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Mucogingival deformities around implants are frequent findings in clinical practice and often present as inadequate keratinized tissue and insufficient mucosal thickness. Phenotype modification therapy can increase peri-implant mucosal thickness and the amount of keratinized mucosa, improving the long-term clinical outcomes of implants. The free gingival graft (FGG) is considered the gold standard to increase keratinized mucosa; however, FGGs on the lingual aspects of implants are less predictable due to technique sensitivity and often present with insufficient gains in tissue thickness due to a limited blood supply. The semilunar lingualized apically positioned flap (SLAP) with subperiosteal tunnel connective tissue graft (CTG) can increase both peri-implant mucosal thickness and keratinized mucosal width circumferentially. SLAP consists of one full-thickness, semilunar incision within the keratinized mucosa and buccal to the implant, as well as two vertical releasing incisions mesial and distal to the implant, extending lingually into the alveolar mucosa. The tissue is apically positioned lingual to the implant and sutured in place, creating buccal space for a CTG via buccal subperiosteal tunneling. SLAP is a minimally invasive and predictable approach for improving the peri-implant mucosal phenotype. This case report demonstrates gains in peri-implant mucosal thickness and the amount of keratinized mucosa over a 10-month period utilizing SLAP with subepithelial CTG. [ABSTRACT FROM AUTHOR]

The reconstruction of alveolar ridge defects can be challenging, especially when the lesion is large, noncontained, and located in the esthetic region. The present report describes the guided bone regeneration (GBR) procedure and prosthetic rehabilitation of a severe perforation defect in the anterior maxilla. Clinical and radiographic evaluations of the lesion indicated an endodonticperiodontal origin, and biopsy results confirmed the absence of malignancy. GBR was performed with the use of cortical mineralized freeze-dried bone allograft (FDBA) combined with recombinant human platelet-derived growth factor-BB (rhPDGF-BB) and a resorbable collagen membrane without the use of tenting or fixation screws. Six months after GBR, CBCT revealed adequate bone fill for the placement of 4.1 × 10-mm or 4.1 × 12-mm dental implants. The implant surgery was fully guided with a two-stage approach. After 10 months of healing, the implants were loaded with a screw-retained porcelain partial denture. The staged GBR approach, using a combination of FDBA, rhPDGF-BB, and a resorbable membrane without the use of tenting or fixation screws, resulted in significant bone fill, successful implant placement, and a functional and esthetic implant-supported prosthesis. [ABSTRACT FROM AUTHOR]

Dental implants are commonly used to replace missing single teeth. However, esthetic rehabilitation of an adjacent tooth may also be required due to diastemas, crowding, or existing large direct restorations to improve the final esthetic outcome. With the advancements in ceramics and bonding techniques, minimally invasive esthetic approaches have become viable for compromised spacing issues. This case report describes a dental technique for the esthetic rehabilitation of compromised anterior spacing with a customized zirconia implant abutment at a maxillary central incisor site and a partial ceramic veneer bonded to the adjacent central incisor. [ABSTRACT FROM AUTHOR]

Introduction: Fahr’s disease and Fahr’s syndrome represent clinical entities that result in diffuse intracranial brain calcification, either by way of genetic mutation in the case of the former or by secondary endocrine dysfunction in the latter.Case Report: We present a case of a middle-aged male with undiagnosed Fahr’s syndrome, identified during evaluation for symptoms of an acute posterior circulation cerebrovascular accident.Conclusion: Fahr’s syndrome is a clinical constellation of symptoms and radiographic findings often seen in late-stage hypoparathyroidism. The intracranial calcifications associated may be related to an increased risk for intracranial cerebrovascular disorders such as ischemic or hemorrhagic infarct.Keywords: Fahr’s syndrome; case report; posterior circulation stroke; cerebellar infarct.

Introduction: More than 40% of Americans are considered obese, resulting in annual healthcare costs estimated at $173 billion.1,2 Various interventions exist to address obesity including lifestyle modification, medications, and several surgical options. A novel ingestible intragastric balloon that self-deflates and is excreted approximately four months post-ingestion is being used in other countries such as Australia, Mexico, and several European countries. Currently, however, there are no US Food and Drug Administration-approved, commercially available options like this in the United States.Case Report: We present a case of a 31-year-old, obese male who presented to the emergency department for abdominal pain approximately 10 weeks after the ingestion of an inflatable balloon for weight loss treatment in Mexico. He was found to have a gastric perforation and required an emergent exploratory laparotomy.Conclusion: While ingestible, weight-loss balloons are not yet commercially available in the United States, emergency physicians may still encounter complications of such devices.

Introduction: Wernicke encephalopathy is a clinical diagnosis that requires a high degree of clinical suspicion to recognize. We report a case of a pregnant patient developing Wernicke encephalopathy in the setting of severe hyperemesis gravidarum. Case Report: The patient was a 22-year-old female 13 weeks pregnant presenting to the emergency department (ED) with neurological deficits after several weeks of hyperemesis gravidarum requiring hospitalization. Exam and workup ultimately revealed the diagnosis of Wernicke encephalopathy. Her symptoms improved after administration of thiamine. Conclusion: Wernicke encephalopathy is a consequence of thiamine deficiency, commonly seen in patients with alcohol use disorder but also with other causes of nutritional deficiency, such as hyperemesis gravidarum. Wernicke encephalopathy is a clinical diagnosis that requires a high degree of suspicion and is, therefore, often missed in the ED setting. Treatment is supplemental thiamine and management of the root cause for nutritional deficiency.

Introduction: Although myocardial injury is common after blunt chest trauma, tricuspid valve injury associated with traumatic atrial septal defect resulting in acute hypoxia is an infrequent event. We report an unusual case of blunt chest trauma referred to us for unexplained hypoxemia, emphasizing the unusual nature of injury and the importance of comprehensive cardiac evaluation in such cases.   Case Report: A 35-year-old male presented to the emergency department after falling from a tree from an approximate height of 15 feet. He sustained multiple rib fractures and a left hemopneumothorax. Examination revealed decreased air entry over the left hemithorax and a systolic murmur over the left sternal border. Electrocardiography showed a junctional rhythm, and troponin levels were significantly elevated. Despite tube thoracostomy, the patient remained hypoxemic. Cardiology evaluation revealed a flail tricuspid valve with severe regurgitation and a traumatic atrial septal defect (ASD). Bidirectional shunting across the atrial septal defect was causing hypoxemia. The patient underwent surgical repair of the ASD and tricuspid valve, which resulted in a successful outcome.   Conclusion: Our case highlights the need for comprehensive cardiac evaluation in such patients. In addition to sonography for trauma, point-of-care echocardiographic examination should be a part of the focused assessment.

