Case: A 12 year old male with a history of autism spectrum disorder and chronic sinusitis presents for forehead swelling. Mother reports that she noticed progressive forehead swelling for about 1 month. She has followed up with the patient’s pediatrician and ENT and given oral cephalexin and fluticasone nasal spray which has not made any changes in symptoms. Patient denies any fevers or headache. Vitals include BP 100/58, HR 90, Temp 97.4F, RR 18, SpO2 98%. Exam is notable for a 3x3cm area of fluctuance centrally located over the forehead with no drainage or surrounding erythema that is minimally tender to palpation.

Differential diagnosis includes: abscess, cyst, lipoma

CT of the facial bones with contrast:

CT interpretation: “Bifrontal and ethmoid sinusitis associated with osseous destruction resulting in a 5 cm bifrontal complex loculated anterior epidural abscess as well as a 3 cm midline frontal subgaleal extracranial scalp abscess. Findings are most consistent with osteomyelitis of the frontal bone and sinuses.”

Case continued: ENT and Neurosurgery are emergently consulted and both recommend transfer to a Pediatric Center for advanced surgical and medical management given extensive nature of infection and reconstruction required post-operatively. The patient is started on broad spectrum antibiotics with vancomycin, ceftriaxone, and metronidazole and transferred to a Pediatric Center ICU with neurosurgical consultation. He was taken to the OR for a bifrontal craniotomy for epidural abscess evacuation and did well post-operatively, discharged on hospital day #4.

Pearls:

• Pott’s puffy tumor is a rare, life-threatening complication of frontal sinusitis characterized by osteomyelitis of the frontal bone with associated subperiosteal abscess causing swelling and edema over the forehead and scalp.
• It can be found in all age groups but most common in adolescents.
• MRI brain with and without contrast is the preferred imaging modality due to increased sensitivity to detect early intracranial and osseous abnormalities.
• Treatment is typically surgical intervention with at least 6 weeks of intravenous antibiotics.
  • The infection is typically polymicrobial warranting gram-positive, gram-negative, and anaerobic antibiotic coverage.

References:

Sharma, P., Sharma, S., Gupta, N., Kochar, P., & Kumar, Y. (2017). Pott puffy tumor. Proceedings (Baylor University. Medical Center), 30(2), 179–181. https://doi.org/10.1080/08998280.2017.11929575

Masterson L, Leong P. Pott’s puffy tumour: a forgotten complication of frontal sinus disease. Oral Maxillofac Surg. 2009;13(2):115-117. doi:10.1007/s10006-009-0155-7

Case: A 34 year old male with a past medical history of polysubstance use is brought in via EMS for an “allergic reaction.” He woke up this morning with tightness in his jaw and legs which has progressed to the inability to open his mouth or walk. Per chart review, the patient was in the ED yesterday acutely agitated and received intramuscular sedation with haloperidol and midazolam. On exam, his vitals are within normal limits. He speaks in full sentences through clenched teeth. Visualization of the oropharynx is limited due to inability to open his jaw. His bilateral lower extremities demonstrate rigid hyperflexion and inversion at the ankle joints. He is otherwise neurologically intact without abnormal findings on skin or lung exam.

Differential diagnosis includes: allergic reaction, extrapyramidal reaction, tetanus

Pearls:

• This patient is likely presenting with an extrapyramidal reaction secondary to receiving haloperidol, a high-potency antipsychotic.
  • Extrapyramidal symptoms include acute dystonia, akathisia, Parkinsonism, tardive dyskinesia, and neuroleptic malignant syndrome.
  • The pathophysiology involves an imbalance of dopaminergic and cholinergic activity, not a true allergic reaction.
• Acute dystonia is typically self-limited and not life-threatening with the exception of rare cases of laryngospasm.
  • Treatment includes benztropine (dopamine agonist) or diphendydramine (anticholinergic).
  • Patients that are discharged from the ED with resolution of symptoms should be given PO benztropine or diphenhydramine for 2 to 3 days due to prolonged effects of antipsychotics that can result in rebound dystonia.
• Drug induced Parkinsonism and tardive dyskinesia usually develop after prolonged use of antipsychotics and are less likely to be reversible.

Case continued: The patient received 50 mg IV diphenhydramine with near immediate resolution of his symptoms. He was observed for a brief period in the emergency department, ambulated, and tolerated PO without difficulty and was shortly thereafter discharged.

References:

Levine M, LoVecchio F. Antipsychotics. In: Tintinalli JE, Ma O, Yealy DM, Meckler GD, Stapczynski J, Cline DM, Thomas SH. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9e. McGraw Hill; 2020.

Case: An 18 year old female with a past medical history of anxiety, 2 weeks post-op from tonsillectomy presents for chest pain. She woke up today with severe, non-radiating central chest pain. Her daily medications include sertraline and oral contraceptives. Vitals are BP 118/86, HR 119, Temp 97.7F, RR 24, SpO2 96% on room air. On exam, she is uncomfortable appearing and tearful. Her oropharynx is clear without signs of erythema or drainage. She is tachycardic without murmurs and has clear lung sounds bilaterally. There are no signs of lower extremity swelling. EKG and point-of-care cardiac ultrasound are shown below:

EKG interpretation: Sinus tachycardia with rightward axis and T wave inversions in anterior leads

POCUS interpretation: Normal LV ejection fraction. No pericardial effusion. Elevated RV to LV ratio. Dilated IVC with < 50% collapse with inspiration. RV free wall hypokinesis with apical hyperkinesis. Tricuspid annular plane systolic excursion 1.0 cm.

Case continued:  Due to high concern for pulmonary embolism, the patient is empirically started on heparin. CTA chest results with acute pulmonary embolism with right heart strain. High sensitivity troponin results markedly elevated at 306 mg/dL. Patient is admitted to the ICU with interventional cardiology consultation. Patient underwent pulmonary arteriogram which demonstrated elevated PA pressures without need for thrombectomy and was discharged in good condition on hospital day #4.

Pearls:

• Infants and toddlers can have normal T wave inversions in the anterior leads known as “juvenile T waves” which should turn upright by age 7.
  • Any T wave inversion in these leads after they have flipped upright is abnormal.
• While the S1Q3T3 EKG finding is classically associated with pulmonary embolism, more common EKG findings suggestive of PE include sinus tachycardia, rightward axis, incomplete right bundle branch block, and T wave inversions in the anterior leads.
• Empirically start anticoagulation in patients with high concern for pulmonary embolism prior to definitive imaging.
• Right ventricular free wall hypokinesis with apical hyperkinesis is known as McConnell’s sign and is pathognomonic for acute pulmonary embolism.
  • Other POCUS findings include an RV:LV ratio > 1 which is sensitive but not specific. A tricuspid annular plane systolic excursion (TAPSE) < 17 mm is a quantitative measure to diagnose right heart dysfunction on echocardiogram.

References:

Kline JA. Venous Thromboembolism Including Pulmonary Embolism. In: Tintinalli JE, Ma O, Yealy DM, Meckler GD, Stapczynski J, Cline DM, Thomas SH. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9e. McGraw Hill; 2020.

Goodacre, S., & McLeod, K. (2002). ABC of clinical electrocardiography: Paediatric electrocardiography. BMJ (Clinical research ed.), 324(7350), 1382–1385. https://doi.org/10.1136/bmj.324.7350.1382

Alerhand S, Hickey SM. Tricuspid Annular Plane Systolic Excursion (TAPSE) for Risk Stratification and Prognostication of Patients with Pulmonary Embolism. J Emerg Med. 2020;58(3):449-456. doi:10.1016/j.jemermed.2019.09.017