Enhanced U.S. Army HIV diagnostic algorithm used to diagnose acute HIV infection in a deployed soldier.

Antibody screening alone may fail to detect human immunodeficiency virus (HIV) in recently infected individuals. By U.S. Army regulation, HIV-infected soldiers are not permitted to deploy to areas of conflict, including Iraq and Afghanistan. We report here the first case of acute HIV infection (AHI) in a soldier in a combat area of operation detected by an enhanced U.S. Army HIV testing algorithm and discuss features of the tests which aided in clinical diagnosis. We tested the sample from the AHI case with a third generation HIV-1/HIV-2 plus O enzyme immunoassay, HIV-1 Western Blot, and a qualitative HIV-1 ribonucleic acid molecular diagnostic assay. Risk factors for HIV acquisition were elicited in an epidemiologic interview. Evaluation of the blood sample for AHI indicated an inconclusive serologic profile and a reactive HIV-1 ribonucleic acid result. The main risk factor for acquisition reported was unprotected sexual intercourse with casual strangers in the U.S. while on leave during deployment. The clinical diagnosis of AHI in a combat area of operation is important. Diagnosis of HIV is key to preventing adverse effects to the infected soldier from deployment stressors of deployment and further transmission via parenteral or sexual exposures.

Acute Myasthenia Crisis: A Critical Emergency Department Differential.

Myasthenia gravis (MG) is the most common autoimmune disorder of the neuromuscular junction (NMJ). It is caused by autoantibodies blocking acetylcholine receptors (AChRs) or structural receptors of the NMJ: agrin, LRP4, and MuSK. These antibodies can block, change, or destroy AChRs or structural proteins of the NMJ, preventing the binding of ACh and therefore, muscle contractions. This molecular dysfunction can manifest as any of the following symptoms: ptosis, diplopia, bulbar dysfunction, or impaired vision in bright light. Symptoms fluctuate in severity throughout the day and with prolonged use of respective muscles. Typical treatment for mild cases is acetylcholinesterase inhibition combined with an immunosuppressor. Myasthenia crisis results from the exacerbation of the aforementioned symptoms and requires intubation for respiratory support. Intensive care along with intensified immunosuppressive treatments and constant monitoring are recommended. We present the case of a 76-year-old man arriving to the emergency department (ED) with symptoms of fatigue and dysphagia, diagnosed as acute myasthenia crisis. Here, we highlight the symptoms of MG, acute myasthenia crisis, and the critical measures that need to be taken.

Wellen's Syndrome: Is One Electrocardiogram Good and Plenty?

The authors present a case of Wellen's syndrome, which has a characteristic T-wave on an electrocardiogram during a pain-free period in a patient with intermittent chest pain. The clinical presentation, pathophysiology, and management is discussed, and the importance of obtaining more than one electrocardiogram (ECG) is explained.  What this case adds to the literature is the fact that Wellen's syndrome patients may present atypically with active chest pain and, as such, should be managed similarly to acute myocardial infarction patients. However, because the diagnosis of Wellen's syndrome depends on an ECG obtained during the ensuing pain-free period, serial ECGs are usually required to reveal T-wave abnormalities in this context and have been shown to be disposition-altering in the Emergency Department (ED). Support for the death-denying outcome preferred in Wellen's syndrome by patients and providers alike depends on recognizing the diagnosis and consulting cardiology expediently.

Traumatic Multi-Finger Amputations After Trying to Rein in a Horse.

The authors present a case of traumatic, multiple partial-digit amputations caused by the patient entangling three of his fingers in the reins of a moving horse. The patient experienced amputation in fingers III-V on the dominant, right hand. The patient was stabilized and provided analgesia before referral to a surgical center for potential replantation. The emergency management of traumatic finger amputations is reviewed.

Orbital Compartment Syndrome: How a Young Man's Vision was Saved by the Timely Actions of an Emergency Medicine Physician.

In the following case presentation, a young man who incurred orbital compartment syndrome (OCS) from physical trauma significantly improved from timely lateral canthotomy. Lateral canthotomy is recommended to be performed as soon as possible to avoid permanent vision loss, which is the most feared complication associated with orbital compartment syndrome. This procedure completely restored vision in the patient and permitted prompt discharge.

Preseptal and Postseptal Orbital Cellulitis of Odontogenic Origin.

The authors present a case of combined preseptal and postseptal cellulitis of odontogenic origin. The infection started as a dental abscess associated with a first maxillary molar. The infection spread into the paranasal sinus, developed into a pansinusitis, and then spread into the preseptal and postseptal tissues. In addition to extraction of the infected tooth, the patient underwent bilateral nasal endoscopy, maxillary antrostomy, total ethmoidectomy, sphenoidotomy, and frontal sinusotomy with balloon dilation. Sinus cultures were positive for 2+ microaerophilic streptococci.