Ultrasound in Emergency MedicinePoint-of-Care Ultrasound (POCUS) for Isolated Pediatric Dysuria: An Unusual Presentation of Acute Appendicitis.

BACKGROUND: Isolated complaint of dysuria in an adolescent is a rare presentation for acute perforated appendicitis. Acute appendicitis typically involves vague periumbical pain that migrates to the right lower quadrant, associated with pain, nausea, and loss of appetite. There have been case reports of associated pyuria and dysuria in addition to classical symptoms, but to our knowledge, this is the first case with isolated dysuria presenting to an emergency department (ED). CASE REPORT: A 14-year-old boy presented to the ED with 3 days of dysuria and subsequent sensation of urinary retention. Urine dip showed occult blood without white cells or nitrites. A bedside renal/bladder point-of-care ultrasound (POCUS) did not show evidence of obstruction. However, it did reveal a retrovesicular fluid collection with an echogenic foci inside suspicious for abscess, likely secondary to ruptured appendicitis. This diagnosis was confirmed with a dedicated right lower quadrant ultrasound, with resultant treatment with i.v. antibiotics and eventual surgical resection of the appendix. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Pediatric and adolescent patients may present with extremely atypical symptoms of a common disease process. In this case, early use of POCUS in the ED helped to quickly identify an acute surgical process and focus diagnostic and therapeutic interventions.

Neurotropic Gamma-Delta T-Cell Lymphoma With CD30-Positive Lymphoid Infiltrates.

Primary cutaneous gamma-delta T-cell lymphoma (PCGD-TCL) is a clonal proliferation of gamma-delta T cells with a cytotoxic phenotype that is typically characterized by an aggressive clinical course with ulcerative plaques or subcutaneous nodules. In this report, the authors describe a patient who developed an ulcerated tumor on the left upper extremity and painful papules and nodules on the right lower extremity. Interestingly, several of the papulonodules on the right lower extremity underwent spontaneous involution. A skin biopsy of the papulonodular lesion demonstrated a superficial and deep perivascular interstitial infiltrate with a population of pleomorphic enlarged CD30-positive T cells. These enlarged lymphocytes lacked expression of TCR beta, CD4, CD8, and the pan T-cell antigen CD7, but were positive for TCR gamma, supporting the diagnosis of PCGD-TCL. The patient rapidly developed pain and severe weakness in the left upper limb and MRI revealed extensive neurolymphomatosis of the left brachial plexus. The patient was treated with chemotherapy with complete remission achieved. Unfortunately, her response was transient and the patient relapsed and ultimately died due to her disease. In this article, the authors describe an extraordinary case of a CD30-positive PCGD-TCL to expand the histopathological spectrum of CD30-positive and gamma-delta-positive lymphoproliferative disorders.