Matthew F. Ryan

Phthiriasis palpebrarum infection: A concern for child abuse

BACKGROUND Pediculosis capitis is a common parasitic infestation, whereas phthiriasis palpebrarum is an uncommon infection due to Phthirus pubis (pubic lice) inoculating the eyelashes and surrounding tissues of the eye. Emergency physicians should recognize the causes of this uncommon disease. Cases of phthiriasis palpebrarum should trigger the clinician to consider the potential for child abuse when suspected or when social history dictates the risk for abuse. OBJECTIVE A case of a pediculosis capitis and phthiriasis palpebrarum coinfection in a 4-year-old girl is presented, which was suspicious for child abuse given the patients social history. Diagnosis, treatment, and need for vigilance when encountering cases of phthiriasis palpebrarum, especially in young children, are discussed herein. CASE REPORT A 4-year-old girl presented with swelling and redness around her eyes. The girl had recurrent head lice infestations, however, on the day of presentation the mother noted lice appeared on the girls eyelashes and eyelids. Head lice typically do not infect the eyes, and given the different morphology of the lice on the patients head and eyes, a diagnosis of phthiriasis palpebrarum was made. Because phthiriasis pubis infection of the eyelids may represent sexual abuse, especially in children, child protective services was notified to ensure patient safety. CONCLUSIONS Pediatric phthiriasis palpebrarum can represent child abuse, and the origins of this infection need to be carefully discerned. A thorough history can provide information to assess whether further action is needed and, if in doubt, social services should be contacted to ensure child safety.

“Bath Salts” Intoxication: A Case Report

We present a case of a potentially lethal ingestion of “Bath Salts.” After presentation, we briefly review the epidemiology and pathology of “bath salts” ingestion.

Intrinsic reactivity of metal–hydroxide complexes: O–H bond activation and adduct formation in gas-phase reactions of Cp2ZrOH+

Abstract Fourier transform ion cyclotron resonance mass spectrometry was used to study the gas-phase reactions of three zirconium(IV) hydroxide ions, Cp 2 ZrOH + (Cp = η 5 -cyclopentadienyl), Cp 2 ZrOD + , and Cp 2 Zr 18 OH + . Product distributions were determined for reactions with alcohols, amines, ethers, esters, and amides. Reactions with alcohols lead to O–H bond activation with formation of alkoxide complexes Cp 2 ZrOR + and elimination of water. Equilibrium constants for the reactions were used to determine the relative energetics of Zr–OR bonds, and the affinities of hydroxide and alkoxides toward the zirconium(IV) center in Cp 2 Zr 2+ decrease (OH − > MeO − > EtO − ≈ iso -PrO − ≈ sec -BuO − ≈ tert -BuO − ) in the same order as the proton affinities of RO − . Adducts of the alkoxide complex ion with alcohols are formed at long reaction times. Reaction with acetic acid leads to formation of the carboxylate complex ion Cp 2 ZrO 2 CCH 3 + and elimination of water. Amines, ethers, esters, and amides all form adducts with Cp 2 ZrOH + , but no other reaction pathways, such as hydrolysis, are observed. The unsolvated zirconium(IV) hydroxide species can coordinate substrates and activate O–H bonds, but it does not efficiently cleave esters and amides despite its reactive, bound hydroxide and coordinative unsaturation. The relationship of these results to solution reactions of metal–hydroxides is discussed.

Ovarian Torsion in a 5-Year Old: A Case Report and Review

Ovarian torsion represents a true surgical emergency. Prompt diagnosis is essential to ovarian salvage, and high clinical suspicion is important in this regard. Confounding the diagnosis in general are more commonly encountered abdominal complaints in the Emergency Department (ED) such as constipation, diarrhea, and urinary tract infections and more common surgical emergencies such as appendicitis. Prompt diagnosis can be further complicated in low-risk populations such as young children. Herein, we describe the case of a 5-year-old girl with a seemingly benign presentation of abdominal pain who was diagnosed in the ED and treated for acute ovarian torsion after two prior clinic visits. A brief discussion of evaluation, treatment, and management of ovarian torsion follows.

Visual Diagnosis: Pediatric Airway Emergency

We present a case of a potentially difficult airway emergency in a pediatric patient. After presentation, we briefly review critical differences between pediatric and adult airways and management of the airway during these emergencies.

