Tick-Borne Diseases.

Ticks are responsible for the vast majority of vector-borne illnesses in the United States. The number of reported tick-borne disease (TBD) cases has more than doubled in the past 20 years. The majority of TBD cases occur in warm weather months in individuals with recent outdoor activities in wooded areas. The risk of contracting a TBD is also highly dependent on geographic location. Between 24 and 48 hours of tick attachment is required for most disease transmission to occur. Only 50% to 70% of patients with a TBD will recall being bitten by a tick, and TBDs are often initially misdiagnosed as a viral illness. Most TBDs are easily treated when diagnosed early in their course.

Spontaneously Conceived Ruptured Heterotopic Pregnancy Presenting with Chest Pain and Dyspnea: A Case Report.

Introduction: Heterotopic pregnancy, defined as simultaneous intrauterine and ectopic pregnancy, is a rare and potentially life-threatening condition. The incidence of heterotopic pregnancy has significantly increased in the modern era, primarily due to use of assisted reproductive technology. Heterotopic pregnancy in the absence of risk factors is uncommon. The symptoms of heterotopic pregnancy are similar to those of ectopic pregnancy, primarily abdominal pain and vaginal bleeding. Case Report: We report a case of heterotopic pregnancy occurring in the absence of risk factors and presenting with primary symptoms of chest pain and shortness of breath. Conclusion: While uncommon, heterotopic pregnancy may occur in patients without risk factors and may present with atypical symptoms such as chest pain and shortness of breath.

Extensive subcutaneous emphysema treated with subcutaneous angiocatheters.

Subcutaneous emphysema (SCE) seen in the emergency department is usually the result of traumatic chest injuries, surgical complications, or invasive airway procedures. SCE is usually a self-limiting phenomenon involving the chest wall and neck, though may progress to involve the deeper tissues leading to respiratory and cardiovascular compromise. Emergent intervention is indicated in such cases of extensive SCE, though the ideal approach to its management is not known. We report a case of successful decompression of extensive SCE using subcutaneous placement of angiocatheters.

An Approach to Point-Of-Care Ultrasound Evaluation of the Abdominal Aorta.

Disorders of the abdominal aorta, including aneurysms and dissection, have potentially high rates of morbidity and mortality. While computed tomography (CT) is the current gold standard to image the abdominal aorta, the process of obtaining a CT may be time-consuming, requires the use of intravenous contrast dye, and involves exposure to ionizing radiation. Point-of-care Ultrasound (POCUS) can be performed at the bedside and has excellent sensitivity and specificity for the diagnosis of abdominal aortic aneurysm and excellent specificity for the diagnosis of abdominal aortic dissection. Additionally, POCUS is non-invasive, cost-effective, lacks ionizing radiation, requires no intravenous contrast dye, and can be performed without taking the patient from a critical care area. Screening for abdominal aortic aneurysm (AAA) can be done in primary care settings as well. This article will review the approach to POCUS of the abdominal aorta to evaluate such critical pathology. In this paper, we will review the sonographic anatomy of the abdominal aorta as well as the choice of the ultrasound probe, description of POCUS image acquisition, and some pearls and pitfalls of using POCUS to aid in the diagnosis of potentially life-threatening abdominal aortic pathology.

Severe copper deficiency anemia caused by zinc supplement use.

Copper deficiency is an uncommon condition primarily affecting the hematologic and neurologic systems. We report a unique case of severe anemia in a patient with copper deficiency caused by zinc supplement use.

Measurement of Procalcitonin as an Indicator of Severity in Patients With Chronic Obstructive Pulmonary Disease Admitted With Respiratory Illness.

Introduction Exacerbations of chronic obstructive pulmonary disease (COPD) are a frequent reason for hospital admission and a major cause of morbidity and mortality. A useful biomarker or indicator of disease severity at the time of presentation could help guide treatment and identify those with poor prognosis who need early aggressive intervention. We hypothesized that patients who present to the hospital with COPD exacerbations who are found to have elevated procalcitonin (PCT) levels will have worse outcomes such as longer admissions, increased intensive care unit (ICU) utilization, and more frequent readmissions than those with normal levels, regardless of presence or absence of infiltrate on initial chest X-ray (CXR). Methods We conducted a retrospective chart review of patients admitted to our facility with a respiratory complaint and a diagnosis of COPD to examine the relation between PCT and disease severity. A total of 156 unique encounters were reviewed, with 87 included in the final data set. Data was collected on baseline medical conditions as well as clinical status at the time of presentation. Primary endpoints included the need for overnight ICU admission, hospital length of stay greater than seven days, and repeat visit within 30 days of discharge. Secondary endpoints included the need for intubation at the time of admission, in-hospital mortality or discharge to hospice, and ICU length of stay. Results Patients with elevated PCT levels (>0.25ng/mL) had a significantly increased likelihood of a need for ICU admission (odds ratio 3.18) and hospital length of stay greater than seven days (odds ratio 3.38). There was no statistically significant difference in the Emergency Department readmission rate or any of the secondary outcomes. Conclusions Our data suggests that PCT may be a useful early biomarker for patients with COPD presenting with an acute respiratory illness.

