An unusually large pleural cyst

A 93-year-old lady presented to the hospital complaining of 3 weeks of dysphagia, weight loss, dyspnea, and audible wheezing. Two days after admission, she was intubated and placed on assisted mechanical ventilation due to severe respiratory distress. A chest radiograph (CXR) showed a curvilinear, well circumscribed left superior paramediastinal opacity with suspected underlying mass (Figure 1, Panel A, arrow). Computed tomography (CT) of the chest with intravenous contrast revealed a large cystic mass measuring 9.3 x 6.4 x 4.6 cm, extending from the left supraclavicular region, immediately inferior to the thyroid gland, to the left hilar region (Figure 1, Panel B, arrow). The patient underwent open thoracotomy, where mass communication to the thoracic duct was noted, and complete surgical excision of a cyst filled with turbid and pale yellow fluid was achieved. Pathology report confirmed the diagnosis of a pleural cyst. The patient had no recurrence on CT and CXR after 4 weeks.
An unusually large pleural cyst


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Painful skin lesions and bloody diarrhea

Pyoderma gangrenosum (PG) is a rare ulcerative lesion, commonly associated with an underlying systemic disease. The diagnosis of pyoderma gangrenosum can be challenging, and often requires a good history and exclusion of other ulcerative cutaneous disease. We present an impressive case of pyoderma gangrenosum in a young woman with bloody diarrhea.

Painful skin lesions and bloody diarrhea


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A dermatologic presentation of pancreatitis

A 40-year-old adopted obese Caucasian male with a past medical history of type 2 diabetes, hypertension, and seizures presented to an Emergency Department with a one-day history of sharp epigastric pain accompanied by nausea and emesis. Dermatologic examination of his arms (Figure A) and legs (Figure B) was consistent with widespread cutaneous xanthomas secondary to hypertriglyceridemia. Venous and arterial (Figure C) blood samples appearing lipemic were obtained. His lipase level was 1,470 U/L and his triglyceride level was 13,563 mg/dL. CT imaging (Figures D and E) was consistent with necrotizing pancreatitis. He required admission to the Intensive Care Unit (ICU) for resuscitation, bowel rest, and supportive care. He underwent emergent plasmaphoresis with the goal of triglyceride reduction. (1) Hypertriglyceridemia is the third most common cause of pancreatitis (after alcohol abuse and gallstones) and is usually seen with triglyceride levels greater than 1000 mg/dL. (2) Patients may have a genetic predisposition such as type V hyperlipidemia and/or may have coexisting secondary causes of hypertriglyceridemia such as alcohol abuse, poorly controlled diabetes, obesity or rapid weight gain, hypothyroidism, uremia, nephritic syndrome, or third trimester pregnancy. (2) Management strategies include supportive care, early initiation of lipid lowering agents, tight glycemic control, plasma exchange, plasmaphoresis, and the use of heparin and insulin to stimulate lipoprotein lipase and chylomicron degradation (although data is limited for all of these strategies). (3) The patient’s prolonged ICU course was complicated by abdominal compartment syndrome, respiratory failure requiring tracheostomy, renal failure requiring renal replacement therapy (limiting the ability to use fibrates), and a partial pancreatic necrosectomy.

A dermatologic presentation of pancreatitis


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Successful treatment of a massive pulmonary embolism using alteplase in a patient taking antipsychotic drugs

An increased risk of pulmonary embolism (PE) has been reported in female patients taking antipsychotic drugs. Furthermore, patients who take antipsychotic drugs are likely to present with malaise; therefore, the onset of PE is easily overlooked and often discovered by necropsy following PE-related sudden death. (1)

A 73-year-old woman was admitted to the emergency room because of severe shortness of breath and a rapid heartbeat, which had started 2 h earlier. Her medical history included severe depression that had left her bedridden for roughly 3 years. During that period, she frequently tired easily; however, her neighbors believed this to be a result of her depression and, therefore, were not concerned. On her arrival to the emergency room, the clinical examination confirmed hypotension (91/40 mmHg), tachycardia (109 bpm), and a peripheral oxygen saturation in room air of 80%. Examination of the cervix and chest revealed jugular venous distension. She had bilateral pitting edema of the lower extremities. On auscultation of the lungs, bilateral coarse crackles were audible.