Introduction: One of the less common and more life-threatening etiologies of adrenal insufficiency is immune checkpoint inhibitor (ICI)-induced primary adrenal insufficiency (PAI). Patients typically present with fatigue, malaise, and nausea and are treated empirically with hydrocortisone.  Case Report: We present the case of a 59-year-old female who presented with hypotension, which initially was thought to be due to hypovolemia or medication-related, but was ultimately found to have PAI. Conclusion: This case highlights the importance of early detection of ICI-induced primary adrenal insufficiency, given its associated morbidity and mortality and its incidence in patients with a history of immunotherapy.

Introduction: Patients living with dementia as well as patients with neurological deficits are at significant risk for injury from multiple sources. Injuries may include falls, neglect, and, in some cases, self-injury. These patients require significant observation and closely monitored care. Case Report: A 90-year-old man presented to a suburban emergency department (ED) by his family, who cared for him at home. The following case report describes a patient with dementia, hemineglect, and bruxism from a previous stroke who suffered a self-induced, partial amputation of his own thumb on the neglected side of his body.   Conclusion: Patients with dementia and neurologic deficits present frequently in the ED. These patients are at considerable risk of self-injury. The emergency physician should maintain vigilance in both screening for injuries and being aware of these risks when planning living arrangements after disposition from the ED.

Introduction: Point-of-care ultrasound (POCUS) is a screening and diagnostic modality frequently used in the emergency department to assess patients with abdominal pain.Case Report: We present a case describing the unusual finding of intraperitoneal fluid with loculations visualized in the right upper quadrant of the abdomen in a patient ultimately diagnosed with pelvic inflammatory disease (PID) with ruptured tubo-ovarian abscess caused by group A streptococcus (GAS), a pathogen rarely implicated in the disease.Conclusion: Uncommon findings on abdominal POCUS should trigger further investigation. In a patient not responding to antibiotics administered for typical PID coverage, GAS should be considered as a possible etiology and a penicillin-based antibiotic administered to prevent progression to tubo-ovarianabscess formation, peritonitis, and sepsis.

BACKGROUND: Catecholaminergic polymorphic ventricular tachycardia (CPVT) is a primary arrhythmia disorder characterized by syncope or sudden cardiac death and typically caused by a gain-of-function of the Ryanodine Receptor Type 2 (RyR2) mutation. Calmodulin is a calcium-binding protein responsible for many intracellular signalling pathways and disruptions in function or regulation may lead to potentially fatal arrhythmias. We present a case of a young patient with CPVT found to have an unusual, potentially causative, Calmodulin 2-a protein coding gene (CALM2) mutation. CASE SUMMARY: A 21-year-old female with autism was brought to the ED following cardiac arrest. Bidirectional ventricular tachycardia was captured on electrocardiogram. Propranolol was initiated, and patient had no further episodes of ventricular arrhythmia. A subcutaneous implantable cardioverter defibrillator (ICD) was implanted, and further genetics testing was done. Rapid Whole Genome Sequencing (PGnome®-RAPID) resulted heterozygous variant of uncertain significance in CALM2 gene NM_001743.5 for variant c.136G>A. DISCUSSION: To the authors knowledge, this is the third known record of such mutation in accordance with the International Calmodulin Registry (n = 74). Identification of CALM mutations can help advance the understanding of genetic underpinnings of arrhythmias and underscore necessity of genetic screening and personalized treatment strategies. Subcutaneous ICDs offer a promising therapeutic option while minimizing risks associated with traditional transvenous ICDs.

Introduction: A tension empyema, in which purulent material accumulates in the chest cavity and leads to cardiopulmonary dysfunction, is a rare complication of empyemas. Moreover, fungal empyemas that grow Candida albicans and cause tension physiology have not yet been previously described.Case Report: In this report, we present an immunocompetent 30-year-old male who presented to the emergency department with worsening shortness of breath and was found to have a left-sided fungal empyema causing tension physiology. Left chest thoracostomy yielded approximately 4 liters of purulent fluid. Pleural cultures eventually grew C albicans, and after antifungal therapy, surgical decortication of the lung, and a prolonged intensive care unit stay, the patient was discharged home in stable condition.Conclusion: While mortality from C albicans empyemas that cause respiratory compromise is exceedingly high, our case highlights that aggressive management with rapid chest thoracostomy and antifungal therapy can lead to a favorable outcome.

Introduction: Medical and nonmedical ketamine use is increasing in the United States. This will likely lead to an increase in emergency department (ED) visits in individuals experiencing associated side effects. Physicians will need to be able to effectively recognize and manage ketamine-related complications.Case Report: A 31-year-old male with a three-year history of inhalational, intramuscular, and intravenous nonmedical ketamine use presented to the ED twice within a week with symptoms of severe atraumatic back pain, abdominal pain, and dyspepsia. A comprehensive workup, including advanced imaging, was unrevealing for identifiable causes, and the patient was discharged with instructions for primary care follow-up for further evaluation. The patient used information shared on Reddit, an online forum and social network, to identify that the cause of his pain was related to chronic ketamine use. Subsequently, upon discontinuation of ketamine, the pain improved in 24 hours. The patient self-navigated to addiction treatment.Conclusion: Emergency physicians should consider sequelae of chronic ketamine use as a possible cause for gastrointestinal and urologic symptoms in the ED. In addition to thorough examination and assessment for other acute medical problems, patients should be offered education, symptomatic treatment, and linkage to harm reduction and substance use disorder treatment services.

