An Emergency Department Patient With Pharyngitis and Final Diagnosis of Rare T-cell Acute Lymphoblastic Leukemia With a Copy of Retinoic Acid Receptor Alpha Gene.

A 21-year-old female with a past medical history of chronic tonsilitis presented to the emergency department (ED) with a sore throat and swelling in her neck for a two-week duration. The patient was noted to have pancytopenia with blasts on peripheral blood differential, so she was transferred for admission at an outside facility for further evaluation and management. Bone marrow biopsy revealed T-cell acute lymphoblastic leukemia (ALL) with 39.5% blasts. CALGB 10403 treatment protocol was initiated two days after her presentation to the ED. The patient also had an extra copy of the retinoic acid receptor alpha (RARA) gene. One year later, the patient was in remission, and cytogenetic results showed a normal female karyotype indicating that the patient no longer had ALL or RARA gene abnormalities. While a sore throat can be a common chief complaint in the ED, ED providers need to keep a broad differential as there are many serious and potentially life-threatening etiologies such as T-cell ALL. T-cell ALL diagnosis is established with the presence of >20% of lymphoblasts in the bone marrow or peripheral blood draw. Cytogenetic changes play a significant role in determining the prognostic factors and management of ALL.

A Terrible Sore Throat: Pharyngitis in an Emergency Department Patient With a Final Diagnosis of Acute Myelogenous Leukemia.

Acute pharyngitis is a common complaint in emergency department (ED), urgent care, and primary care settings. Most cases are due to bacterial or viral infections easily treated with antibiotics or supportive care. However, serious pathologies in the pharyngitis differential include Ludwig's angina, peritonsillar abscess, retropharyngeal abscess, and bacterial tracheitis. Rarely, oncologic conditions such as leukemia may initially present as pharyngitis in an acute care setting. We present a case of pharyngitis in a 32-year-old male ED patient with a final diagnosis of acute myelogenous leukemia (AML). Knowledge of the appropriate ED evaluation of AML is key for accurate diagnosis and prompt referral to avoid unnecessary patient morbidity and mortality.

Procedures Performed by Emergency Medical Services in the United States.

Emergency medical services (EMS) must provide a wide range of care for patients in the out-of-hospital setting. Although previous work has detailed that EMS providers rarely perform certain procedures, (e.g., endotracheal intubation) there are limited data detailing the frequency of procedures across the breadth of EMS providers' scope of practice. We sought to characterize procedures performed by EMS in the United States. We conducted an analysis of the 2011 National Emergency Medical Services Information System (NEMSIS) research data set, encompassing EMS emergency response data from 40 states and two territories. From these data, we report the number and incidence of EMS procedures. We also characterize procedures performed. There were 14,371,941 submitted EMS responses, of which 7,680,559 had complete information on procedures performed on adults. Of these, 4,206,360 EMS responses had procedures performed totaling 11,407,396 procedures. The most common procedures performed were peripheral venous access (28.4%), cardiac monitoring (16.1%) pulse oximetry (13.5%), and blood glucose analysis (10.4%). Procedures were performed most often in patients with traumatic injury (20.0%) followed by chest pain/discomfort (14.0%). Critical procedures (cardioversion, defibrillation, endotracheal intubation, etc.) were infrequently performed (n = 277,785, 2.4%). These data highlight the frequency with which EMS providers perform procedures across the United States. This may help to guide future EMS training and education efforts by highlighting the relative frequency and infrequency of specific procedures.