An arterial blood gas test performed with the patient breathing room air showed evidence of type 1 respiratory failure (pH 7.49, pO2 52.7 mmHg, pCO2 21.0 mmHg). A scan obtained using portable, simple thoracic radiography revealed patchy shadowing (Figure 1). At this point, we suspected a massive pulmonary embolism, and a computed tomography (CT) pulmonary angiogram revealed extensive bilateral pulmonary embolisms (Figure 2). The patient was immediately thrombolysed with alteplase, which commenced 3 h after symptom onset. The dose was calculated for her body weight of 60 kg, resulting in 4 mg given as an intravenous bolus, followed by an intravenous infusion of 36 mg administered over a 1-h period. Eight hours later, following the thrombolytic treatment, the patient improved and was hemodynamically stable (blood pressure 130/68 mmHg, heart rate 90 bpm) with a peripheral oxygen saturation in room air of 93%. Therefore, the patient was successfully thrombolysed without any complications (Figures 3a and 3b).

Several mechanisms have been proposed for the thrombotic complications associated with the platelet aggregation induced by antipsychotic drugs including the presence of anticardiolipin antibodies and type 2A serotonin receptors. (2,3) However, anticardiolipin antibodies were not detected in this patient, and she had not taken medication related to type 2A serotonin receptors. We were able to diagnose the pulmonary infarction by recognizing the presence of abnormal vital signs that we could not explain. Therefore, the proper evaluation of vital signs is important even in patients with considerable malaise.

Successful treatment of a massive pulmonary embolism using alteplase in a patient taking antipsychotic drugs


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Gastromegaly as the cause of unexplained chest pain

A 61-year-old gentleman with past medical history of hypertension, hyperlipidemia, gastroesophageal reflux status post hiatal hernia repair in 1973, and recurrent diverticulitis was admitted to the intensive care unit (ICU) after undergoing elective laparoscopic recto-sigmoid hemicolectomy and colostomy formation. His immediate postoperative course was complicated by syncope while getting out of bed to ambulate. The patient regained consciousness within minutes and noted severe substernal chest pressure and dyspnea at rest. Physical examination revealed a blood pressure of 70/40 torr, heart rate 130/min and respiratory rate 28/min. Chest examination was unremarkable. Mild abdominal distension was noted without discomfort to palpation, and diffuse tympani on percussion. An emergent electrocardiogram was unremarkable. The patient received intravenous fluids and vasopressors. Laboratory testing revealed acute blood loss anemia with drop in baseline hemoglobin of four grams per deciliter. Following stabilization while awaiting blood transfusion, a chest X-ray was performed demonstrat­ing severe gastromegaly, which was then confirmed by abdominal X-ray (Figures 1 and 2). Subsequent abdominal and pelvic computed tomography (CT) with contrast to assess for obstruction, confirmed the pres­ence of gastromegaly without obstruction, and left lower quadrant hematoma without active bleeding (Figure 3). A nasogastric tube on continuous suction was inserted with subsequent resolution of the patient’s symptoms as well as the objective findings of hypotension, tachy­cardia, and tachypnea. A repeat radiograph revealed decompression of the patient’s stomach (Figure 4). Pressor support was weaned, and after completion of the patient’s blood transfusion, stopped. The patient had no further complications post-operatively and discharged home on post-operative day 2.

Gastromegaly as the cause of unexplained chest pain


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Aberrant central venous cannulation of the pericardial vein

Central venous catheter placement is one of the most common procedures in Emergency Departments (ED) and Intensive Care Units (ICU) across the world. A variety of potential complications can occur in patients undergoing these procedures. Incorrect position of the catheter is quite common.Cannulation of azygous arch, occurs in 0.7-1.2% of all central venous catheter insertion, and is seven times more common when access is approached from the left side. (1,2) Due to the venous drainage of the chest wall region, cannulation especially from left side, can lead to the catheters being placed in the aberrant location in hemiazygous vein or one of its tributaries, such as the pericardial veins, as shown in the Figure. The aberrant cannulation of azygous vein or its tributaries carries a high risk for perforation leading to effusions and mediastinal hematomas. (2)Aberrant central venous cannulation of the pericardial vein


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Jaundice and shock after a Father’s Day celebration