Introduction: Rectus sheath blocks have been used for decades in the operating room for analgesia following umbilical surgical procedures. We present the first reported case series of a rectus sheath block used in the emergency department (ED) for the reduction of an umbilical hernia.Case Series: Four patients presented to the ED for painful, non-reducible umbilical hernias. An ultrasound-guided bilateral rectus sheath block was used in all four patients with complete pain relief and an easy hernia reduction.Conclusion: Rectus sheath blocks are an excellent addition to a multimodal analgesic regimen in periumbilical pain and painful procedures. This block is easy to perform and implement for pain control in umbilical hernias in an ED setting.

Introduction: Metallic luster dusts are decorative agents for cakes and other confections. While some powders are labeled “non-edible,” they are also marketed as “non-toxic.” We present a case of a child who developed acute metal pneumonitis after accidental aspiration of metallic luster dust. Case Report: A four-year-old presented to the emergency department (ED) in respiratorydistress after attempting to ingest gold decorative metallic luster dust. In the ED she was placed on supplemental oxygen. Her initial chest radiograph (CXR) was unremarkable. Her condition worsened despite high-flow nasal cannula oxygen, and she was intubated. A repeat CXR revealed patchy perihilar and peribronchial opacities. While receiving aggressive ventilatory support, her CXR worsened over the next 48 hours as bilateral interstitial and alveolar opacities progressed, likely representing acute metal pneumonitis with acute respiratory distress syndrome (ARDS). She remained intubated until hospital day (HD) 5, requiring supplemental oxygen until HD 9. She was discharged home on HD 10. A CXR obtained four months later demonstrated increased interstitial markings throughout both lungs with overinflation and subsegmental atelectasis. The patient had persistent dyspnea upon exertion, with pulmonology documenting that her symptoms were likely sequelae from inhalation of the cake luster dust. Conclusion: Non-edible metallic cake dusts are toxic. “Non-edible” labeling does not convey the health risks associated with handling by children, as evidenced by this case of metal pneumonitis with associated ARDS and chronic pulmonary disease. Accordingly, this descriptor should be abandoned for these products, and physicians should be aware of this potential complication.

INTRODUCTION: Testosterone replacement therapy (TRT) can improve quality of life for men with hypogonadism. However, it is generally avoided in patients with a history of prostate cancer or breast cancer as there is uncertainty about risks. This case illustrates an example of synchronous metastatic prostate cancer and male breast cancer following TRT. PRESENTATION OF CASE: A 72-year-old man with previously treated intermediate-risk prostate adenocarcinoma experienced a gradual rise in prostate-specific antigen (PSA) while self-administering testosterone replacement. He was later found to have recurrent metastatic prostate cancer and prior to initiating androgen deprivation therapy (ADT), he was also diagnosed with male breast cancer. His treatment has consisted of continued ADT for metastatic castration-sensitive prostate cancer (mCSPC) as well as surgical resection of his breast cancer. DISCUSSION: ADT plays a role in treatment of male breast cancer and prostate cancer. TRT remains relatively contraindicated in patients with a history of these malignancies, but the evidence supporting this recommendation is somewhat limited. CONCLUSION: This case highlights the potential risk for synchronous recurrent prostate and new male breast cancer following TRT. Further studies are needed to better elucidate the increased risks of these malignancies with TRT.

Introduction: Tension pyopneumothorax is a rare, life-threatening condition that occurs as a complication of intrathoracic infection or bronchopleural fistula. In the few cases reported in the literature, the patients typically have multiple comorbidities, underlying lung disease, and/or an immunocompromised state.Case Report: This case describes tension pyopneumothorax in a previously healthy adolescent male with no existing risk factors for this disease. After emergent stabilization and admission, surgical exploration of the chest revealed no fistulas or pleural defects. Extensive workup did not show any underlying risk factors for development of this condition.Conclusion: This case of pyopneumothorax with progression to tension physiology is exceedingly rare. Uniquely, the patient had no underlying medical or anatomical predisposition to developing this condition. The case also emphasizes pediatric patients’ capacity to compensate in the setting of critical illness.

Introduction: Carpal tunnel syndrome is an entrapment neuropathy that affects 3% of adults in the United States. The current techniques used for diagnosis have limited specificity/sensitivity, and the techniques used for treatment have limited efficacy.Case Report: A 34-year-old female presented to the emergency department with two months of worsening painful paresthesias in her right thenar eminence. Ultrasound was performed showing a median nerve area of 20.4 square millimeters within the carpal tunnel. Median nerve block was performed within the carpal tunnel causing complete resolution of her pain.Conclusion: Emergency physicians skilled in point-of-care ultrasound and needle-guided procedures can diagnose and treat carpel tunnel syndrome.

Introduction: ST-elevation myocardial infarction (STEMI) can be caused by underlying coronary artery vasospasm (CAV) with or without associated atherosclerotic disease. Coronary artery vasospasm is a rare but potentially devastating manifestation of eosinophilic granulomatosis with polyangiitis (EGPA).Case Report: We describe a 54-year-old male with a known history of EGPA and coronary artery disease presenting to the emergency department with chest pain and an inferior STEMI on electrocardiogram. He was ultimately taken for coronary angiography and found to have a discrete vasospastic lesion in the right coronary artery that was treated with intra-coronary nitroglycerin and calcium channel blockers. He was continued on immunosuppressant agents (prednisone and mepolizumab) for management of EGPA and followed up with outpatient cardiology and rheumatology for vasospastic angina.Conclusion: This case highlights a rare cause of STEMI, discusses the nuances in treatment of STEMI due to CAV, and provides background on pathophysiology and treatment of EGPA.

Introduction: Diagnosing deep venous thromboses and venous thromboemboli (DVT/VTE) in pregnant patients presents a unique challenge for emergency physicians. The risk of DVT/VTE increases during pregnancy, and the potential consequences of misdiagnoses are severe. Point-of-care ultrasonography (POCUS) is frequently a first-line diagnostic imaging modality. However, recent studies have shown a high incidence of thromboses proximal to the common femoral vein during pregnancy, and these would not be visualized using compressive ultrasonography, which traditionally can only visualize thromboses distal to the femoral vein.Case Report: A 38-year-old female, 25-weeks primiparous, presented to the emergency department with a three-day history of left lower extremity swelling. Point-of-care three-point compression testing was used to evaluate for a DVT; however, no thrombus was visualized. Given high clinical suspicion, color and spectral Doppler testing were performed and demonstrated turbulent flow and reduced respiratory variation in the common femoral vein. This prompted further additional testing for a proximal DVT using magnetic resonance venography, which revealed an occlusive left external iliac thrombus. The patient was subsequently started on daily subcutaneous enoxaparin and discharged home with close follow-up.Conclusion: Emergency physicians play a critical role in evaluations for the presence of DVT/VTE, particularly in pregnant patients. We endorse the use of POCUS with three-point compression testing, as well as color and spectral Doppler imaging, to help identify proximal DVTs in this patient population. This case report can aid physicians in the diagnosis of this pathological condition that if left untreated can have severe consequences.

