Polytrauma patient with lateral thoracic spondyloptosis: case report and literature review

Background: Spondyloptosis is caused by high force trauma. The vast majority of cases occur in the sagittal plane and at transition points where ridged sections meet more flexible regions. Lateral thoracic spondyloptosis is extremely rare and there is no current consensus on the optimal treatment plan. Case Description: Here we present a case of a previously physically healthy 24-year-old polytrauma patient after he was struck as a pedestrian by a motor vehicle. Of note the patient was found to have lateral spondyloptosis between T9-10 with complete spinal cord transection. The patient also sustained multi-ligamentous left knee injury, pelvic fractures, open comminuted left tibia and fibular fracture, lacerated liver, bilateral renal lacerations, ischemic bowel, and an aortic arch pseudoaneurysm. Conclusion(s): Lateral thoracic spondyloptosis is a devastating injury with an extreme rate of persistent neurologic deficits. There is no unanimously accepted treatment because of the rarity if the injury and the poor outcomes that patients face. Additionally, patients who experience high level trauma often develop severe psychiatric illness, and the importance of identifying risk factors and implementing care early may improve patient outcomes.Copyright © AME Medical Journal.

INCIDENTAL PULMONARY CAVITARY LESIONS AS AN UNCOMMON PRESENTATION OF LEMIERRE SYNDROME

SESSION TITLE: Systemic Diseases with Deceptive Pulmonary Manifestations SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 12:25 pm - 01:25 pm INTRODUCTION: Pulmonary cavitary lesions can have varying etiologies. Among these, Lemierre syndrome is an uncommon disease which usually presents with symptoms of upper respiratory tract infection with unilateral neck pain, tenderness or swelling. In recent years, antibiotic stewardship for upper respiratory illnesses has led to its delayed diagnosis resulting in possible increased morbidity and mortality. There have been few reported cases of pulmonary cavitary lesions as the initial presentation of Lemierre syndrome. Our patient presented with incidental bilateral pulmonary cavitary lesions, which led to a diagnosis of Lemierre syndrome. CASE PRESENTATION: A 30-year-old gentleman with no significant past medical history visited urgent care for reproducible chest pain following motor vehicle accident. Chest x ray obtained for suspected rib fracture showed bilateral patchy and rounded opacities, confirmed by CT as bilateral cavitary nodules and consolidation. He was referred to our hospital for further care. Two weeks prior, following administration of COVID booster vaccine, he had developed fever, sore throat, tender lump behind left ear, left jaw and anterior left neck. Most symptoms self resolved in 3-5 days except persistent fever. On arrival, patient was febrile to 102F and hemodynamically stable. Physical examination revealed dry mucous membranes and erythematous pharynx. Labs were significant for leukocytosis of 24.5uL with bandemia and elevated inflammatory markers. Three sets of blood cultures were drawn and empirically started on vancomycin and piperacillin/tazobactam. Echocardiogram ruled out heart valve vegetations. CT angiography of neck showed intraluminal thrombi in left internal jugular vein. Blood cultures finalized to Fusobacterium nucleatum and antibiotics were tapered to metronidazole. Due to persistent fever, anticoagulation was initiated with apixaban 5mg twice daily. Pan CT showed improvement in size of many pulmonary septic emboli. After 48 hours of patient being afebrile, he was discharged on antibiotics and apixaban for at least 4 weeks until surveillance CT angiography showed non progression of thrombus. DISCUSSION: Lemierre syndrome is septic thrombophlebitis of internal jugular vein which presents within 1-3 weeks following upper respiratory tract infections with multi-system complications. Management involves prolonged antibiotic course with use of anticoagulation and vein stripping still being debated. Our patient came to the hospital with an incidental finding of bilateral cavitary pulmonary lesions which went on to be diagnosed as Lemierre syndrome from positive blood cultures and CT angiography findings. CONCLUSIONS: Lemierre syndrome is an uncommon disease with mortality up to 18%. A call out to health care providers to keep a low threshold for its diagnosis in patients with initial presentation of bilateral pulmonary cavitary lesions, warranting prompt management. Reference #1: Sinave CP, Hardy GJ, Fardy PW. The Lemierre syndrome: suppurative thrombophlebitis of the internal jugular vein secondary to oropharyngeal infection. Medicine (Baltimore). 1989 Mar;68(2):85-94. PMID: 2646510. Reference #2: Golpe R, Marín B, Alonso M. Lemierre's syndrome (necrobacillosis). Postgrad Med J. 1999 Mar;75(881):141-4. doi: 10.1136/pgmj.75.881.141. PMID: 10448489;PMCID: PMC1741175. Reference #3: Lee WS, Jean SS, Chen FL, Hsieh SM, Hsueh PR. Lemierre's syndrome: A forgotten and re-emerging infection. J Microbiol Immunol Infect. 2020 Aug;53(4):513-517. doi: 10.1016/j.jmii.2020.03.027. Epub 2020 Apr 4. PMID: 32303484. DISCLOSURES: No relevant relationships by Sumukh Arun Kumar No relevant relationships by Megna Machado No relevant relationships by Sushmita Prabhu No relevant relationships by PAWINA SUBEDI No relevant relationships by Mithil Gowda Suresh No relevant relationships by Bradley Switzer

