Ina Dubin

Rare times rare: The hyponatremia, rhabdomyolysis, anterior compartment syndrome sequence:

Lesson Primary polydipsia occurs in up to 25% of patients with chronic psychiatric disorders (especially schizophrenia), related to the disease, its treatment or both. Urine output fails to match intake >10 L/day and water intoxication may develop. Rhabdomyolysis is a rare complication of hyponatremia, and an acute anterior compartment syndrome of the leg, an emergency, may be very rarely associated.

A spontaneous rectus sheath hematoma

An independent 81-year-old woman was admitted with new-onset chest discomfort and shortness of breath when walking. She had hypertension and coronary artery disease (LAD stenting 15 years prior), treated with atenolol and clopidogrel 75 mg. Her vital signs, physical examination, chest X-ray, ECG and serum troponin on admission were normal. Aspirin 100 mg/day was added, and on the third day, coronary angiography was performed through radial access, revealing no significant obstructions. Sixteen hours later she developed sudden right lower quadrant (RLQ) abdominal pain and vomiting. The heart rate almost doubled to 104/min. No peritoneal irritation signs were found, but the Hb dropped from 13.4 to 9.9 g/dL, and a tender RLQ 8 × 9 cm mass appeared. A CT scan revealed a rectus sheath hematoma (RSH) with active bleeding (Fig. 1). Dual anti-platelet therapy (DAPT) was stopped, and platelets (six units) and packed-red-cells (one unit) were transfused. Under close monitoring she stabilized, and was discharged home on the eighth hospital day. An invasive strategy remains the superior approach to acute coronary syndromes in octogenarians [1]. Thus, very many elderly patients receive DAPT after coronary interventions, reducing ischemic events, but invariably increasing the risk of major bleeding to ~ 2% [2]. While gastrointestinal and intracranial bleeding is wellknown, spontaneous bleeding can occur at unusual sites including RSH [3] or retroperitoneal hematoma [4]. These entities are less often considered. Rectus sheath hematoma is an uncommon cause of acute abdominal pain. It presents as a tender unilateral mass in the lower abdomen, with or without hemodynamic instability [5]. An antithrombotic medication is the principal precipitating factor (anticoagulants > DAPT > single antiplatelet agent), as are end-stage kidney or liver disease, or pregnancy. Minor trauma, even cough, is commonly associated [3]. A CT scan with contrast is the best diagnostic modality and may uncover active bleeding (Fig. 1b, c) or secondary hemoperitoneum. Most patients do well on conservative treatment [3], but continuous monitoring is required, and endovascular management (percutaneous arterial embolization) remains an option in more severe cases. The incidence of spontaneous rectus sheath hematoma is likely to increase with current increase in the use of invasive strategies and antithrombotic drugs including DOAC. Its presentation should be known to clinicians in multiple disciplines. Emergency physicians in particular, should be aware of the multiple guises of spontaneous RSH that may mimic many other conditions [3]. Elderly patients on anticoagulant or antiaggregant treatment mandate special attention when they present with abdominal pain; tachycardia, hypotension or syncope; abdominal wall mass; ecchymosis; or significant decrease in HB—in any combination.

Double jeopardy – concurrent lung abscess and pleural empyema

Learning points for clinicians Lung abscess and ipsilateral pleural empyema can rarely coexist in the same patient. The causative organism, Streptococcus intermedius , produces unique virulence factors associated with deep-seated infections and crossing tissue planes in the lung suggesting the abscess as the primary event. Prior laryngeal surgery and radiotherapy increased the patients susceptibility to retention and aspiration, initiating the vicious cycle. A 57-year-old man was admitted with a 6-week history of anorexia, weight loss and night sweats, associated with cough productive of abundant purulent sputum, and more recently, left chest pain. He had been a heavy smoker with COPD, locally advanced laryngeal cancer leaving him after surgical and radiation treatment with permanent tracheostomy but no evidence of recurrence, peripheral artery disease …

Streptococcus anginosus endocarditis and multiple liver abscesses in a splenectomised patient

An unusual case of infective endocarditis and concurrent multiple liver abscesses both caused by Streptococcus anginosus in a splenectomised patient is reported. The microorganism is a very rare cause of endocarditis and its presentation with multiple liver abscesses is highly unusual. It was initially misdiagnosed as Streptococcus sanguinis and issues relating to the different clinical presentations of S. anginosus including the rare cases of endocarditis, the role of the patient’s splenectomy and problems that may contribute to its potential laboratory misidentifications are discussed.