Introduction: Neurogenic pulmonary edema is a rare and potentially life-threatening condition that can present as severe pulmonary edema after significant neurologic insults. This is the first documented instance that shows a plausible causal link between cannabis consumption, psychogenic polydipsia, and the subsequent development of neurogenic pulmonary edema associated with status epilepticus secondary to acute hyponatremia.Case Report: We report a case of a 34-year-old female who presented to the emergency department altered and postictal after a witnessed new-onset seizure. She developed significant respiratory distress that required intubation. Her sodium was 121 millimoles per liter (mmol/L), from 137 mmol/L 36 hours prior on routine outpatient labs. Further history revealed excessive water ingestion after eating a cannabis edible prior to the seizure.Conclusion: This case highlights the importance of recognizing neurogenic pulmonary edema in connection with psychogenic polydipsia, severe hyponatremia, and status epilepticus subsequent to cannabis consumption.

Introduction: The use of telemedicine and ultrasound is emerging and novel in the field of community paramedicine. However, there is a paucity of data supporting its use and even less evidence that shows a morbidity and mortality benefit. This case highlights a unique way to diagnose a common medical emergency, which can lead to a good outcome.Case Report: We describe the use of lung point-of-care ultrasound by a trained community paramedic that led to the identification of a pneumothorax in an 86-year-old male at a scheduled home visit. The images were interpreted over telehealth in real-time by an emergency physician, and the patient was transported to the emergency department where the diagnosis was confirmed by chest radiography. He underwent chest tube placement and was discharged five days later after returning to his baseline.Conclusion: Despite minimal data to support or refute the use of paramedic tele-ultrasound, this case highlights a unique opportunity to expand the use of telemedicine and ultrasound in community paramedicine to improve patient outcomes.

Introduction: Acute hematogenous osteomyelitis may have significant morbidity and mortality if undiagnosed. Because it is uncommon in developed countries and has variable presentations, the patient may undergo several healthcare visits prior to diagnosis.Case Report: We report the case of a 9-year-old male who presented with hip and knee pain with associated fevers and was found to have osteomyelitis and intraosseous abscess in the diaphysis of the right femur. He had multiple emergency department and outpatient visits before the ultimate diagnosis was made. He was treated with irrigation and debridement in addition to intravenous antibiotics.Conclusion: Pediatric acute hematogenous osteomyelitis can have subtle presentations, and this case illustrates some of the difficulties in making the diagnosis. This condition should be considered in the workup of a child with undifferentiated fever, pain, or decrease in mobility.

Introduction: Osteomyelitis can occur at various osseous locations and commonly presents in the emergency department (ED). The incidence of osteomyelitis is 21.8 cases per 100,000 persons annually.1 Hematogenous osteomyelitis typically occurs in the vertebrae; however, it may seldomly occur in the manubrium. Hematogenous osteomyelitis can be seen in patients with complicated thoracic surgery, radiation, fracture, diabetes, immunosuppression, steroid therapy, and malnutrition.2 Because signs and symptoms of osteomyelitis may be nonspecific, clinicians must have high suspicion based on history and physical. Workup should include identifying the source, imaging, and surgical cultures.Case Report: A 60-year-old male with hypertension and diabetes presented with atraumatic right shoulder and chest pain. The patient presented twice to the ED for clavicle pain five days prior. Computed tomography (CT) of the chest detected osseous infection of the manubrium and upper sternum, right clavicle, and mediastinal phlegmon. A CT of the abdomen and pelvis revealed osteomyelitis and discitis of the 12th thoracic and first lumbar vertebral body with gas at the psoas muscle, as well as sigmoid diverticulitis with colovesicular fistula. The patient was started on broad spectrum antibiotics and 1,500 milliliters of lactated Ringer’s in the ED. After evaluation by cardiothoracic surgery, the patient was taken to the operating room for neck exploration, incision/drainage, manubriectomy, and right sternoclavicular joint resection. Surgical, blood, urine, and respiratory cultures grew Klebsiella pneumoniae. After a 34-day hospital course, the patient was discharged on two weeks of oral levofloxacin and follow-up appointments with cardiothoracic surgery and infectious disease. The patient had good prognosis and recovery.Conclusion: Hematogenous osteomyelitis to the manubrium is rare and may present with only chest pain. It is important to consider other sources that seed in the manubrium and imaging to evaluate multisite infection. Treatment should include intravenous antibiotics and/or surgical intervention for debridement with washout or manubriectomy.

Introduction: Recognizing testicular torsion is extremely important in patients presenting to the emergency department (ED) with acute scrotal pain. Traditional manual detorsion techniques are frequently employed by emergency physicians but are not always successful. Delays in detorsion increase the risk of testicular infarction and infertility, and the need for orchiectomy. Novel techniques such as the testicular traction technique have been described as a potential solution for difficult-to-detorse testicles.Case Report: Our case report describes a 20-year-old male with no significant past medical history who presented to a rural ED with acute, atraumatic testicular pain secondary to testicular torsion with an intact cremasteric reflex. After confirming the diagnosis using Doppler ultrasound, manual detorsion using the traditional “open book” technique was attempted and unsuccessful. The patient was subsequently successfully detorsed using the novel testicular traction technique.Conclusion: The testicular traction technique is a safe, rapid, and effective primary or adjunctive technique in manual testicular detorsion. Given the time-sensitive nature of testicular torsions, adjunctive techniques play a crucial role in managing challenging detorsions, particularly in resource-limited rural settings with limited access to urologic services. Although it is commonly thought that the cremasteric reflex is absent in testicular torsions, it may be present in rare circumstances, and its presence should not be an absolute in ruling out torsion.

