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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Giant Right Atrium Secondary to Mitral Stenosis

A 59-year-old Hispanic lady with history of rheumatic fever and chronic atrial fi brillation presented to the emergency department with severe dyspnea. Seventeen years prior to this presentation, she had undergone re-do mitral valve replacement, and tricuspid annuloplasty. The patient’s chest radiograph revealed massively dilated right chambers of the heart (Figure 1). An electrocardiogram showed right axis deviation, atrial fi brillation with a controlled heart rate of 70 beats per minute. A chest computed tomography (CT) scan revealed a gigantic right atrium measuring approximately 12 cm in its largest diameter (Figure 2).
These images are relevant because this reveals one of the few cases of massively dilated right atrium, despite previous mitral valve replacement and tricuspid annuloplasty. Other etiologies of a dilated right atrium in patient with dyspnea in the ED and intensive care unit (ICU) include: chronic obstructive pulmonary disease, tricuspid valvular stenosis, severe mitral valvular pathology with pulmonary hypertension, chronic pulmonary emboli, and untreated congenital heart disease.


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Respiratory Distress in an Elderly - Delayed Presentation of an Odontoid Fracture

An 85-year-old man with history of severe dementia lay down for a nap and was witnessed by his family to immediately lose consciousness, with agonal breathing. He was ventilated by facemask by the paramedics when they attended. His vital signs were stable. On admission to hospital he grimaced to painful stimulus only (Glasgow Coma Score=6/15). His arterial blood gas revealed - pH 7.21, pCO2 70 mmHg and bicarbonate 27 mmol/L. He was intubated.
The patient had a fall 1 week before. He had complained of intermittent headache and neck pain since then. He also developed new symptoms of breathlessness upon lying fl at. Computed tomography (CT) of cranium and neck was done. Figure 1 and 2 showed a fracture through the base of the odontoid (type II). Figure 3 showed prevertebral soft tissue swelling associated with the fracture. After discussion with the family, he was treated conservatively with a cervical collar in view of his advanced age and dementia.


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Rhino-Orbital-Cerebral Mucormycosis in a Critically Ill Patient

A 54 year-old Caucasian gentleman with history of diabetes presented to emergency department with complaints of facial swelling for one week and left orbital pain of one day duration. The patient underwent computed tomography (CT) scan of head with intravenous contrast which revealed infl ammation of left medial rectus muscle and cellulites of medial left orbital coronal space deep to and surrounding the medial rectus muscle with some lateral deviation of the left eye. In addition, left maxillary sinus disease was noted. A tooth in the left maxilla with a fluid collection associated with its root communicating to the left maxillary sinus suspicious for tooth abscess related to sinus disease (Figure 1). The patient’s white blood cells on presentation was elevated and his blood sugar was 597 mg/dL with a chemistry showing an anion gap of 34 and serum ketones. The patient was hypotensive with a systolic blood pressure of 70 mmHg and was admitted into the intensive care unit. After few hours of volume resuscitation the patient was taken to the operating room for orbital cellulites secondary to possible mucormycosis. Extensive surgical debridement ensued and emergent decompression of the left eye performed. The patient was started on liposomal amphotericin-B, and hyperbaric oxygen therapy. His course was further complicated by the development of brain abscess and cerebritis (Figures 2 and 3). The patient underwent bifrontal craniotomy with the evacuation of abscess, ablation of right frontal sinus and intracranial repair of skull base and dural defect. The patient post operative course was uneventful and patient was discharged home with no neurological deficit.
Rhinocerebral mucormycosis is recognized as a potentially aggressive and commonly fatal fungal infection. Mucormycosis is a rare opportunistic necrotizing infection within the class Zygomycetes and the order mucorales. Mucormycosis is commonly seen in patients with diabetes, hemochromatosis, burns, leukemia, lymphoma, HIV and other immunocompromised status. Clinical course of the infection typically begins with the symptoms of sinusitis or rhinitis with mucosal ulceration or necrosis. The infection disseminates to the orbit and cerebrum by direct extension as in our patient, or it may spread by vessels such as those of cavernous sinus. Imaging and early surgical debribement is essential in management of these patients.