The cat did it: erythema nodosum and additional atypical presentations of Bartonella henselae infection in immunocompetent hosts

A healthy patient presented with painful skin lesions on the anterior surface of her legs. Erythema nodosum was diagnosed but all the usual causes were ruled out. The finding of bilateral enlarged axillary lymph nodes with necrosis and granulomas led to the diagnosis of Bartonella infection, an unusual cause of erythema nodosum. Imaging also revealed splenomegaly and small para-aortic lymph nodes. Up to one quarter of the patients with cat-scratch disease present atypically, a considerably higher prevalence than previously reported. A comprehensive review of the literature (PubMed, since inception, all languages) revealed a remarkable array of unusual presentations which are summarised and briefly discussed.

Splenic Rupture After Same Level Fall

A 59-year-old double amputee man with diabetic vasculopathy and end-stage kidney disease was admitted owing to acute hypotension (70 mm Hg) after hemodialysis. He was afebrile, with hemoglobin 7.6 g/dL (usually, 9.1 g/dL) and lactate 4.44 mmol/L (normal, 0.7-2.1 mmol/L). He had mild diffuse abdominal tenderness, clear nasogastric tube fluid, and no melena. Suspecting line sepsis, broad antibiotic coverage was given, but a further drop in hemoglobin occurred (6.7 g/dL). An urgent computed tomography scan demonstrated a ruptured normal spleen and 3 left rib fractures (Figure). Direct questioning revealed that he fell on his left side while trying to use his new crutches just before dialysis. The team was not aware of the fall, and the patient believed it had passed safely. He was transferred to surgical care and treated conservatively until discharge on postadmission day 8. Falls in patients who are elderly are predominantly samelevel falls and are highly prevalent and often recurrent. When patients present after a fall, attention is focused and imaging is directed at its 2 major serious consequences—traumatic brain injury and fragility fractures. Life-threatening internal organ damage is not usually considered. However, a “simple” ground-level fall can cause severe hypotension due to internal bleeding from rupture of a normal

An Accident Waiting to Happen: Thoracic Aortic Aneurysm

From the Department of Medicine, Laniado Hospital, Sanz Medical Centre, Netanya, Israel; and the Faculty of Medicine, Hebrew University and Hadassah Medical School, Jerusalem, Israel. A n 85-year-old man presented with dyspnea and mild left precordial pain. He was a heavy smoker with chronic obstructive pulmonary disease, diabetes, hypertension, and a 20-year history of thoracic aortic aneurysm (TAA) that he refused to have repaired. Over the past few weeks he became increasingly dyspneic, dysphonic, and developed solid-food dysphagia. On admission, he was tachypneic (22/min) and hypoxemic (91%), and breath sounds over the left hemithorax were barely audible. Chest X-ray revealed a large TAA (Figure). Hemoglobin was 10.5 g/dL (normal renal, adrenal, thyroid function), erythrocyte sedimentation rate was 60 mm/h, serum sodium level was 124 mmol/L, urine sodium level was 43 mmol/L, and urine osmolality was 693 mOsm/kg. Chest computed tomography was ominous (Supplemental Figure A and B, available online at http://www.mayoclinicproceedings.org). He died suddenly hours later. Most TAAs are asymptomatic and discovered incidentally on imaging in patients older

An Uncommon Cause of New-Onset Heart Failure

FIGURE 2. Single axial image from chest computed tomographic angiography showing an intimal flap in an aneurysmal ascending aorta (arrow), consistent with Stanford type A dissection. The intimal flap extended into the right common carotid artery (not shown). Small bilateral pleural and pericardial effusions were From the Department of Medicine, Laniado Hospital, Sanz Medical Center, Netanya, Israel (A.S., I.D.); and the Faculty of Medicine, Hebrew University and Hadassah Medical School, Jerusalem, Israel (A.S.).

The bladder ran dry: bilateral ureteral obstruction

A relatively young healthy man (barring obesity and distant gouty arthritis) was admitted with severe acute kidney injury (serum creatinine, 15.9 mg/dL) following acute gastroenteritis and occasional use of diclofenac. Abdominal ultrasound revealed mild left hydronephrosis due to staghorn stone and normal right kidney. Soon after, complete anuria necessitating haemodialysis developed without pain or evidence of infection. CT imaging revealed stones obstructing the right ureter. Following urological surgery, postobstructive diuresis developed and the serum creatinine came down to near normal. The stones were identified as uric acid stones. Anuria has a relatively narrow differential and painless (partially non-dilated) bilateral ureteral obstruction is a distinctly unusual cause. A review of the literature to cover all reported causes of bilateral ureteral obstruction is presented. Only a minority of cases were not associated with an underlying malignant disease or its treatment. The multifactorial aetiology of the patients acute kidney injury (volume depletion, diclofenac and obstructive uropathy) is presented and discussed.

A wandering tube.

The predominant causes of acute mechanical small bowel obstruction in geriatric patients are adhesions and hernias, which is not much different than in other adult age groups. Unusual etiologies may be encountered, such as volvulus or gallstone ileus, but a displaced feeding gastrostomy tube is a distinctly rare cause of intestinal obstruction which needs to be considered by emergency physicians as it may be increasingly encountered.