Anti-N-Methyl-D-Aspartate Receptor Encephalitis: A Challenging Diagnosis in the Emergency Department.

Anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis is an underdiagnosed disease that has been described thus far only in case series. Patients, the majority of which are females, develop neuropsychiatric symptoms that can often be misdiagnosed as purely psychiatric illness. Although teratomas are nearly pathognomonic for anti-NMDAR encephalitis, these are less common in children and males. This case illustrates some common features of anti-NMDAR encephalitis and some of the challenges in diagnosis.

Clinical spectrum of previously undiagnosed pediatric cardiac disease.

Previously undiagnosed pediatric cardiac disease represents a clinical challenge for the emergency physician. The clinical presentation of these disorders can mimic other conditions of the respiratory, gastrointestinal and neurologic systems at a time when the need for early identification and treatment is at a premium. A high index of suspicion and superb clinical acumen is required to make a timely diagnosis and initiate optimal care. METHODS: A retrospective chart review using explicit criteria and a structured data collection process was performed on all children presenting with previously undiagnosed cardiac disease over a five and half year period. RESULTS: Thirty-six patients were identified over a five and a half year period representing one patient per 4838 pediatric ED presentations. A diverse set of chief complaints, triage categories, clinical presentations and diagnoses were identified. Undiagnosed congenital lesions, acquired cardiac disease, dysrhythmias and infectious diseases of the heart were represented. The need for surgical intervention (22%) and mortality (6%) was substantial. CONCLUSION: In the aggregate, these conditions occur at an important rate and represent a high risk subset of pediatric patients presenting to the emergency department. Individually, the conditions occur infrequently and 'pattern recognition' may not aid the clinician. Early diagnosis and prompt intervention is important in this population.

Occult Pericardial Tamponade Presenting With Altered Mental Status.

In the pediatric population, cardiac tamponade may present with altered mental status without any clear signs of trauma. Bedside ultrasound is essential to the early diagnosis of this condition. We describe the case of a 5-year-old boy who sustained a potentially fatal, unrecognized trauma to his chest resulting in cardiac tamponade.

Mortality after discharge in clinically stable infants admitted with a first-time apparent life-threatening event.

OBJECTIVE: The objective of this study is to review the mortality after discharge in clinically stable infants admitted with a first apparent life-threatening event. DESIGN: Retrospective chart review of all infants 0 to 6 months presenting with a first apparent life-threatening event (ALTE) over a 5-year period using explicit criteria. Patients with an emergency department (ED) diagnosis of ALTE, seizure, choking spell, or cyanosis were reviewed by 2 of 3 physicians. Level of agreement between reviewers was monitored. Mortalities were identified by a review of the county death record database and hospital records. RESULTS: Three hundred sixty-six charts were reviewed; 176 cases met inclusion criteria. All apparent life-threatening event (ALTE) cases were admitted; 1 signed out against medical advice. Blood cultures were obtained in 111 patients (63%)-no pathogens were identified. Cerebrospinal fluid analysis and culture was performed in 65 patients (37%)-no pathogens were identified. One patient had pleocytosis. Chest radiographs were obtained in 115 patients (65%); 12 patients had infiltrates. Respiratory syncytial virus nasal washings were obtained in 32% of patients and were positive in 9 patients. The average length of follow-up was 34 months; 2 patients (1.1%) had died at the time of follow-up. Both deaths occurred after hospital discharge and within 2 weeks of the ED visit. Neither of the fatalities had a positive diagnostic evaluation in the ED. The cause of death by coroner report was pneumonia in both instances. CONCLUSIONS: The risk of subsequent mortality in infants admitted from our pediatric ED with an ALTE is substantial. Emergency physicians should consider routine admission for patients with ALTE.

Clinical spectrum of shock in the pediatric emergency department.

OBJECTIVE: The objective of this study was to describe the clinical spectrum of patients presenting with shock or developing shock in a pediatric emergency department (ED) during an 8-year period. METHODS: An observational study of all pediatric ED patients with shock between September 1998 and September 2006 was performed. Trauma activations were excluded. A structured, explicit chart review using a standardized abstraction form and case definition was completed by 3 physicians board certified in pediatric emergency medicine. Interrater reliability was monitored. RESULTS: A total of 147 cases of shock were identified. Septic shock was the underlying physiology in 57% of cases. A pathogen was identified in 45% of these cases. Hypovolemic shock due to gastroenteritis, metabolic disease, surgical emergencies, or hemorrhage was the cause in 24% of cases. Distributive shock represented 14% of cases. Cardiogenic shock contributed to 5% of cases. Patients with septic shock received a mean of 58 mL/kg of crystalloid or colloid versus 50 mL/kg in patients with other causes. Intubation and vasopressor use was required in 41% and 21% of cases, respectively. Clinical signs of shock developed in the ED after initially presenting without clinical signs of shock in 14% of study subjects. Nearly half of these episodes occurred after the administration of antimicrobials or performance of a lumbar puncture. Mortality was 6% overall and 5% in septic shock patients. CONCLUSIONS: Pediatric ED patients with shock represent a diverse population with substantial mortality. Of 147 patients, 21 presented without clinical signs of shock and deteriorated to a clinical condition meeting the definition of shock during the ED course.

An alternate light source to detect semen.

UNLABELLED: The Wood's lamp (WL) has been used in sexual assault evaluations. Recent data have shown that semen does not fluoresce with a WL and that physicians are unable to differentiate semen from other common medicaments using a WL. OBJECTIVES: To determine whether physicians could differentiate semen from other products using an alternate light source (ALS), and to investigate whether a brief training period with the ALS would enhance physicians' ability to differentiate between semen and other commonly used products. METHODS: An ALS, Bluemaxx BM500, was found to cause semen to fluoresce. Physicians were first asked to use this ALS to identify semen and then to distinguish between a semen sample and other products. Physicians then received a training class on the use of the ALS and were then asked to differentiate semen from other products. RESULTS: All physicians identified the semen as fluorescing and 25% successfully differentiated the semen from the other products using the ALS. Products most commonly mistaken for semen were a hand cream, Castille soap, and bacitracin. After the training session, 83% of the physicians successfully differentiated the semen from other products. The ALS, while not specific for semen identification, was 100% sensitive for it. CONCLUSIONS: Physicians instructed in the use of an alternate light source (BM 500) are able to identify semen as fluorescing and can differentiate semen (after a training session) from other commonly used products.