Acute Respiratory Failure With a Rare, Rapidly Progressing Pediatric Desmoid Tumor Anterior Mediastinal Mass.

ABSTRACT: We present an unusual case of a 6-year-old boy who presented with the sudden presence of left neck mass and acute hypoxemic respiratory failure, whose subsequent imaging demonstrated a previously undiagnosed anterior mediastinal mass (AMM) extending into the left neck. Biopsy of the mass was consistent with a desmoid tumor, which is a rare cause of AMM in children. Desmoid tumors are locally aggressive, often invading and enveloping surrounding tissues, but overall slow growing. The sudden growth of the neck mass suggests a very aggressive desmoid tumor, causing an unexpected respiratory compromise. Anterior mediastinal masses may cause symptoms by compressing the heart, great vessels, and airways. However, the patient may adapt and develop compensatory mechanisms to counter the compressive effects. Emergency care of the patient with an AMM who presents with acute respiratory distress includes optimizing oxygenation through promoting a calm environment, oxygenating while minimizing positive end-expiratory pressure, maintaining the patient's compensatory mechanisms by minimizing sedation and muscle relaxation, positioning the patient to minimize compressive effects of the mass on the vital thorax structures, and early consultation with pediatric specialists to develop a shared-emergency treatment strategy and to secure an expedited disposition to the appropriate venue of care.

Snake Eyes: Coral Snake Neurotoxicity Associated With Ocular Absorption of Venom and Successful Treatment With Exotic Antivenom.

BACKGROUND: Coral snake bites from Micrurus fulvius and Micrurus tener account for < 1% of all snake bites in North America. Coral snake envenomation may cause significant neurotoxicity, including respiratory insufficiency, and its onset may be delayed up to 13 h. CASE REPORT: We present a unique patient encounter of M. tener venom exposure through the ocular mucous membranes and a small cutaneous bite, resulting in neurotoxicity. To our knowledge, this is the first reported case of systemic neurotoxicity associated with ocular contact with coral snake venom. Our patient developed rapid-onset skeletal muscle weakness, which is very uncommon for M. tener, along with cranial nerve deficits. Acquisition of antivenom was challenging, but our patient provides a rare report of resolution of suspected M. tener neurotoxicity after receiving Central American coral snake (Micrurus nigrocinctus) antivenom. Our patient subsequently developed serum sickness, a known delayed complication of antivenom. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: The emergency physician should be aware that coral snake venom may be absorbed through different routes. Neurotoxicity and respiratory insufficiency may be fatal and onset may be delayed up to 13 h. North American Coral Snake Antivenom is in very limited supply, so non-Food and Drug Administration-approved alternative coral snake antivenoms may be used for patients demonstrating neurotoxicity. Emergency physicians should be proactive in contacting a toxicologist to procure antivenom, as well as consideration of adjunctive treatments, such as neostigmine. Furthermore, whole immunoglobulin G products, such as antivenom, may result in immediate and delayed reactions.

Pediatric subhepatic appendicitis with elevated lipase.

Appendicitis is the most common surgical emergency in children, of which most are located in the retrocecal space or pelvis. Appendicitis occurring in the subhepatic space is uncommon and may present with atypical features such as right upper quadrant pain, leading to delayed diagnosis and complications. We present a rare case of subhepatic appendicitis in an 11-year-old female, who presented with a three-day history of both right upper quadrant (RUQ) and right lower quadrant (RLQ) abdominal pain and serum lipase elevated four times the upper normal limit. The abdominal ultrasound was normal, except for prominent RLQ abdominal lymph nodes. Hours later, a computed tomography scan revealed a non-ruptured subhepatic appendicitis and normal pancreas. Our patient encounter demonstrates the need to be aware of the atypical presentations of pediatric appendicitis in general and subhepatic appendicitis in particular. Moreover, to our knowledge, this is the first reported case of elevated lipase (with a radiographically normal pancreas) in association with subhepatic appendicitis. Providers should be aware elevated serum lipase levels may be due to conditions other than pancreatitis and further evaluation should be considered if the elements of the clinical picture are incongruent.

Sternoclavicular Joint Infection Presenting as Nonspecific Chest Pain.

BACKGROUND: Sternoclavicular joint infection (SJI), to include septic arthritis (SA), is a rare cause of chest pain and is often found in patients with significant risk factors and sources for SA. Most acute care laboratory results lack significant sensitivity to rule out SA. Radiographic findings in common acute care imaging often does not reveal findings of SA and osteomyelitis in the acute phase of the infection. CASE REPORT: We present a patient without significant risk factors for SA, who initially presented with 3 days of pain to the left chest, left neck and shoulder. He had fever and was treated with a short course of antibiotics for possible pneumonia. His symptoms recurred along with fever 36 days after the initial onset of symptoms and was then diagnosed radiographically with left-sided SJI. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This case reinforces the need to maintain a broad differential diagnosis in the evaluation for chest pain and pursue advanced imaging, such as magnetic resonance imaging, when the pretest probability of SJI is high, especially in the acute phase of the infection.

Bullet fragment-induced lead arthropathy with subsequent fracture and elevated blood lead levels.

Lead foreign bodies in joint spaces, often due to projectiles such as bullets, may cause localized arthropathy. There are no reports of joint fracture related to lead arthropathy. Additionally, lead foreign bodes embedded in the joint space may be a source of systemic lead absorption, causing elevated blood lead levels and toxicity to other organs. We present a young adult patient with retained left hip joint bullet fragments who developed suspected lead arthropathy and subsequent acute left hip fracture, as well as systemic lead absorption demonstrated by elevated blood lead levels.

Pulmonary embolism following celiac plexus block and neurolysis.

Treatment of acute pain in chronic disease requires the physician to choose from an arsenal of pain management techniques tailored to the individual patient. Celiac plexus block and neurolysis are commonly employed for the management of chronic abdominal pain, especially in debilitating conditions such as cancer or chronic pancreatitis. The procedure is safe, well tolerated, and produces few complications. We present a case of pulmonary embolism following a celiac plexus block and neurolysis procedure. Further study is required to determine if celiac plexus ablation, alone or in combination with other risk factors, may contribute to increased risk for pulmonary embolism in patients seeking treatment for chronic upper abdominal pain conditions.