Category Archives: EMages Winners

Second Place: Generalized Flushing Followed by a Bulla

Patrick McLaughlin, MD, MS

Case Presentation

A three month old male born at 39 weeks gestation, with a history of a possible seizure disorder, presents two hours after a large fluid-filled lesion developed on his left forearm. Immediately before he developed this lesion his entire body became red and flushed for 15 minutes then spontaneously resolved. The fluid-filled lesion shown developed on top of a skin lesion that had previously been present since 1 week of life. At 2 months of age he experienced these exact symptoms for which he was hospitalized overnight at another institution. During that admission, the bulla’s fluid was cultured for bacteria but was negative for growth. He completed a 10 day course of oral clindamycin and topical mupirocin without resolution of the lesion. Family denies any fever, purulence from the lesion, sick contacts, burns, pets or changes in the patient’s behavior. read more

Third Place: Not Just Your Typical Newborn Rash

Matthew Cully, DO

Benjamin F. Jackson, MD

A three-day-old term female infant presented to the emergency department with a two-day history of rash to the back of her right leg. The family noticed the rash shortly after hospital discharge and described the rash first as just a few red spots. However, the following day, the rash spread on her right leg and was now described by the family as multiple red and fluid filled spots. No maternal history of herpes simplex virus (HSV) or varicella at time of delivery. The infant was otherwise well, afebrile with appropriate waking, alertness, a3rd Place Pic 1ppetite, voiding and stooling. On physical examination, she appeared well, active and in no acute distress. A linear, vesicular rash with surrounding erythema extended from right posterior mid shin to upper thigh (Image 1 and 2). Pediatric dermatology was consulted and a full neonatal sepsis evaluation including urine, blood and cerebrospinal fluid (CSF) was performed. read more

2nd place Emage Winner: Subgaleal Hematoma beyond the neonatal period

Deepak Choudhary, MBBS, MRCPCH, MD;  Sarah Dipalma, MD; Jessica Strauss, MD; Mary Emborsky, MD; Frank Carnevale, MD

Department of Pediatric Emergency Medicine, Oishei Children’s Hospital, University of Buffalo, New York

A four-year-old African American female presented to our ED with one day history of bogginess of her scalp. The guardian mentioned there were two unwitnessed falls from a trampoline and bunk bed in the last two days. The family denied behavior changes, headache, neck pain, vomiting, numbness or weakness. No bleeding problems were reported by the child or family. read more

1st Place EMage Winner: A Case of the Venomous Arthropod: A Purple Toe?

Dacia J. Ticas, MD;  Cristina M. Zeretzke-Bien, MD

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

A 13-year-old female presented to an outside emergency room (ED) one day prior with a chief complaint of her left great toe turning purple. She denied any weakness or tingling, any shoe tightness, rubbing, or blistering. She presented to the ED again however as symptoms had not improved. The physical exam was only notable for the left great toes’ plantar surface was a deep hue of purple and black. The toe was non-tender, and was not fluctuant or with increased warmth.  The foot and toes had intact sensory and motor function. The dorsal aspect of the foot was unaffected and had an intact nail and nailbed without any visible trauma.  Pulses were palpable. read more

First Place EMages Winner 2015: Neck Pain

Megan Marino, MD

Baylor College of Medicine and Texas Children’s Hospital, H uston, Texas

Department of Pediatrics, Section of Emergency Medicine

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9 year old female with history of acute lymphocytic leukemia (ALL), status post heart transplant 9 months ago for chemotherapy related cardiomyopathy, presented to the emergency department with 4 weeks of worsening neck pain and 2 days of dysphagia and voice changes. She stopped moving her neck, refuses solids, but is able to drink liquids. She has been afebrile.  She has been seen twice by other providers over the last month, was diagnosed with torticollis, and given diazepam and acetaminophen with codeine without improvement. Home medications included tacrolimus, mycophenolate and prednisone.

On physical examination, the patient had a pulse of 133 beats/minute, blood pressure of 100/67 mmHg, temperature of 36.9 °C, respiratory rate of 22 breaths/min, and oxygen saturation of 98% on room air. The patient was sitting in a tripod position with her chin forward and was drooling.  She refused to move her neck and had a muffled voice.  No lymphadenopathy was appreciated. Oropharyngeal exam is shown.

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The differential diagnosis included recurrent ALL, lymphoma, rhabdomyosarcoma, nasopharyngeal carcinoma, post-transplant lymphoproliferative disease (PTLD), epiglottitis, bacterial pharyngitis, tonsillar abscess, or para/retropharyngeal abscess.  The patient had computed tomography (shown). She was intubated in the operating room for airway protection.  Biopsies confirmed Epstein-Barr virus (EBV) positive, PTLD with diffuse large B cell lymphoma.

PTLD is a potentially fatal complication of transplantation. Presentation depends on the type of PTLD and the areas involved.  Symptoms include fever, weight loss, lymphadenopathy, and dysfunction of involved or surrounding structures. It is caused by lymphoid or plasmacytic cell growth in the setting of chronic immunosuppression, often after solid organ or allogeneic hematopoietic cell transplantation.  Most cases are related to the presence of EBV.  The incidence of PTLD is 1% in the transplant population and is seen more frequently in recipients of heart, lung or multi-organ transplants.

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