Imaging option in stingray-induced acute emergency: case report

The Roux-en-Y gastric bypass (RYGB) is a commonly performed bariatric surgery option for individuals with severe obesity. Although gastrointestinal (GI) bleeds are a well-recognized complication of RYGB, it is uncommon in the late postoperative period as the surgical sites heal. It can be challenging to diagnose and manage these GI bleeds due to their isolated location and, consequently, difficult accessibility via traditional endoscopy. Various approaches have been described for the management of this complication with different treatment options, and treatment can vary based on patient risk factors and presentation. We report a case of a patient with bleeding in the gastric remnant 18 years after bypass surgery. Traditional endoscopy and other imaging options were attempted before surgical intervention, with laparoscopy and intraoperative endoscopy being warranted. The patient was discharged in stable condition after spontaneous hemostasis following a complicated hospital course.

Prune belly syndrome, splenic torsion, and malrotation: A case report

Iatrogenic arteriovenous fistulas (AVF) are well described in adults; however, this complication is rarely described and reported in infants. We report the case of a 3-month-old infant with complicated gastroschisis requiring multiple venipunctures who presented with signs and symptoms suggestive of traumatic arteriovenous fistula. Ultrasound imaging confirmed the presence of a wide-necked AVF between the brachial artery and vein. The fistula was surgically repaired. This case report describes the clinical imaging and treatment options for infants with iatrogenic AVF.

Introduction Cholesteatoma in children can be acquired or congenital and is generally extensive. The most commonly used technique for the removal of cholesteatoma is intact canal wall mastoidectomy. This invariably leads to second-look surgery to assess for recurrence or residual cholesteatoma. Magnetic resonance imaging (MRI) with non–echo-planar imaging (non-EPI) diffusion-weighted imaging (DWI) is an accurate noninvasive imaging option that can be used in diagnosing primary cholesteatoma. This can also be used to diagnose residual or recurrent cholesteatoma in patients who have undergone intact canal wall mastoidectomy. Case Report A 7-year-old male patient presented with a 1-week history of foul-smelling discharge from the right ear. On examination, a polypoidal mass with keratinized debris was seen. A diagnosis of cholesteatoma of right ear was made. Imaging with high-resolution computed tomography (HRCT) of the temporal bone and non-EPI DWI MRI confirmed the same. The child underwent an intact canal wall mastoidectomy and was followed up at 2 years with non-EPI DWI MRI to monitor any residual or recurrent cholesteatoma. Conclusion Non-EPI DWI MRI provides a convenient, accurate, and noninvasive method of evaluating and monitoring for residual or recurrent cholesteatoma and thus helps avoid unnecessary second-look surgery.

It is with great honor and pleasure that we introduce to our readers the inaugural issue of Clinical and Experimental Emergency Medicine (CEEM). CEEM is the official peer-reviewed, open-access, quarterly journal of the Korean Society of Emergency Medicine. CEEM will focus on both basic and clinical research of emergency medicine including pathophysiology, epidemiology, diagnosis, prognosis, treatment, and simulation. CEEM accepts editorials, original articles, reviews, letters to the editor, case reports, and interesting images in related areas. CEEM will be of interest to healthcare professionals in acute care and emergency medicine, pediatric emergency medicine, emergency medical services, emergency procedures, cardiology, neurology, resuscitation, trauma, and education. CEEM is one of the only journals that covers both basic, preclinical and clinical research fields entirely focusing on acute care and emergency medicine. Recognizing the widespread impact of electronic open access journals and the need to contain costs, CEEM will only be published in electronic form.

Alcohol withdrawal syndrome’s major consequence, delirium tremens, is a complex issue that greatly raises patient morbidity and fatality rates. Alcohol withdrawal delirium is characterised by tremors, hypertension, profuse sweating, tachycardia and common delirium symptoms such as disorientation, lightheadedness, disturbances of circadian rhythm, processes of thinking and sensory disorders, all occurring over time. A 54-year-old male patient presented with a feature of visual hallucination that the police were standing in front of his house. He had suspicion that someone had kept a listening device in his house and all his conversations were being heard. He was doubtful that he could hear a musical tone and constantly searched for the music-producing device in his clothes, on his body, in his house, etc. As per his acute symptoms presentation, Arsenicum album (Ars. alb) 30 C was prescribed frequently until his symptoms responded to it. His symptoms completely disappeared, and his Clinical Institute Withdrawal Assessment for Alcohol score decreased from 16 to 0 within 5 days. This case report illustrates the potential use of homoeopathic medicine in the management of an acute emergency of Alcohol Withdrawal Delirium.

Background: Uterine torsion in pregnancy is a rare event that requires urgent recognition and management. Its presentation is non-specific and ranges from asymptomatic to severe life-threatening conditions such as placental abruption with hemorrhagic shock and maternal and fetal death. Here we describe our case and reviewed similar literature on gravid uterine torsion. To our knowledge, this is the first report of term uterine torsion complicated by placental abruption and fetal death in Africa. Case Presentation: A 28 years old Ethiopian woman gravida III, para II, presented at 37 weeks of gestation with acute severe abdominal pain, mild vaginal bleeding, absent fetal movement, and shock. Emergency cesarean section was decided with a presumptive diagnosis of placental abruption with hemorrhagic shock and intrauterine fetal demise. Intraoperatively, it was realized that the placenta and the dead fetus were delivered through an inadvertent posterior lower segment hysterotomy made on 1800 levo-rotated uterine torsion. Then the uterus was restored to its anatomic position and the posterior hysterotomy was closed. Despite medical measures, the uterus became atonic and a hysterectomy was required. The patient had an uneventful postoperative and postpartum course. Conclusion: Even if gravid uterine torsion is uncommon, it should be kept in mind as one of the differentials in pregnancy-related acute abdominal emergencies due to its non-specific nature and dangerous impact. Furthermore, it can be obscured and associated with other obstetric emergencies, especially placental abruption.

