Search

Background: An association between splenic infarction, high altitude, and different subtypes of sickle cell disease (SCD) has been reported in the literature, particularly sickle cell trait. However, none of these studies reported the possibility of splenic infarction as a presenting feature of sickle cell/beta+ thalassemia. Case Presentation: A 23-year-old male college student presented to the emergency department with dull pain in the left upper quadrant and without any known history of medical illness. The patient was originally from Qatif, the Eastern Province of Saudi Arabia, and was referred to the study hospital with an ultrasound report showing splenic infarction. Upon presentation to the study hospital, the patient still had mild abdominal pain and early satiety. Examination revealed tachycardia (128/minute), upper abdominal tenderness, and splenomegaly approximately 2-3 cm below the left costal margin, with thrombocytosis and high lactate dehydrogenase (LDH) levels. Hemoglobin (HGB) electrophoresis showed hemoglobin A (HbA) 19.3; HbA2 4.9; hemoglobin F 12.9 and hemoglobin S 62.9, confirming a diagnosis of sickle cell/beta+ thalassemia. The patient was started on IV hydration and therapeutic anticoagulation with enoxaparin 60 mg subcutaneously every 12 hours. The patient's symptoms improved. Therefore, the patient was discharged on life-long apixaban (5 mg PO Bid), with close follow-up at the hematology clinic. Conclusion: Splenic infarction could be manifested as an isolated feature in patients with SCD and its subtypes, such as sickle cell beta+ thalassemia. Therefore, physicians should pay careful attention to these complications and consider HGB electrophoresis as a part of the workup.

Background: Crohn's disease is one of the major inflammatory bowel diseases, which is described as a transmural inflammation and may involve any portion of the luminal gastrointestinal tract. the patient with protein- losing enteropathy (PLE) will mainly present with peripheral edema and gastrointestinal symptoms of diarrhea, steatorrhea, abdominal pain, bloating, or flatulence. Case Presentation: A 19-year-old Kuwaiti female, medically and surgically free, presenting with 14 days history of bilateral painless leg swelling progressively worsening, reached to the sacral area, associated with facial puffiness and lower limb numbness. The symptoms started 5 months ago when she started having diarrhea once per day, watery with mucous. She reported epigastric pain radiating to the left upper quadrant. She had a history of multiple vomiting since then, unintentional weight loss was noticed, around 10 kg, and amenorrhea for 4 months with regular cycles prior. She was managed and stabilized and admitted to the medical ward. During the admission, she was investigated and diagnosed. The patient was discharged after 12 days of overall hospital stay as a case of inflammatory bowel disease. Conclusion: Although PLE is rare, it is, therefore, important to recognize that these complications can cause initial atypical symptoms of Crohn's disease before finalizing the diagnosis.

Background: Splenic abscess is a rare disease that can be due to many causes including infections or adnominal trauma and surgery. Complications of splenic abscess are fatal including septic shock which can be defined as sepsis leading to circulatory, cellular, and metabolic abnormalities, and the patient cannot maintain mean arterial pressure. Case Presentation: In this case, we report a 71-year-old male patient known to have diabetes mellitus, dyslipidemia, hypertension, and coronary artery disease. Past surgical history revealed that he underwent exploratory laparotomy and graham patch repair, followed by exploratory laparotomy with gastrojejunostomy. Patient has a history of deep venous thrombosis for 1 month on anticoagulant. He presented to the emergency department because of decreased level of consciousness. The patient appeared obtunded and pale, his blood pressure and oxygen saturation were low. Computed tomography (CT) pulmonary angiogram showed massive bilateral pleural effusion and abdominal CT showed splenic abscess and colosplenic fistula. Conclusion: Because splenic abscess secondary to previous abdominal surgeries is a rare condition, emergency physicians should have a high index of suspicion for such a rare phenomenon if they encounter severe sepsis or septic shock.