IT'S NEXT TO THE PLEURA

SESSION TITLE: Pneumothorax, Chylothorax, and Pleural Effusion Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: Chest tube placement is generally done to drain air (Pneumothorax) or fluid (Effusion or Hemothorax) from the pleural cavity. The incidence of complications related to such intervention varies between 1 to 6 percent (1), and includes but not limited to malposition, injuring chest wall structures, injuring intrathoracic structures, bleeding, and infection. In this case we present an unusual complication to surgical chest tube placement. CASE PRESENTATION: Our patient is a 59-year-old male, long term resident of a nursing facility with past medical history of alcohol use disorder in remission, alcoholic cirrhosis, seizure disorder, protein-calorie malnutrition and a recent COVID-19 infection. He presented with worsening shortness of breath and was admitted with acute hypoxemic respiratory failure. Initial CT scan showed fibrotic, reticular and cystic changes, traction bronchiectasis and diffuse bilateral ground glass opacities. He was admitted to the medical ICU;he was treated initially with broad spectrum antibiotics and diuresis with minimal response. Eventually steroid therapy was started for Covid related organizing pneumonia, and he improved. Later in his hospital state he developed bilateral small pneumothoraxes that enlarged overtime and a surgical chest tube was placed on the right side. Post procedure chest x ray showed that the tube was kinked, and the pneumothorax was still present. A follow up CT chest confirmed the presence of an extra-pleural hematoma with the tube kinked inside it. CT angiography of the chest was done and showed active extravasation of contrast into the extra-pleural space likely from the intercostal arterial branches. Interventional radiology took the patient to see if they could cauterize the bleeding vessel but they were unable to identify the source of bleeding. Thoracic surgery was also consulted and was planning to take the patient to the OR, remove the tube, evacuate the hematoma and control the bleeding. However, the patient opted against this. DISCUSSION: Extra-pleural hematoma is a rare complication of surgical chest tube placement. It is usually seen after blunt trauma or rib fracture, but can still occur after subclavian vein central line placement or chest tube placement. Bleeding is usually arterial in origin and treatment is often surgical. Radiological characteristics include biconvex shape and the extra-pleural fat sign (2,3,);hypodense rim medial to the hematoma due to the inward displacement of the extra-pleural fat by the hematoma. CONCLUSIONS: Chest tube placement remains a routine procedure that is done in emergency departments and hospital wards. Generally, a safe intervention but clinicians should be aware of the possible complications and their management including extra-pleural hematomas. Reference #1: Pleural procedures and thoracic ultrasound: British Thoracic Society pleural disease guideline 2010 Tom Havelock1, Richard Teoh2, Diane Laws3, Fergus Gleeson4 on behalf of the BTS Pleural Disease Guideline Group. Correspondence to Dr Tom Havelock, Wellcome Trust Clinical Research Facility, Southampton General Hospital, Southampton SO16 6YD, UK;t.havelock@soton.ac.uk Reference #2: Journal of Trauma and Injury 2017;30(4): 202-205. Published online: December 30, 2017 DOI: https://doi.org/10.20408/jti.2017.30.4.202 Traumatic Extrapleural Hematoma Mimicking Hemothorax Yong Seon Choi, M.D., Soon Jin Kim, M.D., Sang Woo Ryu, Seung Ku Kang Department of Thoracic and Cardiovascular Surgery, Mokpo Hankook Hospital, Mokpo, Korea Correspondence to: Soon Jin Kim, M.D., Department of Thoracic and Cardiovascular Surgery, Mokpo Hankook Hospital, 483 Yeongsan-ro, Mokpo 58643, Korea, Tel: +82-61-270-5574, Fax: +82-61-277-0199, E-mail : innocent-blood@hanmail.net Reference #3: The Journal of Emergency Medicine Volume 51, Issue 2, August 2016, Pages 159-163 Nonoperative Management of a Large Extrapleural Hematom after Blunt Chest Trauma LuisGorospe MD, María Ángeles Fernández-Méndez MD, AnaAyala-Carbonero MD, AlbertoCabañero-Sánchez MD, Gemma MaríaMuñoz-Molina MD, PhD DISCLOSURES: No relevant relationships by Ahmad Allaham No relevant relationships by Elyce Sheehan