BackgroundElectrocardiogram (ECG) is the first diagnostic tool physicians use in diagnosing acute myocardial infarction (MI). In this case report, we present a case where the initial ECG diagnosis was that of an acute anteroseptal MI but emergency coronary angiography showed that the infarct-related artery was a small non-dominant right coronary artery (RCA) instead of the anticipated left anterior descending artery (LAD). Isolated right ventricular (RV) infarction from a non-dominant RCA is rarely seen in clinical practice, and it may exhibit ECG changes that can be confused with an acute anteroseptal MI. It is important to appreciate the subtle differences in the ECG changes that occur in either of these two types of MI for appropriate diagnosis and treatment.Case presentationA 49-year-old non-smoking male with prior coronary stent implantation in LAD presented with acute chest pain and his pre-hospital ECG indicated an anteroseptal STEMI possibly due to stent thrombosis, but an emergency angiogram showed patent LAD and Circumflex arteries. There was however thrombotic occlusion of the right, non-dominant coronary artery, which was revascularized with a drug-eluting stent. The patient’s chest pain and ST elevations resolved, and subsequent echo showed moderate RV systolic dysfunction in keeping with RV myocardial infarction.DiscussionRV myocardial infarction is usually due to an occlusion of the dominant RCA proximal to the origin of its RV wall branch, which often results in inferior ST elevation with reciprocal anterior ST depression. The ST elevation over V1 which would accompany RV infarction is often masked due to the more dominant electrical forces of inferior and posterior LV wall infarction. Our case demonstrates that in isolated RV infarction due to non-dominant proximal RCA occlusion, anterior ST elevation can be seen over V1-3, being most prominent in V1, which overlies the right ventricle, and resolved after restoring flow to the RCA. Spatial vector analysis of the ECG or right-sided ECG leads would be helpful to aid the diagnosis of RV infarction when clinical suspicion is present, for example when there is significant hypotension, raised jugular venous pressure but clear lung fields or deterioration after nitrate administration.

Spontaneous Intrahepatic Hemorrhage: A Case Report

A case of acalculous cholecystitis presented as an acute abdominal emergency in a 22 year old woman with severe systemic lupus erythematosus. At the time of presentation the patient was receiving high doses of prednisone and cyclophosphamide to control her underlying disease. Histological examination of the biopsy specimen from the gall bladder showed lupus vasculitis. This complication of systemic lupus erythematosus has not been reported before. Laboratory studies and changes in lupus activity may fail to predict the onset of cholecystitis.

Introduction: Carbamoyl phosphate synthetase 1 (CPS1) is the first enzyme of the urea cycle, which is the pathway responsible for excess nitrogen detoxification and arginine synthesis. Deficiency of CPS1 will cause severe hyperammonemia often already on the first few days after birth. The majority of patients with CPS1 deficiency have a neonatal presentation with encephalopathy and lethargy due to severe hyperammonemia. These patients usually require intensive care treatment with nitrogen scavenging medication and hemodialysis but despite this, the outcome of these cases is guarded. Case Report: Here we report the first case of CPS1 deficiency in a newborn Bahraini girl who was manifesting on the 3rd day of life with encephalopathy, seizures, and hyperammonemia. She was treated with nitrogen scavenging medication and peritoneal dialysis leading to a decrease of the ammonia level. After starting carglumic acid (Carbaglu), which is the allosteric activator of the urea cycle, the metabolic situation was further improved. Unfortunately, the patient had already sustained severe neurological sequelae and expired after one month. Her diagnosis of a defect in CPS1 was suspected based on the biochemical profile and finally confirmed with the finding of a novel mutation in the CPS1 gene. Conclusion: Hyperammonemia is an acute metabolic emergency and often caused by a UCD that should always be part of the differential diagnosis. We report here the first CPS1 deficiency case, confirmed genetically, in Bahrain with novel mutation.

Objective: To present a case of relapsed spinal cord infarction (SCI) as an acute spinal emergency in an in-patient elderly male patient. Methods: This report presents a case of an in-patient 84 years-old man who was admitted due to acute paraparesis with urge incontinence and sudden worsening after initial improvement. To assess his condition, spine magnetic resonance was performed Results: The spine magnetic resonance confirmed relapse of spinal cord infarction, which also involved the medullar conus. Conclusion: This case report presents a very rare event that is poorly described in literature. A strict follow up of risk factors and regular neurological evaluations during ihospitalization are recommended, especially in older patients.

Strangulation of pelvic varicocele in pregnancy: Case report

Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients With Asymptomatic Hypertension in the Emergency Department

The temporomandibular joint (TMJ) or TMJ is a type of ginglymoarthrodial joint and its articulation involves both sliding and hinge type movements. Dislocation of this joint is a very painful condition and needs acute emergency care. Most of these acute dislocations can be managed by emergency physicians. However, chronic dislocations can be managed with the conservative approach. TMJ disorders are the rare complications in those patients, which are under antiretroviral therapy and until now, there are only few cases reports in the literature. We report three cases of TMJ dislocations that were managed successfully in an emergency room. No conclusive cause-effect relationship has been found linking the TMJ disorders to the human immunodeficiency virus-antiviral treatment.