Objective: The coronavirus disease (COVID-19) pandemic has disrupted healthcare systems worldwide, resulting in decreased and delayed hospital visits of patients with non-COVID-19-related acute emergencies. We evaluated the impact of the COVID-19 pandemic on the presentation and outcomes of patients with non-COVID-19-related medical and surgical emergencies. Method: All non-COVID-19-related patients hospitalized through emergency departments in three tertiary care hospitals in Saudi Arabia and Bahrain in June and July 2020 were enrolled and categorized into delayed and non-delayed groups (presentation ≥/=24 or

Background: Amphetamines are central nervous system stimulant illicit drugs. It has multiple side effects like hypertension, tachycardia, arrhythmias, psychosis, coronary and peripheral vasospasm, insomnia, tremor, gastrointestinal disturbances, and dependence. Case Presentation: We report a case of a 30-year-old male who was brought to the emergency department unconscious, apneic, cyanosed, and with unrecordable blood pressure. Amphetamine was detected in his toxicology screen. Abdominal computed tomography showed massive pneumoperitoneum and ascites. Conclusion: Amphetamine abuse could have several side effects such as, restlessness, irritability, insomnia, tachypnea, tachycardia, and hypertension. In few cases, patients can have atypical presentation as a direct consequence of ruptured viscus which will hinder the diagnosis and protract delivering the right management.

Introduction In late 2019, a novel coronavirus was identified as the pathogen responsible for a cluster of pneumonia cases in Wuhan, a city in the Hubei Province of China. Elevated cardiac troponin is a marker of myocardial injury, which is commonly seen in hospitalized patients with COVID-19 due to unclear reasons. The frequency of elevated troponin levels in patients with COVID-19 is variable and is reported in up to 7-36% of patients. The troponin level may be associated with the severity of COVID-19, and mild cases of COVID-19 tend to have a normal troponin level. This study aims to determine the frequency of patients with COVID-19 who had elevated troponin levels on presentation to the ED and determine the factors associated with elevated troponin levels. Additionally, the study aims to identify the association of elevated troponin and the outcome of COVID-19. Methodology A retrospective study wherein the factors associated with elevated troponin levels in COVID-19 pneumonia were evaluated. The study was conducted in King Fahd Hospital of the Imam Abdulrahman Bin Faisal University. The Hospital Information System was used to identify all visits to the ED from March 2020 to November 2020 for patients who tested positive for SARS-CoV-2. In addition, a structured data collection form was used to collect data from the electronic health records. The data collection was conducted by emergency medicine physicians who were given a detailed explanation of the purpose of the study and had training and supervision by the principal investigator. Results The study involved 214 patients who presented to the ED and had positive results on the SARS-CoV-2 reverse transcription polymerase chain reaction (RT-PCR) test and had troponin-I levels measured. Patients with elevated troponin levels were more likely to require supplementary oxygen compared with those with normal troponin levels (88.0 vs. 58.5%

The novel Coronavirus disease 2019 (COVID-19) pandemic has resulted in many adverse outcomes and challenges, and a false-positive result is one of them. Despite that this issue has a substantial impact, there is a scarcity in the literature of its prevalence or impact, and more knowledge is needed. This case report will present the case of a 54-years-old female who was misdiagnosed as COVID-19. The misleading COVID-19 diagnosis can result in significant consequences such as delaying surgeries, unnecessary quarantine and treatments, transplant lists omission, and unnecessary sick leaves. Moreover, as seen in our case, it delayed the other investigations and admitted a healthy patient to a COVID-19 isolation ward. Therefore, physicians should consider the possibility of false-positive results and utilize other investigation tools to further diagnose suspicious cases.

We herein report a case involving the development of a bilateral subacute subdural hematoma (SDH) after minor trauma, with only two wounds over the nose and no abnormal clinical and radiological findings at first presentation. A 25-year-old male patient presented to the emergency department (ED) after a minor trauma. X-ray was done on the facial bone to rule out nasal fracture which showed no abnormalities and then he was subsequently discharged. Three weeks later, the patient complained of a headache that persisted for a week, which brought him to the hospital. The initial impression was migraine after the primary healthcare visit, for which MRI was arranged, but as the headache persisted, he went to the ED twice again, and a CT scan was done during his second visit to the ED, which showed bilateral subacute SDH (SASDH).