SEQUELAE OF COVID-19 COUGH: A RARE LIFE-THREATENING PRESENTATION

SESSION TITLE: Management of COVID-19-Induced Complications SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 1:45 pm INTRODUCTION: Rib fractures are an infrequent consequence of severe cough. In some patients, undetected rib fractures can lead to life-threatening outcomes. We bring to light a case of uncontrolled cough associated with COVID-19 infection resulting in multiple rib fractures that were missed in 2 hospital visits and subsequently diagnosed when the patient presented in acute distress and at high risk of decompensation from a hemothorax and a diaphragmatic hernia that required expedited evaluation, ICU admission, and surgical intervention. CASE PRESENTATION: This is a case of a 73 years old male who presented with shortness of breath and worsening dry cough of 4 weeks duration. He was seen in the ED 3 weeks previously for severe right-sided chest pain that was evaluated by a CT chest that did not reveal any acute findings. He was discharged home on pain medications. He had a repeat admission in 2 days and was diagnosed with acute hypoxic respiratory failure secondary to COVID-19 infection. CT abdomen was done for continued right upper quadrant pain which showed an upper abdominal wall hernia. He was discharged with instructions to follow up with outpatient surgery for hernia repair. In the interim, the patient continued to have excessive dry cough, progressively worsening shortness of breath, and bruising over the right abdominal wall and back. He returned to the ED where he was found to be hypoxic, and hypotensive. Imaging studies revealed a large right pleural effusion, fracture of the right sixth rib and seventh rib, and herniation of the hepatic flexure of the colon into the chest. He was subsequently admitted to the cardiothoracic ICU and underwent flexible bronchoscopy, right VATS, evacuation of hemothorax, complete decortication, and repair of diaphragmatic hernia. DISCUSSION: This case is an unusual presentation of an amalgamation of complications resulting from an unrelenting cough that prompted rapid recognition and swift action. Cough-induced complications are rare but can be life-threatening. Various imaging studies can be pursued to avoid a delay in diagnosis. CONCLUSIONS: Persistent cough is a common complication of COVID-19 infection. A clinician should have a high index of suspicion for rib fractures, diaphragmatic hernia, and hemothorax in a patient with persistent or progressive symptoms. Reference #1: Camarillo-Reyes LA, Marquez-Córdova RI, Surani S, Varon J. Hemothorax induced by severe cough: An unusual presentation. SAGE Open Med Case Rep. 2019;7:2050313X19846043. Published 2019 Apr 26. doi:10.1177/2050313X19846043 Reference #2: Daccache A, Haddad J, Ghanem A, Feghali EJ, El Osta B. Cough-induced rib fracture in a smoker: a case report. J Med Case Rep. 2020;14(1):147. Published 2020 Sep 5. doi:10.1186/s13256-020-02497-4 DISCLOSURES: No relevant relationships by Navya Akula No relevant relationships by Sanjana Chetana Shanmukhappa No relevant relationships by Muhammad Ahmed Malik No relevant relationships by Aqsa Malik No relevant relationships by Fahd Shaukat

