Abdominal pain and fever in a patient with human immunodeficiency virus: a case report.

BACKGROUND: Neutropenic enterocolitis (NE), or typhlitis, a condition typically associated with severe neutropenia in the setting of chemotherapy, is highly morbid (50-100%) and benefits from early diagnosis. It has been associated with neutropenia in the setting of human immunodeficiency virus (HIV) but has not been described in a patient with HIV who was not neutropenic on presentation. We present the case of a patient with HIV who was not neutropenic on presentation but found to have NE. CASE PRESENTATION: A 27-year-old male with a history of HIV on antiretroviral therapy and epilepsy presented with concern for breakthrough seizure. The patient revealed he was having non-bloody, non-bilious emesis and diarrhea for 3 days. Initial labs were white blood cell count 3.9 × 109/L, absolute neutrophil count (ANC) 3.14 × 109/L, CD4 count 290 cells/mm3, and undetectable viral load. A computed tomography (CT) scan of the abdomen/pelvis with contrast revealed wall thickening of the cecum and proximal ascending colon (Fig. 1), suggestive of NE. The patient was started on cefepime and metronidazole but switched to piperacillin/tazobactam after he became leukopenic/neutropenic. CONCLUSIONS: Neutropenic enterocolitis, typically presenting with fever, abdominal pain, and hematochezia, can be difficult to identify, particularly in patients without a history of malignancy. However, it should be considered in patients with HIV presenting with these symptoms, even with a normal ANC and CD4 count above 200 cells/mm3. Prompt diagnosis can be made with CT, and early initiation of broad-spectrum antibiotics greatly reduces the risk of morbidity/mortality.

Identifying the Gaps: Needs Assessment to Guide Development of a Dedicated Toxicology Curriculum for Emergency Medicine Residents.

INTRODUCTION: The American Board of Emergency Medicine identifies medical toxicology as an essential curricular element for emergency medicine (EM) residencies; however, access to medical toxicology education varies widely by institution. We hypothesized that EM residents are uncomfortable with core toxicology content and would be interested in  a dedicated toxicology curriculum. METHODS: An electronic needs assessment survey developed by experts in EM and medical toxicology was sent to residents and program leadership at nine EM programs participating in the Emergency Medicine Education Research Alliance (EMERA), a geographically diverse sampling of academic EM residency programs. We queried the presence of a current toxicology curriculum, interest in a dedicated toxicology curriculum, and comfort with core toxicology concepts for board examinations and in clinical practice.  RESULTS: A total of 148 residents and 8 faculty leadership completed the survey.  Only 29% of resident respondents felt comfortable with toxicology concepts, and only 66% of respondents reported access to a toxicology curriculum. Of those without a known toxicology curriculum, most were interested in a formal curriculum. Faculty respondents reported 6/8 programs offered a toxicology curriculum. Faculty at the two programs without a formal curriculum expressed interest in a dedicated curriculum. CONCLUSIONS: Emergency medicine residents remain uncomfortable with the core toxicology content in clinical practice. The majority of residents without a known toxicology curriculum would be interested in a dedicated toxicology curriculum.

Acute Angle-Closure Glaucoma Secondary to a Phakic Intraocular Lens, an Ophthalmic Emergency.

Implantable collamer lenses (ICL) are phakic (natural lens remains in place) lenses that were first developed in the 1990s for correction of high myopia. The effectiveness and safety of ICLs are making them an increasingly popular option for vision correction in the myopic patient, competing with traditional options like glasses, contacts, and procedures such as laser-assisted in situ keratomileusis. Although generally safe, due to the position of the phakic ICL in the eye, pupillary block remains a rare but vision-threatening complication of ICL implantation. Pupillary block caused by phakic ICL is a serious complication that requires urgent recognition and intervention and is poorly described in emergency medicine literature. We describe a case of pupillary block five years after ICL implantation that was refractory to standard medical therapy, highlighting the importance of early diagnosis and referral for more definitive therapy.