Perforated viscus is a fatal condition associated with a high mortality rate that necessitating immediate management. In gastric cancer, perforation is a relatively late rare presentation. In this study, we report a case of a 40-year-old male who presented with perforated gastric cancer. In the emergency department (ED), the provisional diagnosis was septic peritonitis and shock. However, upon exploratory laparotomy, pyloric tumor was detected metastasizing to the duodenum, liver, and porta hepatis.

Normal pressure hydrocephalus (NPH) is a rare pathological condition of the brain in which the ventricles are enlarged due to cerebrospinal fluid accumulation and is associated with normal opening pressure on lumbar puncture with a large-volume cerebrospinal fluid (CSF) tap. This results in three classical symptoms: mental impairment, gait disturbance, and urinary or fecal incontinence. We present a case of idiopathic NPH in which a 64-year-old retired man with diabetes was brought to the emergency department after recurrent previous falls. The patient complained of an unsteady gait and presented with the typical triad of NPH which is mental impairment, gait disturbance, and incontinence. The patient was a known diabetic, and his gait was characterized by shuffling, bradykinesia, and mild drifting toward the right side. A head computed tomography scan revealed brain tissue volume loss, with disproportionate dilation of the lateral and third ventricles. A lumbar puncture with a large-volume CSF tapping produced normal opening pressure (18 mmHg); thus, the diagnosis of NPH was made. The patient underwent shunt surgery, and his balance and memory improved significantly after the procedure. Also, no event of fecal incontinence occurred. NPH resembles several neurodegenerative disorders. Due to this, it can be difficult to diagnose. Emergency physicians, as frontline healthcare providers, may encounter such cases.NPH should be considered in patients presenting with an unsteady gait, memory impairment, and urinary or fecal incontinence by taking a detailed history and conducting a physical examination to prevent future complications.

Objective The objective was to evaluate the efficacy and safety of single-dose ketamine infusion in adults with sickle cell disease (SCD) who presented with acute sickle vasoocclusive crisis (VOC). Methods This study was a parallel-group, prospective, randomized, double-blind, pragmatic trial. Participants were randomized to receive a single dose of either ketamine or morphine, infused over 30 min. Primary outcome was mean difference in the numerical pain rating scale (NPRS) score over 2 h. NPRS was recorded every 30 min for a maximum of 180 min and secondary outcomes were cumulative dose of opioids, emergency department (ED) length of stay, hospital admission, change in vital signs, and drug-related side effects. Authors performed the analysis using intention-to-treat principle. Result A total of 278 adults with SCD and who presented with acute sickle VOC participated in this trial. A total of 138 were allocated to the ketamine group. Mean (±standard deviation [SD]) NPRS scores over 2 h were 5.7 (±2.13) and 5.6 (±1.90) in the ketamine and morphine groups. The ketamine group received significantly lower cumulative doses of morphine during their ED stay (mean ± SD = 4.5 ± 4.6 mg) than of the morphine group (mean ± SD = 8.5 ± 7.55 mg). Both groups had similar rates of hospital admission: 6.3% in the ketamine group had drug-related side effects compared to 2.2% in the morphine group. Conclusion Early use of ketamine in adults with VOC resulted in a meaningful reduction in pain scores over a 2-h period and reduced the cumulative morphine dose in the ED with no significant drug-related side effects in the ketamine-treated group.