Introduction: Opioid use is an epidemic that plagues the United States. Patients frequently present to the emergency department (ED) after opioid toxicity, which can lead to respiratory failure, apnea, and death. Although there is an effective antidote, naloxone, the current guidelines surrounding post-naloxone administration monitoring are loosely defined.Case Report: We present a case in which an individual was administered naloxone after an intentional opioid overdose and was monitored for four hours, as is standard in our institution. He remained in the ED for additional workup following this observation period and subsequently experienced signs of severe respiratory depression, requiring bag-valve-mask ventilation, naloxone, and admission. Had he been discharged, as is typical after a four-hour observation period, the consequences could have been fatal. We present multiple theories as to why his opioid toxidrome may have presented in a delayed manner, including ingestion of fentanyl analogues and variability in metabolization of both opioids and naloxone. We also explore alternative overdose antidote products approved by the US Food and Drug Administration, which may impact post overdose care.Conclusion: This case suggests that the correct amount of time to monitor patients after naloxone administration may be longer than originally thought. Our aim in this article was to further the discussion regarding the most appropriate observation period in cases of opioid toxicity.

Introduction: Spontaneous intracranial hypotension (SIH) is an uncommon and frequently misdiagnosed condition characterized by a lower-than-normal volume of cerebrospinal fluid (CSF) caused by leakage of CSF through the dural membrane. The primary manifestation of SIH is an orthostatic headache, which is frequently accompanied by nausea and vomiting. Patients with connective tissue disorders are at increased risk for spontaneous CSF leaks due to the structural weakness of their dural membranes.Case Report: An 18-year-old woman with no reported past medical history presented to the emergency department with 10 days of a bifrontal headache that was orthostatic in nature with associated nausea and vomiting. She was noted to have several marfanoid features on physical examination. Spontaneous intracranial hypotension was ultimately diagnosed and treated successfully with an epidural blood patch. Subsequent genetic testing revealed a diagnosis of Marfan syndrome.Conclusion: Spontaneous intracranial hypotension is an uncommon cause of headache. Individuals with connective tissue disorders such as Marfan syndrome are at increased risk for SIH. Knowledge of the relationship between these two conditions allows for a more rapid diagnosis of SIH.

Introduction: Acute mountain sickness, high-altitude pulmonary edema (HAPE), and high-altitude cerebral edema (HACE) are a spectrum of high-altitude conditions, with HACE being the most life-threatening. Most cases develop at altitudes of greater than 4,000 meters (~13,000 feet) above sea level and after one to five days.Case Report: A previously healthy 46-year-old female presented to the emergency department with ataxia, altered mental status, and vomiting that developed after rapidly ascending to ~2,400 meters (~7,800 feet) above sea level. She was treated for HACE and HAPE with resolution of her symptoms within 24 hours.Conclusion: High-altitude pulmonary edema and HACE can develop rapidly and at moderate altitudes. Expeditious recognition and treatment is imperative to avoid life-threatening complications.

Introduction: Renal artery aneurysm rupture is a rare but morbid diagnosis, often requiring emergency surgery and nephrectomy. Clinical presentation can mimic more common pathology in non-pregnant women such as ruptured ovarian cyst.Case Report: We present a case of a woman with a prior history of ovarian cyst presenting with a ruptured renal artery aneurysm. Prompt computed tomography (CT) imaging revealed a left renal artery aneurysm rupture with hemoperitoneum and renal infarct. She underwent emergency laparotomy and nephrectomy and was ultimately discharged in good condition.Conclusion: While ovarian cyst rupture is the most common cause of spontaneous hemoperitoneum in non-pregnant women of childbearing age, renal artery aneurysm rupture should be considered and prompt CT imaging obtained, particularly in cases of hemodynamic instability, to ensure prompt treatment.

Introduction: Acute confusional migraine (ACM) is a rare variant of migraine that is benign and self-resolving but difficult to diagnose. Without known causative pathophysiology and a lack of recognition in the International Classification of Headache Disorders (ICHD-3), ACM offers a puzzling clinical presentation. There currently is no standardized treatment for ACM, but with a growing anecdotal dataset there is the opportunity to formally recognize and establish protocols to improve patient care and outcomes.Case Report: A 14-year-old female presented to the emergency department (ED) with acute onset of confusion, vision changes, right-sided weakness, and dysarthria one hour prior to arrival. A stroke workup at the initial ED offered no pertinent findings. The patient was transferred to a pediatric specialty ED where all symptoms, aside from numbness and a mild headache, resolved during transfer. After administration of a migraine cocktail at the pediatric specialty ED, all remaining symptoms completely resolved. The patient was discharged home from the ED the same evening with outpatient follow-up.Conclusion: This case presents the difficulty of diagnosing and treating ACM prior to its self-resolution. It highlights the need for formal recognition of the condition by the ICHD-3. In doing so, greater recognition will promote more research, awareness, and establishment of a standardized treatment for ACM.

Objective: The predictability and long-term success of periodontal regeneration begins with oral hygiene education, disease management, and an individually tailored periodontal maintenance protocol. The treatment outcomes could be enhanced when biologics and bone grafts are combined. The aim of this report was to describe the outcome of two complex infrabony defects in the same patient treated with recombinant human platelet-derived growth factor-BB (rhPDGF-BB) and freeze-dried bone allograft (FDBA) over 10 years. Case presentation: Two complex infrabony defects were treated following guided tissue regeneration principles and procedures. Fullthickness flaps were raised to allow visualization of the defects. The areas were debrided, and exposed root surfaces were planed. FDBA and rhPDGF-BB were combined to fill both defects. A collagen membrane was used over the bone graft in one case. The flaps were reapproximated to achieve primary closure. The patient was seen for regular periodontal maintenance visits and clinical and radiographic follow-ups over 10 years. Throughout the examination periods, the probing depths improved without bleeding on probing, and there was radiographic evidence of bone regeneration. Conclusion: The growth factorinfused bone graft was successfully utilized for periodontal regeneration in complex bony defects. [ABSTRACT FROM AUTHOR]

Introduction: Severe metabolic alkaloses are relatively rare but can carry a high mortality rate. Treatment involves supportive care and treatment of underlying causes.Case Report: A 55-year-old male dependent on a gastrojejunostomy tube presented to the emergency department for altered mental status. The patient had metabolic alkalosis, electrolyte abnormalities, and prolonged QT interval on electrocardiogram. Examination and history revealed that chronic drainage of gastric fluid via malfunctioning a gastrojejunostomy tube resulted in profound alkalosis. The patient recovered with supportive care, electrolyte repletion, and gastrojejunostomy tube replacement.Conclusion: This case highlights the importance of gastrointestinal acid-base pathophysiology.

