A Case Report of Delayed Presentation of a Carotid-Jugular Fistula Caused by Blunt Injury from an Arrow.

BACKGROUND: Acquired arteriovenous fistulas (AVFs) are most commonly caused by direct arterial trauma, with 90% of traumatic AVFs due to penetrating trauma. Post-traumatic common carotid artery-internal jugular vein fistulae are rare, with an incidence of 4% to 7% of all traumatic AVFs. CASE REPORT: We present a case of delayed presentation of a patient with shortness of breath, neck pain, and worsening right upper extremity paresthesias 10 days after a blunt injury to the neck by an arrow. He was subsequently found to have a common carotid artery-internal jugular vein fistula and a common carotid pseudoaneurysm on computed tomography angiography. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Post-traumatic common carotid-jugular AVFs are uncommon, especially in patients with delayed presentations and a blunt injury mechanism. If left untreated, AVFs may progress to high-output cardiac failure, atrial fibrillation, and embolization. Clinicians must be aware of this finding, given the potential for significant morbidity.

The seemingly innocuous presentation of metastatic pancreatic tail cancer: a case report.

BACKGROUND: Pancreatic cancers of the tail have an especially poor prognosis due to their late detection. An earlier diagnosis depends on a better understanding of the clinical course of the disease; however, much of the current literature focuses on pancreatic head adenocarcinomas owing to their higher incidence. Thus, we add our case report to the current literature of pancreatic tail cancers in the hope of aiding earlier detection. We present an interesting case of a patient who initially presented with innocuous abdominal pain and a single episode of vomiting who was subsequently diagnosed with metastatic pancreatic tail cancer. CASE PRESENTATION: A 56-year-old Hispanic man with a past medical history of alcohol and cocaine abuse was initially evaluated in our clinic after presenting to the emergency department with sudden onset of abdominal pain and one episode of emesis. On further questioning, he stated that he had been experiencing dull, intermittent left back pain for the past 2-3 years. Laboratory tests were performed, which showed that the patient had new-onset diabetes, and imaging revealed a pancreatic tail mass with metastases to the liver. Biopsy confirmed the diagnosis of stage IV metastatic pancreatic tail adenocarcinoma. During follow-up 1 month later, the patient reported that he had been largely asymptomatic since his hospital admission; however, his left back pain had increased in severity. He was then started on a FOLFIRINOX chemotherapy regimen (5-fluorouracil/leucovorin, irinotecan, and oxaliplatin). CONCLUSIONS: There are many pitfalls in the diagnosis of pancreatic cancer, especially pancreatic tail cancer due to its vague symptoms. Thus, pancreatic cancer of the tail often presents late with a very poor prognosis. Because there is currently no widespread screening for pancreatic cancer, it is often difficult for practitioners to identify pancreatic tail cancers. Current research suggests that there is a strong association between new-onset diabetes after the age of 50 and pancreatic cancer, and tumors detected at the onset of diabetes are favorable to resection. Pancreatic cancer has also been shown to be associated with certain risk factors, such as smoking, high body mass index, chronic pancreatitis, and a family history of pancreatic cancer. Thus, when patients with presentations similar to our patient's with new-onset diabetes after the age of 50, along with vague symptoms such as back or abdominal pain as well as the presence of risk factors, we suggest that it is beneficial for practitioners to maintain a high index of suspicion for pancreatic cancer.