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Angioedema Associated to Ophthalmic Beta-Blockers

A 79 year-old African American lady presented to the emergency department with complaints of dyspnea which followed the second application of her recently prescribed eye drops (timolol 0.25% ophthalmic solution). She had been taking azythromycin for an upper respiratory infection as well. However, she had taken this antibiotic in multiple occasions in the past. She denied any other medications or recent trauma to the oral cavity. The patient was admitted to the intensive care unit and emergently intubated via the nasotracheal route. She received intravenous corticosteroids with minimal response, eventually requiring a temporary tracheostomy. The patient was successfully weaned from mechanical ventilation and the angioedema resolved after 3 weeks. No further
ophthalmic beta-blockers were prescribed.


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Persistent Left Superior Vena Cava: Incidental Discovery in Adult

A middle age Caucasian gentleman presented to the Emergency Department with fever, chills and hypotension. Chest X-ray revealed consolidation in right lower lobe consistent with pneumonia. A chest radiograph after central line placement revealed a venous anomaly. CT scan with contrast revealed persistent left superior vena cava and absent right superior vena cava.


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Consumption of Raw Oysters and Vibrio Vulnificus Sepsis

We present the case and images of a 52 yearold Hispanic gentleman with a history of hepatitis C and chronic liver disease that developed Vibrio vulnifi cus sepsis secondary to eating raw oysters.
His course was complicated by necrotizing fasciitis in the upper extremities and renal failure.


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Acute Confusion: An Unusual Presentation of Miliary Tuberculosis

Clinical presentation of miliary tuberculosis is highly variable. Patients that present with central nervous system disease such as meningitis or tuberculoma is seen in up to 20% of the cases. Meningeal involvement is usually seen in up to 54% of the cases of miliary tuberculosis, and in just a few minority of patients the AFB smears are positive.


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Mineral Oil: The Occult Cause of Critical Illness

A 59 year-old lady with a history of diabetes,
hypertension, and coronary artery disease presented to
the emergency department complaining of progressive
shortness of breath over a 6 month period. On initial
examination she was found to be hypoxemic with a
PaO² of 50 mmHg. A chest radiograph left lower lobe
consolidation (Figure 1). The patient was given broadspectrum
antibiotics and admitted to the intensive care
unit (ICU). In the ICU she remained on antibiotics
and bronchodilator therapy was started. Despite these
interventions, she showed no evidence of improvement
over next 48 hours.
Additional questioning revealed that the patient
had a history of chronic constipation for which she had
been using mineral oil as a laxative over the last decade.
A computed tomography (CT) scan of chest revealed
a large area of consolidation extending from the left
hilum into the left lower lobe with satellite nodules in
the left lower lobe (Figure 2). The patient underwent
bronchoscopy with bronchoalveolar lavage, which
showed mucin with intermixed degenerated epithelial
elements and focal foamy histiocytes. Transbronhcial
biopsies of the region yielded moderate patchy to
diffuse infi ltrate of multi-vacuolated histiocytes,
with occasional foreign body giant cells. The Sudan
black stain was positive. These fi ndings corroborated
a suspicion of lipoid pneumonia. Antibiotics were
stopped at that time. A follow up chest x-ray showed
improvement over 3 months with resolution of infi ltrate
over 6 months.
Lipoid pneumonia occurs mainly in children
and the elderly, who are at risk for aspiration. Because
of its high viscosity, mineral oil depresses the cough
refl exes, facilitating aspiration even in normal persons,
and patients with swallowing dysfunction are at an
increased risk. This condition can be underdiagnosed
as mineral oil is often not considered important by the
patient to be listed with the medications which they are
taking.


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Images in critical care: Colonothorax

A 48 year-old Hispanic gentleman presented to the emergency department (ED) with 2-hour history of acute dyspnea. The patient had the history of motor vehicle accident 15 years prior to presentation. A chest x-ray done in the ED revealed pneumothorax and hydrothorax in the left chest. The patient had emergency closed tube thoracotomy with resolution of the pneumothorax. The chest tube began to drain fecal contents. A computed tomography (CT) scan of chest revealed evidence of a large diaphragmatic hernia with greater omentum and colon in chest and a colopleural fistula secondary to necrosis of incarcerated-strangulated segment of colon. The patient underwent thoracotomy with reduction of the incarcerated bowel and omentum into the abdominal cavity through the diaphragm, and the diaphragm was repaired. This procedure was immediately followed by an exploratory laparotomy with segmental resection of the transverse colon and end-to-end anastomosis. The patient did well and was discharged home after 10 days of hospitalization.


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