We report the first case of imatinib use in an adolescent with diabetes and suggest that it impacts the natural course of disease. A 14-year-old male patient presented in diabetic ketoacidosis (DKA) and was diagnosed with presumed autoantibody-negative type 1 diabetes (T1D) as well as myeloid neoplasm with platelet-derived growth factor receptor beta (PDGFRB) rearrangement. After starting exogenous insulin and imatinib, he experienced a 1.7-point reduction in glycated hemoglobin (HbA1c) and a 71% reduction in insulin requirement with sustained partial diabetes remission. Our case suggests imatinib as a potential therapeutic agent for pediatric T1D.

Introduction: Ferric derisomaltose is the newest available parenteral iron formulation. Studies have demonstrated a good safety profile with improved tolerability compared to alternative parenteral iron formulations. To date there have been no reported acute, life-threatening cardiac events associated with ferric derisomaltose.Case Report: An 86-year-old male who had previously tolerated routine iron infusions received a first dose of ferric derisomaltose at an outpatient infusion clinic. Six minutes into the infusion the patient became unresponsive with no palpable pulse. Return of spontaneous circulation was achieved after two minutes of chest compressions. Electrocardiogram showed complete heart block requiring transcutaneous pacing and vasopressor administration. The patient was transferred to the emergency department for stabilization and then admitted to the cardiac intensive care unit. During admission, the patient received a dual-chamber, permanent pacemaker without complication and was ultimately discharged.Conclusion: It may be reasonable to consider parenteral iron as a toxicological etiology for patients presenting with complete heart block temporally associated with parenteral iron administration, particularly in patients with underlying conduction abnormalities.

Introduction: Phlegmasia cerulea dolens (PCD) is an uncommon, potentially life-threatening complication of acute deep venous thromboses that requires a timely diagnosis. The name of the condition, the visual diagnostic criteria, and the preponderance of cases in the literature referencing findings exclusively in patients with lighter skin complexions means that PCD may not be on the differential diagnosis for the patient with more melanated skin who is experiencing this time-sensitive vascular emergency.Case Report: We describe one case of PCD in a patient with darker skin complexion and the importance of identifying clinical findings, regardless of skin color, given the paucity of reference images for PCD in darker complected patients. Our literature review yielded 60 case reports for PCD. Only two papers included images referencing patients of color.Conclusion: Accurate diagnosis requires recognition of diagnostic findings, which may vary significantly between phenotypically distinct populations. Many pathognomonic physical exam findings rely on descriptors based on presentation in phenotypically white patients.

Introduction: Spontaneous esophageal rupture, or Boerhaave syndrome, and upside-down stomach are rare pathologies associated with grave sequelae. Boerhaave syndrome can have a mortality rate as high as 44%. Upside-down stomach accounts for less than 5% of hiatal hernias and can lead to incarceration and volvulus.Case Report: An 80-year-old woman presented to the emergency department with sudden onset, severe epigastric pain. Physical examination revealed normal vital signs with mild epigastric tenderness. Imaging obtained revealed a large hiatal hernia and findings concerning for esophageal perforation. The patient was started on 3.375 grams of intravenous piperacillin/tazobactam, and transfer to a tertiary care facility was initiated. After transfer, esophagography confirmed a perforation near the gastroesophageal junction and findings consistent with an upside-down stomach. The patient underwent successful repair of the esophageal perforation and gastropexy followed by intensive care unit admission and ultimately discharge.Conclusion: Boerhaave syndrome and upside-down stomach are two conditions with high associated morbidity and mortality requiring prompt intervention. Information obtained in the history and physical examination including acute onset of chest pain after vomiting, tachypnea, subcutaneous emphysema, and hypoxia can assist in the diagnosis of the described pathologies. These signs and symptoms can be subtle on examination but are important in raising clinical suspicion for an otherwise rare etiology for acute onset chest pain.

Case Presentation: A 22-year-old female presented to the emergency department with a two-month history of worsening fatigue, unintentional weight gain, and progressive facial swelling. Physical examination findings included hirsutism, moon facies, and abdominal striae. Subsequent brain magnetic resonance imaging revealed the presence of a 2.4-centimeter pituitary macroadenoma, confirming the diagnosis of Cushing’s disease. The patient was then admitted for neurosurgical tumor resection.Discussion: Cushing’s disease is exceedingly rare and often presents with symptoms resembling more prevalent disorders, contributing to delays in diagnosis. Therefore, maintaining a high index of suspicion for this disease is crucial for emergency physicians.

Solitary fibrous tumors are rare mesenchymal neoplasms that can range from slow-growing to aggressive tumors. This report presents a unique case of a young male patient with a solitary fibrous tumor involving the seminal vesicle, a rare location, and reinforces incidental discovery of these tumors on imaging and physical exams. Detection of these tumors is imperative to identify and treat malignancy. In our case, a 39-year-old previously healthy Asian male presents to the emergency department as a trauma admission post bicycle crash and is incidentally found to have a pelvic mass on computed tomography imaging of the pelvis. The patient underwent trans-anal biopsy which showed spindle epithelioid cells positive for CD34 and STAT6 markers, with a morphological and immunohistochemical profile consistent with a solitary fibrous tumor. The patient underwent surgery with a robotic-assisted laparoscopic pelvic mass resection and now follows up annually with imaging for observation.