Background: Glucose-6- phosphate dehydrogenase (G6PD) is an enzyme that plays a vital role in eliminating reactive oxygen species (ROS) which are considered to be toxic to the cells. Deficiency of this enzyme causes hemolysis. This study presents a case of a middle-aged woman with the late onset of G6PD with methemoglobinemia. Case Presentation: A case of 57-year-old female was reported, who was presented to the emergency department with jaundice, dyspnea, dark urine and low oxygen saturation. On further investigation the patient's methemoglobin level reached up to 5.1%. Thus, the patient was diagnosed with the late onset of G6PD with methemoglobinemia. Conclusion: The G6PD deficiency could present late in life especially in areas with mild variants. On rare occasions, it could be present with severe hemolysis associated with methemoglobinemia. In these cases, it is important to find the cause. The use of methylene blue as an antidote is harmful.

Methemoglobinemia is a blood disorder in which there is an elevated level of methemoglobin. In contrast to normal hemoglobin, methemoglobin does not bind to oxygen, which leads to functional anemia. The signs of methemoglobinemia often overlap with other cardiovascular and pulmonary diseases, with cyanosis being the key sign of methemoglobinemia. Emergency physicians may find it challenging to diagnose cyanosis as a result of methemoglobinemia. Our patient is a healthy 28-year-old male, a heavy smoker, who presented to the emergency department with multiple minimum bruises on his body, claiming he was assaulted at work. He appeared cyanotic with an O2 saturation of 82% (normal range is 95-100%) in room air. He also mentioned that his sister complained of a similar presentation of cyanosis but was asymptomatic. All these crucial points strengthened the idea that methemoglobinemia was congenital in this patient. The case was challenging to the emergency physician, and there was significant controversy over whether the patient's hypoxia was a result of the trauma or congenital methemoglobinemia.

Moyamoya disease (MMD) is a rare cerebrovascular occlusion condition characterized by ‎progressive stenosis in the terminal portion of the internal carotid arteries on both sides. The measured incidence of MMD is 0.086 per 100,000 people. MMD has variable ‎neurological manifestations, however, seizure is a significant manifestation of MMD with ‎few reported studies. The combination of sickle cell disease (SCD) and MMD confers a much ‎higher risk of ischemic stroke. In this paper, we describe a 32-year-old female with a known ‎case of SCD taking tramadol for a vaso-occlusive crisis, who was presented to the emergency ‎department by a family member due to a low level of consciousness. Despite ongoing ‎management, the patient developed multiple seizure attacks and intubation was ‎performed. A computed tomography (CT) brain angiogram was performed, and the ‎diagnosis of MMD was made. The patient was shifted to the intensive care unit (ICU) and in spite of the ongoing management in the ICU, the patient died. In this case, we highlight the importance of considering MMD as a ‎differential diagnosis when dealing with an SCD patient who developed refractory status epilepticus.‎.

Thyroid storm is a rare and a life-threatening condition, and serious complications could happen if not diagnosed and managed early. The typical clinical manifestations of hyperthyroidism are exaggerated in thyroid storm, particularly marked pyrexia and tachycardia, and altered mental status as agitation, delirium, or coma. Many precipitating factors contribute to the presentation of thyroid storm, and new recent factors like Epstein-Barr virus (EBV) could play a significant role. Serious and rare complications from the thyroid storm can increase the risk of mortality and morbidity up to 30% as fulminant hepatic failure, which is reported only a handful of times in the literature. Also, congestive heart failure can be part of the multiorgan dysfunction from the presentation, if associated with the thyroid storm. In this report, we present a case of thyroid storm precipitated by EBV and causing fast atrial fibrillation complicated by congestive heart failure and fulminant hepatic failure for 46-year-old Bangladeshi male not known to have any medical illness. He presented to the emergency department with 10-day history of an on and off subjective fever, associated with generalized abdominal pain and vomiting. He developed palpitation at the day of presentation. He was managed, stabilized, intubated, and shifted to the ICU as the patient started to be apneic after the conscious sedation for the cardioversion. During the admission anti-EBV viral capsid antigen IgM antibody was positive. The patient was discharged after five days in ICU and 14 days of overall hospital stay. Although the complication of thyroid storm as fulminant hepatic failure and congestive heart failure are rare, they should be considered in cases with thyroid storm. The pre-existing of EBV as a precipitating factor should always be considered, and more studies in these regards need to be done.

