Tuba Cimilli Ozturk

A challenging differential diagnosis of optic neuropathy in ED: CSD

Optic neuropathy due to cat scratch disease (CSD) is a rare occurrence associated with macular star formation and is characterised by sudden mostly unilateral painless loss of vision. The aetiological agent in CSD is Bartonella henselae. Ocular complications present in up to 10% of patients and include neuroretinitis, conjunctivitis or uveitis. Ocular bartonelosis is usually self-limited. A case of a man patient with neuroretinitis caused by B. henselae is reported.

Potassium permanganate ingestion as a suicide attempt

Potassium permanganate is a highly corrosive, water-soluble oxidizing antiseptic. A 68-year-old female patient was admitted to our Emergency Department after ingestion of 3 tablets of 250 mg potassium permanganate as a suicide attempt. The physical exam revealed brown stained lesions in the oropharynx. Emergency endoscopy was performed by the gastroenterologist after the third hour of ingestion. Emergency endoscopy revealed multiple superficial (Grade I-II) lesions on the esophagus and cardia, which were considered secondary to the caustic substance. The mainstay in the treatment of potassium permanganate is supportive and the immediate priority is to secure the airway. Emergency endoscopy is an important tool used to evaluate the location and severity of injury to the esophagus, stomach and duodenum after caustic ingestion. Patients with signs and symptoms of intentional ingestion should undergo endoscopy within 12 to 24 h to define the extent of the disease.

Diagnostic value of Tei index for acute myocardial infarction in patients presenting to emergency department with ischemic chest pain and correlation with Hs-troponin

Background: Acute myocardial infarction is one of the most common causes of mortality in developed countries, and high-sensitive troponin test usually becomes positive within 3 h from the onset of symptoms. Myocardial perfusion index (Tei index) is a parameter measured during the echocardiographic examination. Objectives: The aim of this study is to investigate the diagnostic value of the Tei index for early diagnosis of acute myocardial infarction in the emergency department and to evaluate the correlation between the Tei index and Hs-Troponin value. Materials and Methods: A total of 129 cases were evaluated, and patients were divided into two groups according to their final diagnosis as “acute myocardial infarction (non-ST segment elevation myocardial infarction)” and “non-acute myocardial infarction” groups. Baseline and third-hour Hs-Troponin levels and Tei index values were determined, and their correlation was analyzed. Results: A total of 84 cases were diagnosed with acute myocardial infarction (non-ST segment elevation myocardial infarction), 84.5% had positive Tei index results at the time of admission while the remaining 45 patients were diagnosed as non-acute myocardial infarction and only 48.9% of them had positive Tei index. The diagnostic value of the Tei index and Hs-troponin were calculated as 79.8% and 60%; 67.9% and 60%, respectively. Also, we found that a 0.02 or more increase in the Tei index value has a 97.6 sensitivity and 97.5 specificity for the diagnosis of non-ST segment elevation myocardial infarction. A weak correlation was found between the Tei index and Hs-Troponin values in the acute myocardial infarction group (r = 0.425) and a negative correlation in non-acute myocardial infarction patients at presentation. Conclusion: It is suggested that the use of Tei index might be used as a supportive measure for the early diagnosis of acute myocardial infarction, and the deterioration of Tei index seems to be more significant than Hs-Troponin especially in ruling out acute myocardial infarction.

Predictors of false negative diffusion-weighted MRI in clinically suspected central cause of vertigo

Introduction: Vertigo is classified as peripheral and central. Differentiation of stroke mimics is the most important diagnostic challenge. There is no clinical guidance for the indications of neuroimaging in isolated vertigo patients. The primary aim of this study is to test the diagnostic value of a DWI‐MRI protocol to rule‐out a central cause in patients with acute isolated vertigo in the ED. Methods: We prospectively enrolled 144 patients who were presented with isolated vertigo to the ED. A detailed neurological examination and maneuvers were performed for differential diagnosis. All patients underwent CT and/or DW‐MRI either during ED visit or at the follow‐up, if necessary. Out‐patient follow‐up exams and evaluations were repeated until all patients had a definitive diagnosis. Results: In the study, 137 of the 144 patients completed the follow‐up period, and 34 of 137 patients were diagnosed with central vertigo. Six of 34 central vertigo patients had normal DW‐MRI findings. One was diagnosed with migraine headache and five with vertebra‐basilar insufficiency during the out‐patient follow‐up. One of the 28 patients with a pathological MRI was diagnosed with mass and the rest was stroke. The utility of DW‐MRI in vertigo patients was moderately high (sensitivity: 82%, specificity: 100%). We found that age, history of HT, history of CAD and vertigo unresponsive to ED treatment were significantly associated with a central cause of vertigo. Conclusion: We suggest that unresponsiveness to ED treatment, especially in patients with a history of HT and CAD, should alert physicians for central causes and warrant DW‐MRI imaging.

Assessment of intra-interobserver reliability of the sonographic optic nerve sheath diameter measurement

Diagnosis and measuring the level of increase in intracranial pressure (ICP) is critical, especially for the management of trauma patients in the emergency department and intensive care unit. However, measurements are operator‐dependent as in all of the sonographic diagnoses. The aim of this study is to assess the operator variations in the measurement of optic nerve sheath diameter (ONSD). There were four emergency medicine specialists involved in the study. Each had at least 1 year of experience of ultrasound scans and performed at least 25 prior ocular scans examining the ONSD. Two measurements were made 1 week apart from both axial and longitudinal planes. Sixty healthy adults were involved in the study and every investigator obtained four measurements from each. Intra‐interobserver reliabilities were tested. The investigators performed 60 ocular ultrasounds on individual healthy adults and obtained two measurements in axial and longitudinal planes 1 week apart. Therefore, 960 measurements were analyzed. The levels of compatibilities for most of the measurements were found at acceptable levels statistically. However, it is not possible to say that there was a perfect compatibility among the sonographers according to the previously conducted reliability studies of ultrasound measurements. According to our results, it is hard to say that sonographic measurement of the ONSD is a highly reliable method both in longitudinal and transverse planes.

Barotraumatic subcutaneous orbital emphysema after nose blowing: case report.

Orbital subcutaneous emphysema is defined as the abnormal presence of air within the periorbital soft tissue. It occurs generally as a result of blunt or penetrating facial trauma. Spontaneous barotraumatic emphysema is a very rare entity that generally results due to a sudden increase in the intraorbital pressure. If there is not an obvious visual acuity loss even with high ocular pressure, it is generally managed conservatively. However prolonged elevation of intraorbital pressure may cause an irreversible, ischemic visual loss secondary to an ischemic optic neuropathy or an acute central retinal artery occlusion.Emergency decompression may be required. Here we are presenting a patient with barotraumatic orbital subcutaneous emphysema, occurring after forceful nose blowing who was managed conservatively without any complications.