Introduction: Vision loss is a symptom found frequently in patients presenting to the emergency department (ED). Central retinal artery occlusion (CRAO) is an uncommon yet time-sensitive and critical cause of painless vision loss in which delayed diagnosis can lead to significant morbidity. Emergency medicine literature documents the ability to diagnose a CRAO using ultrasound by identifying the hyperechoic thrombus coined the retrobulbar spot sign.Case Report: We present the case of a patient presenting with painless monocular vision loss for which CRAO was diagnosed in the ED using point-of-care ultrasound enhanced by the utilization of serial Doppler examinations as well as calculation of the central retinal artery resistive index.Conclusion: Despite the pre-existing literature on point-of-care ultrasound investigation of central retinal artery occlusion, there are no emergency medicine case reports describing serial examination of the central retinal artery by spectral Doppler or calculation of arterial resistive index to improve this evaluation and monitor progression of the pathology. [2024;7(5)1–5.]

Introduction: Peritonsillar abscesses form between the tonsillar capsule, the superior constrictor, and palatopharyngeus muscles. Physicians traditionally make this diagnosis clinically; however, ultrasound allows clinicians to further identify and differentiate between peritonsillitis, peritonsillar abscess, and phlegmon formation. By increasing both the sensitivity and specificity, ultrasound improves the diagnostic accuracy for patients with peritonsillar abscesses. This case demonstrates the utilization of ultrasound in peritonsillar abscesses and the application of point-of-care ultrasound (POCUS) in identifying complications of procedures used for treatment in the emergency department (ED).Case Report: A 19-year-old male presented to the ED with complaints of severe sore throat and fever for the prior five days. A POCUS using an endocavitary probe with sterile cover demonstrated hypoechoic debris with a “swirl sign.” Ultrasound was used to successfully guide needle aspiration by using in-plane needle guidance. The patient had significant bleeding after needle aspiration, and repeat POCUS clearly identified a new pocket of blood that had formed and was contained in the soft tissue. We monitored the size of the hematoma in real time with ultrasound to ensure the hematoma had no rapid expansion and was stable.Conclusion: Among the differential diagnoses for sore throat, the diagnosis of peritonsillar abscess is particularly concerning as it is both common and generally requires swift intervention. Presentations can range from a mild infection to a life-threatening emergency with potential airway compromise. The two primary avenues for treatment include either needle aspiration or incision and drainage. Ultrasound can successfully identify the abscess and other landmarks for safe and successful drainage, as well as early identification of complications.

Introduction: Visceral arterial aneurysms and pseudoaneurysms are rare but dangerous pathologies, with reported incidence of 0.01–0.2% of the worldwide population, as found on autopsy. Pancreaticoduodenal artery pathology accounts for approximately 2% of all visceral aneurysms; it is commonly caused by chronic inflammatory processes, such as pancreatitis or adjacent pseudocysts. Morbidity and mortality commonly result from rupture of the aneurysm itself, leading to life-threatening hemorrhage into the peritoneum or gastrointestinal tract.Case Report: Here we present the case of a 64-year-old male patient with previous history of alcohol use disorder leading to chronic pancreatitis and prior embolization of an inferior pancreaticoduodenal pseudoaneurysm, who presented to the emergency department (ED) with abdominal pain, nausea, and vomiting, and was found to have a large recurrent inferior pancreaticoduodenal pseudoaneurysm with associated obstructive cholangitis and pancreatitis via contrast-enhanced computed tomography (CT) of the abdomen and pelvis. The patient was managed emergently by interventional radiology angiography with embolic coiling and percutaneous biliary catheter placement, and he subsequently underwent biliary duct stenting with gastroenterology. The patient was successfully discharged after a brief hospitalization after resolution of his pancreatitis and associated hyperbilirubinemia.Conclusion: Pancreaticoduodenal artery aneurysms and pseudoaneurysms are rare and dangerous visceral pathologies. Patients can be diagnosed rapidly in the ED with CT imaging and needurgent endovascular management to prevent morbidity and mortality.

Introduction: The asp caterpillar (Megalopyge opercularis) is endemic to the southeastern United States, with most sightings in Florida, Texas, and Louisiana. A few hundred caterpillar envenomations are reported annually with most cases occurring in July–November. Asp caterpillars have hollow spines along their backs that contain venom. Contact with these spines is what produces the characteristic “sting” resulting in contact dermatitis and a localized hypersensitivity reaction collectively referred to as lepidopterism. Symptoms of lepidopterism may include severe burning pain, pruritis, edema, nausea, vomiting, abdominal pain, and headache. Symptoms are often self limited, and treatment should focus on expedited removal of implanted spines and aggressive symptom management.Case Report: We present the case of a patient presenting to the emergency department (ED) with acute-onset severe left forearm pain with associated pruritic rash incurred while working in a retail store. Initial therapeutic management included administration of analgesics, antihistamines, and steroids. After obtaining a comprehensive history and consulting with the Poison Control Center, we suspected an asp caterpillar envenomation. Following extraction of the caterpillar spines with silk tape, the patient’s symptoms improved. After a period of observation in the ED, the patient was discharged home without any known sequelae.Conclusion: Although asp caterpillars typically inhabit trees and foliage, human exposure to the caterpillar may occur in developed environments. Effective history-taking, prompt communication with toxicologic experts, and complete removal of intact spines are essential for early identification and effective clinical management of asp caterpillar envenomation.

Introduction: Rectus abdominis muscle strains are common and can be debilitating in both professional and amateur athletes who engage in strenuous activity.Case Report: We report a rare case of rectus abdominis muscle tear in an amateur bodybuilder diagnosed by point-of-care ultrasound (POCUS) in the emergency department (ED). The patient had presented to the ED three separate times after strenuous exercise, received costly diagnostic workups, and ultimately was diagnosed on the third visit with grade 2 bilateral rectus abdominis tear. The patient was given appropriate education and sports medicine follow-up. He underwent rehabilitation focused on trunk and core stability. At eight-week follow-up, the patient had made a full recovery.Conclusion: To our knowledge, a case of bilateral rectus abdominis tear diagnosed by ultrasound in the emergency setting has not been previously published. Our case report highlights the utility of POCUS in diagnosing musculoskeletal pathology and preventing costly bounce-back visits.