Expanding Prevertebral Soft Tissue Swelling Subsequent to a Motor Vehicle Collision

Cervical acceleration/deceleration or whiplash injuries are a common cause of cervical spine trauma. Cervical acceleration/deceleration can result in vertebral fractures, subluxations, and ligamentous and other soft tissue injuries. Severe injuries are often evidenced by increased prevertebral swelling on lateral X-ray. Assessment of the prevertebral space on lateral cervical spine films is an essential component for identifying potential traumatic neck injuries. We describe a case in which an 84-year-old man on coumadin presented to the emergency department after a low-impact motor vehicle crash. The patient initially complained of neck and shoulder pain which subsequently progressed to hoarseness, dysphagia, and dyspnea. Imaging studies revealed significant prevertebral tissue swelling with anterior compression of his airway that required airway stabilization via awake fiber-optic intubation and reversal of his anticoagulation therapy.

Lyme Carditis in an Immunocompromised Patient

We present a case of a 68-year-old man with a history of liver transplant and of chronic immunosuppression therapy who presented to the emergency department (ED) for fevers and worsening fatigue for two days. On further investigation, the patient was found to have a new first-degree heart block on his electrocardiograph. Coupled with the history of a recent tick bite, the patient was diagnosed with vector-borne carditis. Although the patients titers for various vectors remained negative, due to a long history of immunosuppression, he was treated for Lyme disease and his heart block completely resolved with antibiotic treatment. We describe details of the case as well as discuss the impacts of immunosuppression on vector-borne disease. Immunosuppressed patients represent a special population and can present with chief complaints made even more complicated by their medical history, and this case illustrates the importance of being mindful of how immunosuppression can affect a patients presentation. As the efficacy of antirejection medications improved, the ED may see an increasing number of patients with solid organ transplants. A greater understanding of this special patient population is key to formulating optimal treatment plans.

Guillan-Barre Syndrome in a Patient with Uncontrolled Diabetes and Severe Peripheral Neuropathy

The complications of diabetes are frequently encountered in the Emergency Department. In contrast, Guillan-Barre Syndrome (GBS) is a relatively rare diagnosis requiring a high index of suspicion which can cause significant morbidity and mortality if not recognized and properly treated. GBS is an acquired condition which is usually preceded by a viral upper respiratory or gastrointestinal (GI) illness which can cause peripheral weakness and potentially diaphragmatic paralysis leading to life-threatening respiratory failure. Herein, we present a case of a 57-year-old male with a history of poorly-controlled diabetes who presented with both sensory and motor weakness of the distal upper and lower extremities; the patient was ultimately diagnosed with Guillan-Barre syndrome. This case illustrated an uncommon disease process that was initially mistaken for an extremely common disease both of which require very different management. This illustrative case is important to the emergency medicine physician because quick identification can stave off untoward complications and increased morbidity and mortality of GBS including respiratory distress and airway emergencies.

Severe unexplained relative hypotension and bradycardia in the emergency department.

A precipitous episode of hypotension with concomitant bradycardia is a true medical emergency especially in patients with chronic hypertension and often requires hospitalization for detailed interrogation of the underlying causes. We describe herein a case of a patient with chronic labile hypertension who presented to the ED with a sharp drop in blood pressure and heart rate which was not simply explained by an antihypertensive overdose but more so by an aggregate of the patients multiple chronic medical conditions. This report highlights the complexities of treating simultaneous hypotension and bradycardia and the importance of discerning the underpinnings of the causes including past medical issues, patient medications, and the timeline of key events leading to the issue at hand.

Delayed upper-airway injury after accidental alkaline ingestion

A 62-year-old man presented to the emergency department one week after accidentally drinking an alkaline cleaning agent stored in unlabeled bottle. The day of the incident the patient presented to an outside hospital where he was admitted for an upper endoscopy of the esophagus which was found to be negative for acute injury. An initial chest X-ray taken the day of the incident was also found to be normal. After discharge the patient continued to have a sore throat and marked dysphagia which caused him to vomit repeatedly. Moreover, the patient began to develop chest pain with associated shortness of breath. We present a case of delayed airway injury and tracheal thickening and associated chest pain after alkaline ingestion and we discuss herein the pathophysiology and management of alkaline ingestions.