Category Archives: 2019 EMage Winners

1st Place EMage Winner: Helluva Uvula

Evan Laveman, M.D. ; Kelly Kelley, MSN, RN, ; Christopher Redgate, MD, MS,

Pediatric Emergency Department, Department of Emergency Medicine, Harbor-UCLA

Case Presentation: Helluva Uvula

A 16-year-old male with no past medical history presented to the Pediatric Emergency Department (PED) for 4 months of nasal congestion worsening over the past month. He immigrated from Honduras with his father 20 days ago and over this time noticed a decreased ability to breath through his nose. Most troubling, he started to develop foul smelling nasal discharge mainly through his left nare. His only medical contact had been at a U.S. clinic when he first arrived where he was prescribed a nasal spray and cetirizine with no relief. He felt moderate sinus pressure but denied weight loss, fevers, chills, headache or vision changes. read more

2nd Place EMage Winner-Bronchial Atresia in an 18‐Month‐Old

Tanya Dall, MD; Tyler Ayalin, MD
Dr. Dall UCI/CHOC ‐ Children’s Hospital of Orange County; Dr. Ayalin ‐ CHOC

An 18-month-old male with no previous medical history presented to the pediatric ED during the summer for 4 months of cough. The parents described the cough as intermittent, lasting weeks at a time, before resolving and then recurring. The cough was associated with intermittent shortness of breath. He had been seen several times in the ED and by his pediatrician and was pending an outpatient ENT workup for intermittent stridor. His parents brought him to the ED because of a choking episode with perioral cyanosis while feeding. The initial CXR below demonstrated a distinct right upper lobe hyperlucency. Working diagnoses included asthma, airway obstruction, and foreign body. Bilateral decubitus xrays were performed, suggesting air trapping. A CT chest was performed that raised concern for bronchial atresia of the right upper lobe. read more

3rd Place EMage Winner-Bruising after a Viral Illness

Laura A Scieszka, MD  and Tricia Swan, MD

University of Florida College of Medicine, Department of Pediatric Emergency Medicine, Gainesville, Florida

Case

A 6-year-old, unvaccinated, female presented to our pediatric emergency department with 2 days of unexplained bruising, left ankle pain and swelling, and intermittent gingival bleeding following a recent illness of vomiting and non-bloody diarrhea which had resolved 2 days prior to presentation.  Her associated symptoms included mild periumbilical abdominal pain and reported abdominal distension. Her parent denied any recent trauma, travel, medication use, ingestions, fevers, or jaundice.  The patient had no contributory family history. Physical exam findings were significant for dried blood in her mouth, around her teeth, and on her lips; tenderness to palpation of the dorsal aspect of her left ankle with mild swelling; and multiple large ecchymosis to her bilateral lower extremities, right flank and right shoulder. Her workup included a left ankle CT, abdominal ultrasound with Doppler, hepatitis panel, and Epstein Barr Virus, all of which were negative. Her remarkable lab results were prolonged aPTT >150, prothrombin 46.7, and INR 3.8. During her inpatient stay, she had decreased activity of factors 2 (thrombin), 7, 8, and 9. Mixing studies did not correct the patient’s bleeding time, which indicated the presence of an anticoagulant. Her diluted Russell viper venom (DRVV) test was positive, which is consistent with lupus anticoagulant (LA) antiphospholipid antibody syndrome (APS). read more