Introduction: Unlicensed cosmetic procedures, which come at increased risk of infection and potential surgical complications, have introduced new challenges in healthcare. Physicians should be aware of presentations that may arise secondary to these procedures.Case Report: We describe a case in which a previously healthy, 28-year-old female presented with new-onset seizures and acute respiratory distress syndrome (ARDS) in the setting of a recent cosmetic procedure with silicone injections to the gluteal region. The patient’s hospital course was complicated by altered mental status, respiratory failure, rapid hemodynamic compromise, and eventual death.Conclusion: In rare cases, one possible complication of cosmetic procedures is silicone embolism syndrome, which is characterized by pneumonitis, alveolar hemorrhage, and ARDS. The patient described in this report also experienced neurologic symptoms including seizure and altered mental status. This is a clinical diagnosis that relies upon thorough history-taking and detailed physical exam. Documentation on this phenomenon is limited, and medical management has not yet been standardized for this condition. Morbidity and mortality remain high.

Case Presentation: We describe the presentation, evaluation, and management of a young female patient presenting to the emergency department with atraumatic orbital emphysema, a rare condition. This patient was diagnosed using point-of-care ultrasound and computed tomography and was managed expectantly.Discussion: Atraumatic orbital emphysema is a rare clinical condition more common in early middle-aged female patients with certain historical features such as chronic sinusitis, facial surgery or trauma, tobacco smoking, or current upper respiratory symptoms. While most cases will resolve spontaneously, rarely this condition can lead to vision-threatening orbital compartment syndrome, requiring lateral canthotomy or needle decompression.

Introduction: Implantable cardioverter-defibrillator (ICD) lead perforation through the myocardium may result in chest pain and electrocardiogram (ECG) changes concerning for ST-segment elevation myocardial infarction. The clinical context of the ECG aids in appropriate management.Case Report: We report the case of a 71-year-old woman experiencing chest pain after an ICD placement two weeks earlier. On presentation, she exhibited ST-segment elevation on her ECG. Computed tomography confirmed ICD lead migration. The patient’s hemodynamics were normal, and she was discharged home after a five-day hospital stay following a lead revision.Conclusion: Although rare, ICD lead perforation is a potential cause of chest pain and ischemic ECG changes. Emergency physicians should consider lead perforation as a potential differential diagnosis when evaluating chest pain in patients with ICDs, taking into account the potential complications of coronary angiography.

Introduction: Ovarian artery aneurysm is a rare diagnosis, primarily associated with late pregnancy and the postpartum period. It can cause life-threatening hemorrhage when ruptured. Even more rare are ovarian artery aneurysms in postmenopausal women.Case Report: We present a case of a postmenopausal female presenting to the emergency department with flank pain. Point-of-care ultrasound showed free fluid in the abdomen. She was diagnosed with an ovarian artery aneurysm on computed tomography angiography and treated successfully with embolization.Conclusion: Ruptured ovarian artery aneurysm is an uncommon cause of intra-abdominal hemorrhage in women.

Introduction: Severe hypernatremia is a critical situation, and when coupled with intravascular depletion and hypotension can create a treatment dilemma.Case Report: We present the case of a medically complex patient who had gradually worsening alteration of mental status and mean arterial pressures in the 50s on presentation to the emergency department.Conclusion: Final diagnoses included severe hypernatremia and hypovolemic shock secondary to poor oral intake. We used judicious fluid repletion with gradual improvement in sodium levels and permissive hypotension to avoid rapid osmotic shifts. Balancing reperfusion and the risk for osmotic effects of aggressive fluid resuscitation can be a challenging situation for the multidisciplinary team.

A 24-year-old woman, G6P2032, initially presented with a right-sided ruptured tubal ectopic pregnancy. Salpingectomy was performed with care to completely remove the fallopian tube. The patient then presented with ipsilateral interstitial pregnancy 11 weeks later and initially underwent systemic methotrexate injection, which failed to resolve the pregnancy. She then underwent laparoscopic cornuostomy and dilation and curettage. Cornuostomy was performed with injection of dilute vasopressin around the gestational sac to help minimize blood loss, followed by hydrodissection and sharp dissection to remove the pregnancy. Judicial electrocautery was used and the myometrium and serosa were closed in layers. Attention was given to preserve uterine myometrial tissue integrity at the cornua. The patient recovered and was discharged. Her beta-hCG level trended from 11,902 mIU/mL pre-surgery to 7726 on postoperative day 0, and 289 on postoperative day 7. Pathology from the interstitial region showed fragments of chorionic villi, and the dilation and curettage pathology demonstrated decidualized secretory endometrium. Short-interval interstitial ectopic pregnancies after prior salpingectomy for tubal ectopic pregnancy are extremely rare. This case demonstrated successful management with a minimally invasive laparoscopic cornuostomy. This case also displays that ipsilateral interstitial pregnancy can occur after salpingectomy even after care is taken to remove all visible portions of the fallopian tube. Thus, patients should be counseled carefully about the risks of short-interval pregnancy after a recent tubal ectopic pregnancy.

Cognitive impairment in focal cerebellar disorders has been widely recognized and is described as cerebellar cognitive affective syndrome (CCAS). However, the relationship between CCAS and crossed cerebello-cerebral diaschisis (CCD) has rarely been discussed. The present report describes the uncommon phenomenon of CCD in two cases with isolated cerebellar infarction, and discuss its contribution to cognitive impairment. Cognitive performance was examined using the CCAS scale and a battery of neuropsychological assessments. Moreover, the relative distribution of cerebral and cerebellar blood flow was measured using three-dimensional arterial spin labeling imaging. Case 1 showed deficits in general cognition and had impaired language, episodic memory, and executive function. Case 2 showed deficits in general cognition at baseline, and cognitive deterioration of visuospatial abilities, language, episodic memory, and executive function was observed at the 3-month follow-up. Both cases met the diagnosis criteria of CCAS. Reduced cerebral blood flow was observed in the cerebral hemisphere contralateral to the cerebellar infarction at baseline in Case 1, and at the 3-month follow-up in Case 2. The present report describes cognitive decline after isolated cerebellar infarction in combination with contralateral cerebral hypoperfusion, as measured using quantitative arterial spin labeling. One possible mechanism involves the functional depression of cerebello-cerebral pathways.