Peptic ulcer is a defect in the mucosal layer of the stomach or duodenum that extends into the deeper layers of their walls. Patients with peptic ulcer disease (PUD) may be asymptomatic or have mild abdominal discomfort. It is one of the common etiologies of perforated viscus resulting in secondary peritonitis, a life-threatening condition that carries high risk for morbidity and mortality especially in those who present late to the hospital or due to unrecognized and misdiagnosed perforation. Early detection of perforation of peptic ulcers should be based on clinical data and imaging techniques. We report a case of a 56-year-old female who presented to our ED with right upper quadrant (RUQ) pain radiating to the right shoulder, alleviated by food, and not aggravated by anything. On examination, the patient was vitally stable, tenderness in the RUQ was appreciated, and Murphy sign was positive. Thus, she was diagnosed with perforation of anterior first part of the duodenum. What makes our case peculiar is the presentation of biliary colic in the setting of perforated peptic ulcer.

Calciphylaxis is a rare but highly fatal vascular calcification disorder with a predilection for patients with end stage renal disease (ESRD). The pathogenesis of calciphylaxis is unknown, however, several risk factors have been identified such as hypercalcemia, hyperphosphatemia, hyperparathyroidism, low serum albumin, and history of warfarin therapy. This article presents a case of calciphylaxis induced by warfarin in a COVID-19 patient.

Malignant pericardial sarcomatoid mesothelioma is a massively rare tumor accounting for 0.8% of all cases of mesothelioma. Superior vena cava syndrome (SVCS) occurs due to a partial obstruction or compression to the superior vena cava, which hinders the blood outflow to the upper body. It can be caused by an intrinsic factor such as thrombosis, or by an extrinsic factor such as tumors. Clinical presentation includes edema of the face and upper limbs, plethora, dyspnea, dysphagia, stridor and cough. we are reporting a case of a 56-year-old female, who is a known case of hypertension on angiotensin-converting enzyme inhibitors (ACEIs). Presented to the emergency department with intermittent facial swelling and dyspnea. Imaging and pathology reports confirmed the diagnosis of intermittent SVCS secondary to pericardial sarcomatoid mesothelioma with pericardial effusion. What makes our case unique is that both the etiology and the presenting complaint are rare entities, as most SVCS cases are continuously symptomatic throughout the disease course, and are usually caused by a lung cancer or lymphoma.

There is a dearth of robust evidence regarding coronavirus disease 2019 (COVID-19)-related coetaneous manifestations, complications and adverse treatment events. Upon review of the literature there are only a few cases reported of acute generalized exanthematous pustulosis (AGEP) in COVID‐19 patients after treatment. Therefore, we are reporting a case of a 34-year-old male not known to have any chronic illness. His severe COVID-19 infection resolved four days prior to presentation to the Emergency Department with pustular rash on erythematous base over his face, neck, upper limbs, anterior and posterior trunk including oral cavity and tounge. The rash started after he took azithromycin, oseltamivir, ribavirin, lopinavir, hydroxychloroquine, prednisolone, ceftriaxone, clindamycin, interferon (IFN) beta, and ceftazidime for COVID-19. Skin punch biopsy was done and he was diagnosed with AGEP but it was still not known if it was related to COVID-19 or a drug-induced condition. Patient was treated with betamethasone valerate 0.1% ointment and lotion, promethazine hydrochloride 25mg tablet, paracetamol 500mg tablet, calcipotriol 50mcg/g and betamethasone 0.5mg/g gel. He discharged the same day to manage at home despite not improving. In the end, we found only a few studies that describe the cutaneous manifestations of COVID-19 infection, which were mainly case reports. We can’t be sure that AGEP is a late and severe complication of COVID-19 infection. However, AGEP could be a rare adverse effect of hydroxychloroquine therapy. Improving the knowledge about a wide range of different signs and symptoms of the disease and its severity in addition to all possible adverse treatment events and complications can improve patient safety, survival rate, and quality of life.