Comparing Autopsy Thoracic Injury Patterns between In-Hospital CPR Patients Receiving LUCAS Device vs Manual Chest Compressions

Background: Current research comparing CPR-associated injuries between those receiving LUCAS device and manual CPR has primarily focused on patients who suffered out-of-hospital cardiac arrest. During the SARS-CoV-2 pandemic, more hospitals leveraged mechanical CPR devices to provide distant yet high quality chest compressions for in-hospital cardiac arrest (IHCA) patients. We sought to investigate autopsy thoracic injury patterns in in-hospital non-traumatic cardiac arrests, comparing traditional manual compressions with the mechanical LUCAS device compressions. Design: Autopsies were screened for a history of in-hospital cardiopulmonary resuscitation in the absence of prior traumatic injuries at a single, large quaternary care center from 1/1/2018 to 06/30/2021. 20 received LUCAS compressions and 40 received manual compressions. Student's T-Tests were used to compare means for continuous variables, while chi-squared and Fischer's exact tests were used for categorical variables. An alpha of 0.05 was chosen as the threshold for statistical significance. Results: A statistically significant decrease in the rate of sternal fractures and rate of multiple sternal fractures during mechanical CPR was found. A statistically significant increase in other soft tissue injuries, such as pleural wall or lung injuries was seen in mechanical CPR cases, while an increased rate of bilateral rib fractures was noted in manual compression cases. Conversely, no difference in the number or laterality of rib fractures were noted. There was no significant difference in age, biological sex, or rate of scoliosis or kyphosis between cohorts. Results are listed in table 1. (Table Presented) Little research has looked at the injury patterns of mechanical CPR in the IHCA patient population. These results point to a potential difference in thoracic injury patterns from manual compressions when compared to LUCAS device compressions. The statistically significant decrease in sternal fractures with mechanical compressions is noteworthy. Conversely, the increase in other soft tissue injury demands further examination. The decrease in bilateral rib fractures with LUCAS use suggests that placement of the device may play a role in the epidemiology of rib injuries, but not in the number of ribs injured. Further research should examine rib injuries in more detail, and quantify additional comorbidities in both survivors and non-survivors of cardiac arrest.

Multiple myeloma presenting as a pathological rib fracture in a primary health care center and its diagnostic challenges during the COVID 19 pandemic

Multiple Myeloma commonly presents with a myriad of symptoms, signs and abnormal laboratory findings namely bone pains, pathological fractures, lytic bone lesions, anaemia, high ESR, hypercalcemia, raised globulin and presence of monoclonal band in serum/urine. Here, we present a 54-year-old gentleman whose initial presentation was a pathological rib fracture. However, review of his past medical history revealed gout (now asymptomatic) and abnormal laboratory findings that helped us to subsequently diagnose as Multiple Myeloma. The importance of simple investigations like ESR when managing patients with nonspecific symptoms in primary care, listening and looking for signals that suggest an alarming aetiology, following up of investigations and the continuity of care assured by the electronic medical record is highlighted by this case report. [ FROM AUTHOR] Copyright of Middle East Journal of Family Medicine is the property of Medi+WORLD International Pty. Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full . (Copyright applies to all s.)

POS-834 SPONTANEOUS RESOLUTION OF LARGE PERICARDIAL EFFUSION AFTER CARDIOPULMONARY RESUSCITATION IN A CHRONIC KIDNEY DISEASE PATIENT ON MAINTENANCE HAEMODIALYSIS

