Search

A 74-year-old woman presented with fever, jaw claudication and bilateral temporal pain lasting for 1 week. On examination, the bilateral temporal arteries (TAs) were nodularly swollen, tender and hypopulsatile ([figure 1A][1]). A blood test showed elevated white cell count (9.33×109/L), high

Candida dubliniensis phenotypically mimics Candida albicans in its microbiological features; thus, its clinical characteristics have yet to be fully elucidated. Here we report the case of a 68-year-old Japanese man who developed C. dubliniensis fungemia during treatment for severe coronavirus disease 2019 (COVID-19). The pa-tient was intubated and received a combination of immunosuppressants, including high-dose methylpredniso-lone and two doses of tocilizumab, as well as remdesivir, intravenous heparin, and ceftriaxone. A blood culture on admission day 11 revealed Candida species, which was confirmed as C. dubliniensis by mass spectrometry. An additional sequencing analysis of the 26S rDNA and ITS regions confirmed that the organism was 100% identical to the reference strain of C. dubliniensis (ATCC MYA-646). Considering the simultaneous isolation of C. dubliniensis from a sputum sample, the lower respiratory tract could be an entry point for candidemia. Although treatment with micafungin successfully eradicated the C. dubliniensis fungemia, the patient died of COVID-19 progression. In this case, aggressive immunosuppressive therapy could have caused the C. dubliniensis fungemia. Due to insufficient clinical reports on C. dubliniensis infection based on definitive diagnosis, the whole picture of the cryptic organism is still unknown. Further accumulation of clinical and microbiological data of the pathogen is needed to elucidate their clinical significance.

Objective Several scoring systems have been developed to identify patients who require massive transfusion (MT) after major trauma to improve survival. The primary goal of this study was to investigate the usefulness of enhanced computed tomography attenuation values (CTAVs) of major vessels to determine the need for MT in patients with major blunt trauma. Methods This single-center retrospective cohort study evaluated patients aged 16 years or older who underwent contrast-enhanced computed tomography scan of the torso after major blunt trauma. The CTAVs of six major vessel points in both the arterial and portal venous phases at initial computed tomography examination were assessed and compared between the MT and the no MT group. The capability of enhanced CTAVs to predict the necessity for MT was estimated based on the area under the receiver operating characteristic curve. Results Of the 254 eligible patients, 36 (14%) were in the MT group. Patients in the MT group had significantly higher CTAVs at all sites except the inferior vena cava in both the arterial and portal venous phases than that in the no MT group. The descending aorta in the arterial phase had the highest accuracy for predicting MT, with an AUROC of 0.901 (95% confidence interval, 0.855 to 0.947; P Conclusion Initial elevation of enhanced CTAV of the aorta is a predictor for the need for MT. A higher CTAV of the aorta should alert the trauma surgeon or emergency physician to activate their MT protocol.

Managing acutely agitated or violent patients in the emergency department (ED) represents a significant challenge. Acute agitation as an initial manifestation of neuro-Behcet’s disease (NBD) is an extremely rare clinical entity. A 44-year-old male, who had been complaining about a severe headache and fever for several days, was admitted to our ED due to acutely presented incontinence and agitation. On admission, physical restraint and sedation with sevoflurane and propofol were required for his combative and violent behavior. Cerebrospinal fluid examination revealed increased cell count. Fluid attenuated inversion recovery magnetic resonance imaging showed a high intensity signal in the left parietal lobe and bilateral occipital lobe. As infectious meningoencephalitis was suspected, empirical therapy was immediately started. He recovered uneventfully without neurological defect in seven days. Based on positive human leukocyte antigen B-51 and clinical manifestations, the diagnosis of NBD was made and remitted by steroid therapy. Although acute NBD commonly presents with focal neurological symptoms, psychiatric symptoms could be considered the first manifestation. A focused and thorough examination coupled with appropriate management strategies can assist emergency clinicians safely and effectively manage these patients.

Highlights • Neurofibromatosis type 1 is rarely complicated with an artery aneurysm formation and rupture. • Rupture of artery aneurysms in the neck region can be life-threatening because of upper airway obstruction and hemorrhagic shock. • Endovascular treatment has been shown to be safe and effective in NF-1 patients with artery aneurysm formation and rupture.

Rectus sheath hematoma is an unusual but well-known clinical problem. Our hospital admitted a 54-year-old woman complaining of harsh right-sided hypogastric pain that started while muscle training. Computed tomography of the abdomen and pelvis demonstrated a right rectus sheath hematoma. As the hematoma did not increase, the patient was conservatively treated. Despite increased awareness of rectus sheath hematoma, its early diagnosis and treatment still present a challenge to emergency physicians. Swift acknowledgement of this rare cause of abdominal pain may avoid more intrusive examination, unnecessary hospitalization, and laparotomy. Careful consideration of the patient’s medical history and a high index of suspicion are needed to diagnose this complication.

Highlights • A chest stab wound can have various clinical presentations ranging from no intrathoracic injury to life-threatening, extensive damage to the great vessels. • Early removal of the foreign body is recommended to prevent further damage to the heart. • Emergency physicians should seriously consider psychiatric consultation to prevent repeated suicidal attempts., Introduction Penetrating thoracic traumas have a wide spectrum, ranging from mild traumas to life-threatening injuries. Presentation of case This paper illustrates a 40-year-old male with a penetrating pulmonary artery injury that was successfully treated with emergency surgery. The patient visited local hospital by foot complaining of moving object on his chest and was found that an ice pick was penetrating the man's left chest. An ambulance took the patient to our emergency department. Computed tomography of the chest showed linear metallic density in the pulmonary trunk and a small amount of pericardial fluid. Emergency surgery for removal of the object and repair of the pulmonary artery was performed. The ice pick had been stuck in the main pulmonary artery through the pericardium without any injury to the left lung or internal thoracic artery. Postoperative course was uneventful. Discussion A multidisciplinary team designed our treatment strategy, enabling us to select the optimal treatment, including diagnostic techniques and surgical approach. A successful trauma management depends on whether a life-threatening conditionexists. Major vascular injury should be rapidly assessed in these cases. Psychiatric aspects of the case are also discussed. Conclusion Early removal of the foreign body is recommended to prevent further damage to the heart.