Lee-Min Wang

Pneumoscrotum after blunt chest trauma.

Pneumoscrotum, the accumulation of air inside the scrotum, is a rare complication associated with blunt chest trauma. We report a case of severe subcutaneous emphysema, pneumothorax, pneumomediastinum, pneumopericardium, and pneumoscrotum after blunt chest trauma in a 44-year-old man. He presented with progressive swelling of the neck that descended to the chest, abdomen, both legs, and scrotum. Radiography and computed tomography of the chest and abdomen confirmed the diagnosis of a tracheal injury complicated by severe subcutaneous emphysema, pneumothorax, pneumomediastinum, pneumopericardium, and pneumoscrotum. Primary repair of the tracheal injury was performed, and he was weaned successfully from the ventilator by day 5. He was discharged on day 7.

Otalgia and eschar in the external auditory canal in scrub typhus complicated by acute respiratory distress syndrome and multiple organ failure

BackgroundScrub typhus, a mite-transmitted zoonosis caused by Orientia tsutsugamushi, is an endemic disease in Taiwan and may be potentially fatal if diagnosis is delayed.Case presentationsWe encountered a 23-year-old previously healthy Taiwanese male soldier presenting with the right ear pain after training in the jungle and an eleven-day history of intermittent high fever up to 39°C. Amoxicillin/clavulanate was prescribed for otitis media at a local clinic. Skin rash over whole body and abdominal cramping pain with watery diarrhea appeared on the sixth day of fever. He was referred due to progressive dyspnea and cough for 4 days prior to admission in our institution. On physical examination, there were cardiopulmonary distress, icteric sclera, an eschar in the right external auditory canal and bilateral basal rales. Laboratory evaluation revealed thrombocytopenia, elevation of liver function and acute renal failure. Chest x-ray revealed bilateral diffuse infiltration. Doxycycline was prescribed for scrub typhus with acute respiratory distress syndrome and multiple organ failure. Fever subsided dramatically the next day and he was discharged on day 7 with oral tetracycline for 7 days.ConclusionScrub typhus should be considered in acutely febrile patients with multiple organ involvement, particularly if there is an eschar or a history of environmental exposure in endemic areas. Rapid and accurate diagnosis, timely administration of antibiotics and intensive supportive care are necessary to decrease mortality of serious complications of scrub typhus.

Disseminated histoplasmosis presenting as haemolytic anaemia

A 65-year-old woman, a hepatitis C virus carrier with a history of gallstones for which she had laparoscopic cholecystectomy in August 2007 (when complete blood cell counts and chest x-ray were normal) started taking prednisolone 10 mg per day for haemolytic anaemia in March 2008 (when a chest x-ray revealed an infiltrative lesion over the right middle lung). She was admitted to our institution in September 2008 for a cough with scanty sputum, night sweating and leg oedema for 1 month and a body weight loss of 6 kg over the preceding 6 months. Physical examination showed a pale appearance with mild icteric sclera and no hepatosplenomegaly. Laboratory evaluation revealed: a white blood cell count of 4000/mm3 with 84.1% neutrophils; haemoglobin 8.8 g/dl; platelet count of 42×103/mm3; C-reactive protein 4.2 mg/dl; …

A Patient with Constrictive Pericarditis Diagnosed by Echocardiography in the Emergency Department

A 64-year-old man presented with progressive swelling of the scrotum for four days, accompanied by gradually increasing dyspnea on exertion and cough severity. The chest radiograph disclosed a normal heart size but severe, dense calcifications in the pericardium. Echocardiography demonstrated thickness and calcification of the pericardium, normal left ventricular systolic but impaired diastolic function, dilatation of both atria and respiratory variation in both the mitral and tricuspid forward flow. The typical ultrasound findings enabled us to differentiate constrictive pericarditis from restrictive cardiomyopathy. The patient refused a pericardiectomy, so medical treatment was instituted.

Necrotizing Fasciitis with Subcutaneous Emphysema in a Diabetic Patient

Received: April 23, 2008 Accepted for publication: June 5, 2008 From the Department of Emergency Medicine, Taichung Veterans General Hospital, National Taichung Nursing College National Taiwan University, National Yang-Ming University, Chung Shan Medical University Address reprint requests and correspondence: Dr Sung-Yuan Hu Department of Emergency Medicine, Taichung Veterans General Hospital 160 Section 3, Chungkang Road, Taichung 40736, Taiwan (R.O.C.) Tel: (04)23592525 ext 3664 Fax: (04)23594065 E-mail: song9168@pie.com.tw 急重症影像

Bilateral Hydronephrosis and Hydroureters as First Manifestation of Abdominal Actinomycosis: A Case Report

Obstructive uropathy is a commonly encountered medical condition in an emergency room. Many intraabdominal lesions, such as infections, inflammations, stones or tumors, may cause it. We report a case of abdominal actinomycosis in a 41-year-old female who had been pathologically proved pelvic actinomycosis, which may be related to the use of an intrauterine contraceptive device (IUCD) with initial manifestation of obstructive uropathy. Her abdominal computed tomography (CT) scan revealed an unusual clinical feature consisting of an infiltrative and irregular retroperitoneal soft-tissue mass encasing the adjacent ureters resulting in bilateral hydronephrosis and hydroureters. Abdominal actinomycosis is an uncommon infectious disease that must be included among the differential diagnoses of infiltrative intra-abdominal disorders, especially in the patient with an IUCD. Therefore, all emergency physicians should be alert to any patient with an IUCD in situ in the emergency department (ED). Definite diagnosis is generally based on the histopathologic identification of the actinomycotic sulfur granules, culture of the Actinomyces or both.

Pneumomediastinum as first manifestation of emphysematous pyelonephritis in a patient who is non-diabetic.

Emphysematous pyelonephritis (EPN) is a rare but life-threatening acute suppurative infection of the kidney, characterised by production of gas within the renal parenchyma, collecting system or perirenal tissue. It has a high mortality rate (70% to 90%), and the majority of patients have diabetes mellitus. The left kidney is most common involved and Escherichia coli is the most common pathogen. EPN complicated with pneumomediastinum (PM) has been reported in only four cases previously. Here, a case of PM as first manifestation of EPN in a non-diabetic 81-year-old man is reported. He had experienced back pain and abdominal fullness for 1 week. A plain radiograph, CT aortography and MRI confirmed the diagnosis of EPN complicated with PM. The patient died on the 22nd day of treatment with antibiotics of cefmetazole, gentamycin and metronidazole.