Successful Distal Urethral Stone Removal in the Emergency Department.

Nephrolithiasis is a common pathology encountered in the primary care and emergency department (ED) setting. In 2009 alone, there were over one million ED visits related to nephrolithiasis Higa et al. (2017) [1]. Emergent treatment options range from non-invasive pain control and patient education to lithotripsy and other invasive urologic procedures depending on stone location and related pathology. Urethral calculi are estimated to represent 0.3% of all urinary stone diseases Verit et al. (2006) [2]. There are very few case reports documenting distal urethral stone removal in the ED. Here we present a case of distal urethral stone impaction and the removal of this stone by ED providers, leading to expedited care and prevention of consultation and possible admission.

Facial Baroparesis Mimicking Stroke.

We report a case of a 55-year-old male who experienced unilateral facial muscle paralysis upon ascent to altitude on a commercial airline flight, with resolution of symptoms shortly after descent. The etiology was determined to be facial nerve barotrauma, or facial baroparesis, which is a known but rarely reported complication of scuba diving, with even fewer cases reported related to aviation. The history and proposed pathogenesis of this unique disease process are described.

Idiopathic Spinal Epidural Lipomatosis Causing Cauda Equina Syndrome.

Spinal epidural lipomatosis (SEL) is a rare condition defined by the hypertrophy of adipose tissue in the spinal epidural space, often resulting in compression of nerves in the region affected.1 This case describes a 64-year-old man who presented with cauda equina syndrome. Magnetic resonance imaging of the spine revealed extensive SEL of the lumbar spine. He underwent decompression and fusion with subsequent improvement of symptoms. This is one of the few cases reported of lumbar SEL in a non-obese patient in absence of long-term corticosteroid usage. We review possible etiologies.

Acute intractable vomiting and severe ketoacidosis secondary to the Dukan Diet©.

BACKGROUND: The benefits of low-carbohydrate, high-protein diets, such as the Dukan Diet©, are well documented, whereas reported adverse effects are rare in literature. Such diets mimic starvation states in that they promote the breakdown of fat and the production of ketones secondary to fatty acid metabolism. In fact, one measure of the effectiveness of such diets is the presence of ketosis. To our knowledge, there have been no reported cases of ketoacidosis resulting from the Dukan Diet. OBJECTIVES: The purpose of this case report is to illustrate the importance of a detailed dietary history in patients with severe ketoacidosis secondary to the Dukan Diet and suggest treatment that may allow outpatient management. CASE REPORT: A 42-year-old Iranian woman with no prior medical problems presented with 10 h of intractable nausea and vomiting secondary to ketoacidosis 2 days after starting the Dukan Diet. CONCLUSION: Although rare, ketoacidosis secondary to a low-carbohydrate, high-protein diet can have serious complications if untreated. Clinical suspicion should arise in any patient presenting with intractable nausea and vomiting after starting a diet such as the Dukan Diet. Early recognition and intervention is essential to quicken patient recovery and outpatient management.

Detection of Loxosceles species venom in dermal lesions: a comparison of 4 venom recovery methods.

STUDY OBJECTIVE: Loxosceles species spider envenomations may produce necrotic, disfiguring dermal inflammatory lesions resembling neutrophilic dermatoses. With definitive treatment options lacking, clinicians are reluctant to obtain invasive biopsy specimens for diagnostic analysis. We compared less invasive venom collection methods and determined the time limit after inoculation for feasible venom recovery in an animal model. METHODS: Nine New Zealand rabbits were randomized to 1 of 3 groups (n=3). Groups 1 and 2 were inoculated intradermally with 3 microg of L reclusa venom at 5 inoculation sites per rabbit. Albumin (3 microg) was injected intradermally in each rabbit as a negative control. Hair (group 1) and aspirate samples (group 2) were collected (1 time per site) over a 1-week period after inoculation. Group 3 was inoculated with 3 microg of Loxosceles species venom on 1 flank and 3 microg of albumin on the opposite flank. Daily serum specimens were collected over a 7-day period. On day 7, dermal punch biopsy specimens were taken from the venom and control inoculation sites. Hair, aspirate, biopsy, and serum specimens were assayed for venom by using an enzyme-linked immunosorbent assay. A generalized linear model was fit with the generalized estimating equation method to estimate the mean differences between groups. RESULTS: Venom was detected in hair, aspirate, and biopsy specimens on all days of the study period. Hair samples yielded venom recovery on day 1 (median 0.062 ng/100 microL; mean difference 0.054 ng/100 microL; 95% confidence interval [CI] 0.048 to 0.059) through day 7 (median 0.020 ng/100 microL; mean difference 0.020 ng/100 microL; 95% CI 0.013 to 0.027). Aspirates were positive for venom recovery on day 1 (median 0.275 ng/100 microL; mean difference 0.231 ng/100 microL; 95% CI 0.192 to 0.271) through day 7 (median 0.0 ng/100 microL; mean difference 0.032 ng/100 microL; 95% CI -0.18 to 0.078). The highest venom yield was from the biopsy specimens (median 1.75 ng/100 microL; mean difference 0.041 ng/100 microL; 95% CI 0.033 to 0.027). Venom was undetectable in all serum samples. CONCLUSION: Loxosceles species venom is detectable in hair, aspirate, and dermal biopsy specimens at least 7 days after venom inoculation and undetectable in serum by using the rabbit model.

A new assay for the detection of Loxosceles species (brown recluse) spider venom.

STUDY OBJECTIVE: Dermal lesions from unrelated arthropod species and medical causes appear similar to Loxosceles species (brown recluse spider) bites. This may result in delayed diagnosis and treatment. We developed a sensitive Loxosceles species venom enzyme-linked immunosorbent assay (ELISA) and characterized the specificity of the assay by evaluating antigenic cross-reactivity from a variety of North American arthropod venoms. METHODS: North American arthropod (14 spiders, 2 scorpions, and 1 bee) venoms were studied. Three venom amounts (diluted in 100 microL of ELISA buffer) were assayed: 16,000 ng, 2,000 ng, and 40 ng. The latter quantity was selected because this is the observed maximum amount of venom we detect when inoculating dermis with amounts likely to be deposited by a spider bite. The larger venom amounts are overwhelming quantities designed to test the limits of the assay for arthropod venom cross-reactivity. Similar amounts of Loxosceles species venom and bovine albumin served as positive and negative controls, respectively. RESULTS: At the lowest amount of venom tested (40 ng), the ELISA detected only the Loxosceles species positive control. When 2,000 ng was assayed, only Scytodes fusca and Kukulcania hibernalis arachnid venoms (in addition to Loxosceles species) cross-reacted to the assay. Finally, at 16,000 ng, the ELISA assay modestly detected Diguetia canities, Heteropoda venatoria, Tegenaria agrestis, Plectreurys tristes, Dolomedes tenebrosus, and Hadrurus arizonensis arachnid venoms. CONCLUSION: Cross-reactivity was observed in 8 of 17 North American arthropod venoms when large venom amounts were assayed with a Loxosceles species ELISA. By using a relevant quantity of venom, 40 ng, the assay was specific for Loxosceles species venom. The venom specificity of the ELISA may allow clinical application in Loxosceles species endemic regions of North America.