Category Archives: EMages Winners

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

3rd Place EMage Winner-Ventriculitis and Pronounced Hydrocephalus from Neisseria meningitidis

Charles Hwang, MD and Carolyn Holland, MD, MEd

UF Health

Department of Emergency Medicine

A previously healthy, unvaccinated 10-month-old boy presented to the emergency department with a 3-day history of fatigue and somnolence.  Examination revealed an obtunded infant with sluggish pupils, bulging anterior fontanelle, bradycardia, hypertension, and extensor posturing with no purposeful movement.  His workup revealed a white blood cell count of 50.6 x 103 mm-3, bandemia of 8%, and hyponatremia of 119 mmol L-1.  A computed tomographic (CT) scan (Figure 1) of his brain showed hydrocephalus with fluid levels in bilateral ventricles with debris within the cerebrospinal fluid (CSF).  He was started on broad-spectrum antibiotics, and an external ventricular drain was placed.  CSF studies demonstrated WBC 905 mm-3, RBC 21 mm-3, glucose < 2 mg dL-1, protein 302 mg dL-1.  CSF culture confirmed Neisseria meningitidis.  Magnetic resonance imaging (MRI) (Figure 2) of the brain showed severe, diffuse meningitis and ventriculitis with purulent accumulation in the ventricles, sulci, and cisterna magni. read more

2nd Place EMage Winner-Increased Head Size

Susan Chigorom MD; Robert Barricella, MD; Maria Theresa Alvarez‐Ballway, MD; Diane Sin Quee, MD

Department of Pediatrics, Rutgers New Jersey Medical School

Luigi Bassani, MD

Department of Neurosurgery, Rutgers New Jersey Medical School

Case Presentation

3 month old female born via normal spontaneous vaginal delivery at term with 1 week NICU stay for indirect hyperbilirubinemia presents to the emergency department for increasing head size for 2 weeks. Prior to this patient has been active and playful with no change in behavior, except for a 2 day fever 1 week prior to presentation which resolved. Patient had prior nasal congestion which mother attributed to common cold. Mother denied recurrent or chronic sinusitis or infections. Patient initially presented to her pediatrician who started monitoring head circumference and subsequently referred to the Emergency department for further evaluation. Prenatal history was negative for fever, infection or sexually transmitted diseases. read more

1st Place EMage Winner: Her Skin is Cracking

Mary Claiborne, MD; Shilpa Dass, MD; Robert M Lapus, MD; Samuel J Prater, MD

Department of Emergency Medicine, McGovern Medical School at UTHealth, Houston, Texas

Children’s Memorial Hermann Hospital

Case Presentation:

An 11 year old African American female with trisomy 21, corrected congenital heart defect, and atopic dermatitis presented with generalized pruritus and scaliness for 2-3 days. Mom has been putting petroleum jelly on the lesions, however because of the worsening appearance, she presented to the emergency department. read more

3rd Place EMage Winner-The Tall Tongue

Christopher Redgate, MD, MS

Kelly Kelley, MSN, RN, CPNP, CNS

Manpreet Singh, MD, MBE

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

A 13-year-old female patient presented to the emergency department (ED) for left eye pain. A clinician noted prominence in the left side of her tongue (Picture 1). Further history revealed progressive tongue swelling during the prior year along with throat fullness and “discomfort.” At that time, an Otolaryngologist (ENT) stated she had an “enlarged tongue” but subsequent follow-ups were not pursued. Since then, she developed loud snoring with no voice changes or dysphagia. read more