Introduction: Here, we discuss a chronic kidney disease (CKD) patient with large pericardial effusion who arrested secondary to tamponade and had an unintentional pericardial decompression secondary to cardio pulmonary resuscitation (CPR) that subsequently saved his life. Methods: PRESENTATION 67 years old male, a case of CKD on maintenance hemodialysis (for last two years) but inadequately dialyzed over last two months after recent covid pneumonia was detected to have large pericardial effusion (red arrows) on echocardiography (Figure 1). He was planned for intensive heparin free dialysis in view of absence of frank clinical and echocardiographic findings of tamponade with close surveillance for pericardial effusion. 60 minutes into hemodialysis, patient developed dyspnea, hypotension, and cardiac arrest. Return of spontaneous circulation was achieved after three cycles of cardiopulmonary resuscitation. Echocardiography (echo) guided pericardiocentesis was planned based on clinical suspicion of tamponade. But, echocardiography revealed only mild pericardial effusion (Figure 1). Chest x ray showed new left pleural effusion. Pleurocentesis revealed hemorrhagic fluid. Subsequently done CT thorax showed multiple rib fractures. Patient was discharged on day eleven in stable condition with repeat chest X ray and echocardiography showing no further collection. Figure1: Panel A ( Pre CPR echo, Large pericardial effusion - red arrows), Panel B (Post CPR echo, minimal pericardial effusion) [Formula presented] Results: DISCUSSION Though cardiac tamponade is largely a clinical diagnosis, various other features like echocardiography aid in its diagnosis. Diagnosis of tamponade in CKD patient with pericardial effusion is difficult because of several reasons. All classical clinical features of tamponade like hypotension or elevated systemic pressures may not be manifested all the time in cases of tamponade. Our patient developed clinical signs of tamponade 60 minutes into dialysis session indicating that precipitation of tamponade was likely due to reduction in preload due to ultrafiltration (UF) during hemodialysis. Though, daily dialysis is the initial preferred treatment of choice for uremic pericardial effusions in CKD patients without clinical or echocardiographic signs of tamponade, there are case reports which support early pericardiocentesis as treatment of choice in all large pericardial effusions in CKD patients on maintenance hemodialysis (MHD). In our case of large pericardial effusion, due to absence of frank clinical/ echocardiographic evidence of tamponade, we were prompted to go for aggressive dialysis treatment plan, but had tamponade during dialysis. CPR can cause inadvertent injury to surrounding structures, ribs, abdominal organs and vascular injury. In our case, CPR associated injury lead to unintentional pericardial decompression probably due to rib injury or due to high force generated during CPR coupled with high pericardial pressures which overcame the tensile strength of pericardium resulting in pericardial decompression. Findings of fractured ribs on CT scan post resuscitation in our case supports that high force and pressure were generated during CPR. Conclusions: This case report supports early pericardiocentesis as treatment of choice for large pericardial effusion in CKD patients on MHD. Also, care should be taken while dialyzing these patient as rapid UF can precipitate tamponade. No conflict of interest

Fragility fracture of the fourth rib in a patient with a cardiac pacemaker: an uncommon case.

PURPOSE: In patients with a cardiac pacemaker, pocket-related complications such as nerve impairment or bone fractures are infrequent. We present a man with a fracture of the 4th rib several months after pacemaker implantation. CASE PRESENTATION: A 74-year-old man, with a left prepectoral pacemaker implanted 13 months ago, presented complaining of chest pain. The pain started after a sudden trunk rotation and right arm flexion movement with a crack. There was tenderness to palpation and crepitation over the left upper ribs. Computed tomography identified a non-displaced fracture line in the anterior aspect of the left 4th rib. After kinesiotaping and activity restriction, pain alleviated. CONCLUSION: Pacemaker implantation might have caused shoulder dysfunction and pectoral tightness resulting in reduced flexibility of the trunk. Consequently, a reaching motion of the arm with a trunk rotation might have directed rotational force vectors towards the osteopenic left 4th rib causing a fragility fracture. In elderly with a pacemaker, osteopenia and concomitant sarcopenia may create a predisposition to this atypical complication.

[Successful treatment of a geriatric COVID-19 patient with severe chest trauma : An interdisciplinary case report]. / Erfolgreiche Behandlung des schweren Thoraxtraumas einer geriatrischen COVID-19-Patientin : Ein Fallbericht von interdisziplinärer Bedeutung.

The coronavirus disease 2019 (COVID-19) has spread rapidly worldwide and leads to high morbidity and mortality. Clinical experience regarding the surgical management in COVID-19 patients is limited. We report the interdisciplinary approach in a COVID-19 patient with severe thoracic trauma and pulmonary symptoms, who was admitted to the emergency unit after blunt chest trauma with dislocated serial rib fractures and concomitant hemothorax.