Expression of the triggering receptor expressed on myeloid cells-1 mRNA in a heterogeneous infected population.

This study is to investigate the clinical utility of detection of peripheral blood triggering receptor expressed on myeloid cells (TREM)-1 mRNA as an early indicator of sepsis among critically ill patients and to compare the results of TREM-1 with those of C-reactive protein (CRP). A prospective, non-interventional study of 127 patients with at least two criteria of the systemic inflammatory response (SIRS) was performed. TREM-1 was assessed by real-time quantitative reverse transcription-polymerase chain reaction. The diagnosis of SIRS only was made in 41 patients (32%), and the diagnosis of sepsis was made in other 86 patients (68%). TREM-1 mRNA expression had the comparably discriminative value to differentiate the presence from the absence of infection, with an area under the receiver-operating characteristic curve (AUC) of 0.75 [95% confidence interval (95% CI), 0.67-0.84] than CRP [AUC, 0.72 (95% CI, 0.62-0.81)]. As an indicator of sepsis, a TREM-1 mRNA expression ratio cutoff value of 58.8 had a sensitivity of 72%, a specificity of 71%, a positive likelihood ratio of 2.5 and a negative likelihood ratio of 0.39. Furthermore, TREM-1 mRNA expression was selectively higher in septic patients caused by extracellular bacteria or fungi [112.4 (19.3-680.1)], than in those caused by intracellular bacteria or viruses [18.8 (7.6-53.0), p < 0.001]. There was no difference in plasma CRP levels between both septic groups (p = 0.782). TREM-1 and CRP are similar diagnostic markers of sepsis. The different ability of extracellular and intracellular pathogens to induce TREM-1 expression may provide a potential marker for differential diagnosis.

Vertebral artery dissection and cerebellar infarction following chiropractic manipulation.

Vertebral artery dissection (VAD) associated with chiropractic cervical manipulation is a rare but potentially disabling condition. In this report, we present a young patient manifesting with repeated vertigo. Owing to the initial misdiagnosis, the patient later developed cerebellar stroke with inability to stand or walk. Vertigo and disequilibrium are the usual presenting symptoms of this condition, which can result from inner ear or vestibular nerve dysfunction, vertebrobasilar insufficiency, and even lethal cerebellar infarction or haemorrhage; these last two, although rarely seen in young adults, can be caused by traumatic or spontaneous arterial injury, including injury secondary to chiropractic cervical manipulation. A number of cases of VAD associated with chiropractic cervical manipulation have been reported, but rarely in the emergency medicine literature. We present a case of this rare occurrence, and discuss the diagnostic pitfalls.

Left flank pain as the sole manifestation of acute pancreatitis: a report of a case with an initial misdiagnosis.

Acute pancreatitis is not an uncommon disease in an emergency department (ED). It manifests as upper abdominal pain, sometimes with radiation of pain to the back and flank region. Isolated left flank pain being the sole manifestation of acute pancreatitis is very rare and not previously identified in the literature. In this report, we present a case of acute pancreatitis presenting solely with left flank pain. Having negative findings on an ultrasound initially, she was misdiagnosed as having possible "acute pyelonephritis or other renal diseases". A second radiographic evaluation with computed tomography showed pancreatitis in the tail with abnormal fluid collected extending to the left peri-renal space. We performed a literature review and discussed this rare occurrence of acute pancreatitis. We also discussed the clinical pitfalls in this case.

Descending necrotising mediastinitis: a report of misdiagnosis as thoracic aortic dissection.

Descending necrotising mediastinitis is an uncommon disease in the emergency department. Early recognition is important for a good prognosis for this fatal condition. This report describes a case of a healthy 79 year old woman who was seen in the urgent care centre with the initial presentation of chest pain. Misdiagnosis was made because of the mis-reading of a flap-like artefact over the ascending aorta and difficulty interpreting subtle change of mediastinal soft tissue infiltration. The patient was then treated as dissecting aneurysm over ascending aorta until her condition deteriorated. Although aggressive treatment comprising thoracotomy, cervical incision and drainage, and antibiotics were begun, the response was poor. Emergency physicians should be familiar with this rare but highly lethal disease. Correlation should be made in a patient complaining about chest pain, especially combined with fever, sore throat, dysphagia, or neck swelling.