Febrile seizures: A review.

Febrile seizures are common, occurring in up to 5% of children in the United States. Frequently perceived by caregivers as a life-threatening event, febrile seizures are a common cause of emergency department visits. The concern for permanent neurologic sequelae and future epilepsy after febrile seizures has resulted in a significant amount of research on these topics. The development of childhood vaccines over the past several decades has led to a significant reduction in childhood bacterial meningitis. This in turn has led to a dramatic change in the evaluation and treatment of febrile seizures. In this review, the different types of febrile seizures as well as the evaluation and prognosis of each are discussed.

Thrombotic microangiopathy presenting with stroke-like symptoms.

Thrombotic microangiopathies are a diverse group of clinical syndromes characterized by microangiographic hemolytic anemia, thrombocytopenia, and organ dysfunction. We report a unique case of thrombotic microangiopathy in an adult caused by vitamin B12 deficiency that presented with stroke-like symptoms.

Mycoplasma pneumoniae-induced rash and mucositis.

Mycoplasma pneumoniae-induced rash and mucositis (MIRM) is a recently defined clinical entity characterized by pneumonia caused by M. pneumoniae with associated mucositis and frequent cutaneous lesions of a characteristic pattern. Although often similar in presentation, MIRM has distinct clinical and histologic features that are different from erythema multiforme and Stevens-Johnson syndrome/toxic epidermal necrolysis. We report a case of MIRM in a nine-year-old boy.

Infected intracranial dermal sinus tract in a child.

Dermal sinus tracts (DSTs) are rare congenital defects occurring along the cranial spinal axis. They may extend from the skin into the deeper structures of the central nervous system. While most DSTs remain clinically occult, they can provide a route of entry for skin pathogens to cause intracranial infection. We report a child with a recent history of fever of unknown etiology who presented to our emergency department with a subcutaneous occipital mass. She was ultimately diagnosed with an infected intracranial dermal sinus tract. In this report, we provide a review of the literature on the diagnosis and management of this unique entity.

Acute necrotizing encephalopathy: A case report.

Acute necrotizing encephalopathy (ANE) is a recently identified, uncommon encephalopathy affecting children. ANE is characterized by a preceding viral illness followed by seizures and rapid progressive neurologic deterioration. The diagnosis of ANE is made based on clinical presentation and characteristic multifocal brain lesions seen on computed tomography (CT). We report a previously healthy two-year-old boy who presented to our emergency department (ED) after a seizure in the setting of fever and diarrhea. He was ultimately diagnosed with ANE and treated with steroids and IVIG. Early identification of this high morbidity condition by its typical clinical picture and characteristic radiologic findings is key to allow for optimal treatment.

Fever Without Source in Unvaccinated Children Aged 3 to 24 Months: What Workup Is Recommended?

ABSTRACT: Fever is the most common complaint for infants and children brought to the emergency department. Most febrile children younger than 3 years will have a clinically apparent source of infection. However, in approximately 20% of these children, a source cannot be identified by history and physical examination alone. The recommended diagnostic approach to children younger than 3 years presenting with fever without source (FWS) has changed dramatically over the past 30 years because of the widespread use of the Haemophilus influenza type b and polyvalent pneumococcal vaccines. The percentage of children in the United States unvaccinated at 24 months is now over 1% and seems to be increasing. This article will review what is currently known about FWS in children aged 3 to 24 months in the modern era and how it pertains to unvaccinated children treated in the emergency department. An algorithm for the treatment of unvaccinated young children presenting with FWS is proposed.

Ruptured abdominal aortic aneurysm identified on point-of-care ultrasound in the emergency department.

BACKGROUND: Ruptured abdominal aortic aneurysm (AAA) is a highly lethal condition which requires rapid identification and treatment to improve the chance of survival. Computed tomography is the diagnostic modality of choice for ruptured AAA though it is time-consuming and often requires movement of the patient out of the emergency department (ED). Point-of-care ultrasound in the ED has excellent sensitivity and specificity for the detection of AAA, though less is known about its use to diagnose AAA rupture. We report a case of ruptured AAA identified on ultrasound performed at the bedside in the ED. CASE PRESENTATION: A 77-year-old woman on warfarin with a known AAA presented to our ED with 2 days of epigastric abdominal pain. Point-of-care ultrasound revealed several findings suggestive of rupture of the AAA, which was confirmed on computed tomography. The patient was subsequently taken for emergent operative repair of the AAA and was later discharged from the hospital. CONCLUSIONS: Characteristics suggestive of AAA rupture may be seen on ultrasound. As ED physicians become more familiar with the use of point-of-care ultrasound in the evaluation of abdominal pain, identification of these characteristics may aid in the rapid diagnosis of AAA rupture.