A 44-year-old gentleman with history of type-2 diabetes mellitus and chronic liver disease secondary to hepatitis B/C co-infection presented to our ICU with septic shock and multiorgan failure due to Gram negative rod bacteremia. His source of infection was presumed to be soft tissue as he had bilateral lower extremity pain and edema accompanied by fever 24 hrs prior to admission. Physical exam was relevant for jaundice, bilateral lower extremity edema and erythema with multiple tense hemorrhagic bullae overlying the medial and inferior aspect of the left lower leg (Figure 1). The patient’s family reported consumption of large quantities of oysters on a Father’s Day celebration 3 days prior to the onset of our patient’s symptoms. No other acquaintance was reported ill. The patient responded to levofloxacin and was discharged from the ICU within 72 hrs. Blood cultures reported Vibrio vulnificus and the skin lesions resolved after subsequent wound care.


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The “radiographic” effects of therapeutic hypothermia

Therapeutic hypothermia (TH) has become the standard
of care for comatose victims of cardiac arrest with return
of spontaneous circulation (ROSC). This therapeutic
modality has several physiological and molecular
mechanisms by which it provides protection to several
organs. We recently encountered a “radiologic” effect of
this intervention.


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Traumatic pneumomediastinum

A previously-healthy thirty-year old man presented to the Emergency Department at Hawke’s Bay Hospital with central chest pain, following blunt chest trauma whilst SCUBA diving. He was at a depth of approximately five metres, during his ascent, when he was dumped onto a rock by a wave, hitting the left side of his chest. Several hours later, he developed central chest tightness and mild dyspnoea. He had no dysphagia or abdominal pain. Examination findings showed normal vital signs, reduced air entry over left chest wall, and a “crunchy” systolic murmur. He had subcutaneous emphysema around his neck. His trachea was


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An unusual cause of dyspnea

A 41 year-old woman case with nonproductive cough, dyspnea, weight loss and fever is described. Laboratories were remarkable for hypoxemia, leukocytosis, anemia and elevated hepatic enzymes. Chest X-ray demonstrated bilateral interstitial opacities. She was hospitalized with diagnosis of suspected pneumonia. Patient’s condition progressed to multiple organ failure and unfortunately, death. The diagnostic of gastric adenocarcinoma with lymphangitic spread was established at autopsy. Lymphangitic carcinomatosis can be easily confused with other interstitial lung diseases especially when primary malignancy is unknown. Physicians must be aware of nonspecific findings of this disease in order to obtain a diagnosis and institute adequate therapy.


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An Unusual Chest Pain

A 67-year-old gentleman with a prior history of coronary artery disease and a four-vessel coronary artery bypass graft five years prior to admission, presented to the hospital complaining of a 12-day history of midsternal chest pain. A chest radiograph performed 18 months prior to this presentation revealed a normal cardiovascular silhouette and normal mediastinum. Upon presentation, a new chest radiograph revealed a wide mediastinum. A computed tomography done emergently revealed an aortic thrombus starting at superior mediastinum and large (6 cm) pseudoaneurysm in anterior mediastinum. An emergency angiogram revealed that the pseudoaneurysm to be emerging 2 cm below the innominate takeoff in the ascending aorta, which corresponded exactly to the prior CABG cannulation site. The patient underwent successful repair.


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Portal and Splenic Vein Thrombosis Caused by Acute Pancreatitis

A 30-year-old Hispanic gentleman with past medical history of hypertension and dyslipidemia, presented to the emergency department with complaints of a blunt, constant, epigastric pain radiating to his back for 24 hours. Physical examination revealed a man in severe distress, tachypneic and tachycardic. Laboratory data, as well as the physical exam, were consistent with acute severe pancreatitis. The patient was admitted to the intensive care unit (ICU) and a computed tomography (CT) of his abdomen was obtained revealing a large thrombus in the portal vein (Figure 1).
The patient’s condition deteriorated requiring assisted ventilation and vasopressor support. Two weeks following his admission to the ICU, a repeat CT of the abdomen revealed persistence of the portal vein thrombus and a new splenic vein thrombosis (Figure 2). The patient was managed conservatively with anticoagulation and eventually weaned off assisted ventilation. The patient was discharged home several weeks after his initial admission.


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