment. Point-of-care ultrasound can also be used to evaluate central retinal arterial occlusion, whereby a retrobulbar spot sign is present. We present a case series of 4 patients presenting with monocular vision loss who were found to have central retinal artery occlusion. We describe what a retrobulbar spot sign is and how its presence or absence can assist in the evaluation and treatment of these patients.

Vitriolage by Sulfuric Acid: Unique Challenges and Considerations in Patient Resuscitation.

BACKGROUND: In the United States, over 1 million burns require medical treatment each year. Chemical burns represent an infrequent but devastating percentage of all burns, which account for a large proportion of all burn-related deaths. Of the various causes of chemical burns, sulfuric acid is most commonly involved in occupational and accidental burns, and even cases of assault. CASE REPORT: We describe the case of a 27-year-old man who presented to our Emergency Department (ED) after an assault with sulfuric acid. During his presentation, particular attention and care was given to his decontamination, airway management, and correction of life-threatening metabolic derangements. After stabilization in the ED he survived an extensive hospital admission. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Patient outcomes and prognosis after chemical burns are dependent on prompt recognition/suspicion and rapid initiation of treatment. Even with prompt treatment, severe physiologic and psychologic injuries often afflict the patient. While encountering these devastating injuries, the emergency physician must carry a heightened sense of care and protection for both patient and staff to ensure optimum outcomes.

Altered Mental Status in the Emergency Department.

Altered mental status is an umbrella term that covers a broad spectrum of disease processes that vary greatly in chronicity and severity. Causes can be a primary neurologic insult or a result of a systemic illness resulting in end-organ dysfunction of the brain. Acute changes in mental status are more likely than chronic changes to be immediately life-threatening and are therefore the focus of this review. Given the potential time-sensitive nature, acute changes in mental status must be addressed immediately and with urgency. We recommend a primary survey followed by a secondary survey with special attention to immediate life-threatening reversible causes. We then recommend a systems-based approach searching for any other life-threatening or reversible causes. Because the differential for altered mental status is broad, a comprehensive emergency department evaluation including a detailed history and physical exam as well as laboratory and radiographic testing is needed.

Acute streptococcal meningitis presenting as bilateral conductive hearing loss.

Bacterial meningitis is a relatively uncommon condition encountered in the emergency department and the constellation of symptoms varies. Hearing loss has been well documented in the literature as a complication of the disease process, but not as the presenting complaint. We describe a case of a 59-year-old female who presented to the emergency department with sudden onset bilateral hearing loss who was found to have S. pneumonia meningitis bacterial meningitis. Even with advances in therapy, bacterial meningitis still carries a significant mortality rate. Early diagnosis and treatment is critical to achieving good outcomes.

Locked-in syndrome responding to thrombolytic therapy.

Locked-in syndrome (LIS) is an exceedingly rare condition that has been described as a fate worse than death. Unfortunately, exam findings can be subtle and imaging is poorly sensitive, often leading to a delay in diagnosis. We present a case of a 70-year-old female who presented to our emergency department after developing respiratory distress followed by sudden unresponsiveness. She was diagnosed with LIS and had an immediate and remarkable improvement after administration of tissue plasminogen activator (TPA). Patients presenting with sudden onset altered mental status require a very careful physical exam, even if deemed comatose, and should be considered for emergent imaging for stroke. Fortunately, our patient recovered well and was discharged home in good condition.

Acute Coronary Syndrome in Octogenarians: Expect the Unexpected.

BACKGROUND: Ischemic heart disease is the leading cause of death in the United States and the world. Advanced age is the strongest risk factor for ischemic heart disease and the best independent predictor for poor outcomes after acute coronary syndrome (ACS). Elderly patients are at high risk for ACS, and numerous studies have shown that octogenarians in particular experience increased morbidity and mortality compared to younger patients. CASE REPORT: We describe a case of an 83-year-old woman who presented to the emergency department with a chief complaint of sore throat and was found to have a non-ST elevation myocardial infarction (NSTEMI) and was treated successfully with primary coronary intervention (PCI). WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Chest pain is a common presenting symptom for ACS, but elderly patients with MI are more likely to present with other chief complaints. Only 40% of patients in the National Registry of Myocardial Infarction database ≥ 85 years of age had chest pain on initial presentation. Recent studies comparing invasive therapy (PCI or coronary artery bypass graft) with optimal medical therapy for patients > 75 years of age diagnosed with NSTEMI have reported a reduced risk of death and major cardiac events with invasive therapy. Emergency physicians should have a high level of suspicion for ACS in octogenarians, even in those presenting without chest pain. Timely diagnosis and management can improve morbidity and mortality in these patients.

Cardiac Tamponade Diagnosed by Point-of-Care Ultrasound.

We present a case involving a 12-year-old boy who presented to the emergency department and was diagnosed with a pericardial effusion with tamponade physiology by point-of-care ultrasound. The diagnosis resulted in prompt treatment and definitive therapy.

Absent Pulmonary Artery Presenting as High-Altitude Pulmonary Edema.

CASE PRESENTATION: A 22-year-old male with no known past medical history presented to our emergency department complaining of difficulty breathing. A plain film chest radiograph revealed findings consistent with a tension pneumothorax. DISCUSSION: However, due to physical examination findings inconsistent with the imaging report, a computed tomography of the chest was ordered which revealed an absent right pulmonary artery.The patient was ultimately treated for high altitude pulmonary edema and discharged on nifedipine and supplementary oxygen.