Sometimes the Answer Lies Beyond the Obvious : Emergency Medicine News (2023)

Sometimes we are lulled into complacency by the parade of otitis media and strep throat cases that march regularly through the pediatric ED, and unusual cases serve to remind us of the varied nature of emergency medicine and provide a thrilling respite from the everyday mundane case. Although the cases in this special report are unusual, they serve as a reminder that we as emergency physicians always have to look beyond the obvious and consider that the most apparent diagnosis may not be the full story.

Case 1

A 12-year-old girl was fishing with her parents in Galveston Bay, located on the upper coast of Texas. Near the end of the day, she hooked a small Gafftopsail catfish (Bagre marinus). While attempting to remove the fish from her line, her right index finger was impaled by the fish's dorsal spine.

She experienced immediate pain, and her parents provided first aid by rinsing her hand in the bay and then applying ice to the affected finger. Her parents noted that the affected hand was initially very pale, but they attributed this symptom to the ice. Later that evening, she had increasing pain and then developed fever, nausea, and vomiting. By the next morning, her fever had abated, as had her nausea and vomiting, but the redness that had been restricted to her finger alone had spread to her entire hand.

Upon arrival at the emergency department, the young lady's hand was noted to be red with multiple small bullae along the dorsal surface of her index finger and thumb. She also had involuntary muscle spasms in her hand. Her vital signs were normal except that her temperature was 100.1°F.

What are the possible issues involved in this case?

The Gafftopsail catfish, also known as a Gafftop or Seacat, is a relatively small catfish native to the Gulf of Mexico, to Atlantic coastal waters from Cape Cod, MA, to Yucatan, Mexico, and to the Caribbean Sea, although it occasionally enters freshwater. Gafftopsail catfish weight on average only 2.5 pounds, and like many catfish, have rigid spines. The Gafftopsail is among the many species of catfish that produce toxic venom, with near-immediate pain that spreads from the affected body part centrally. The pain has been variably described as stinging and burning.

The area around the initial point of envenomation can appear pale initially although erythema generally develops within minutes to hours. Edema may be present, and in some cases, systemic symptoms like diaphoresis, nausea, and muscle fasciculations can occur. Although the pain from a Bagre marinus envenomation is severe, it is also relatively transient. Most patients have had significant if not complete pain relief within one to three hours, although others experience symptoms for longer periods. Rarely, patients experience severe systemic symptoms such as hypotension and res-piratory distress, and there are many reports of retained catfish spine fragments causing significant symptoms for months to years.

It is clear from the family's description of the girl's symptoms that some of what she experienced can be directly attributed to exposure to Bagre marinus venom, but is that the whole story?

While it would be simple to attribute this girl's symptoms to the effects of Bagre marinus venom, there is a particular feature of her presentation that makes it prudent to consider a secondary diagnosis. Recall that her hand, in addition to being erythematous, also had bullous lesions. Add this symptom to the fact that she had a skin wound exposed to the warm, brackish waters of Galveston Bay, and it becomes important to consider an infection caused by the organism Vibrio vulnificus.

V. vulnificus is a common inhabitant of warm saltwater or brackish water, and it often contaminates filter-feeding shellfish such as oysters. Physicians most commonly associate this organism with foodborne septicemia in immunocom-promised patients. Indeed, V. vulnificus is the leading cause of lethal foodborne illness in the United States, but it also can cause local skin infections when it contaminates open wounds. Even in this scenario, the individuals most severely affected are those with some form of immunocompromise, but, as in this case, normal hosts also may be infected. The combination of cellulitis, bullous skin lesions, and exposure to saltwater or brackish water should lead the emergency physician to consider this diag-nosis. Failure to treat V. vulnificus infection promptly can lead to necro-tizing fasciitis. V. vulnificus is sensitive to many antibiotics including trimethoprim-sulfamethoxazole, doxycycline, gentamicin, many third-generation cephalosporins, and others. Multiple antibiotics are often required to ensure arrest of the infection.

This patient was treated with a combination of intravenous and oral antibiotics. Her symptoms were substantially better on the second day of therapy, and she recovered completely without significant sequelae.

Case 2

A 16-year-old boy of Vietnamese heritage presents to the emergency department with his maternal grandmother who is his primary caretaker. She requests a test to see if he is taking drugs. On further questioning, the young man reports that he passed out in his-tory class earlier in the day. Witnesses reported that he fell from his chair to the floor, and had a few twitching movements of his arms and legs. He did not become incontinent, and he recovered spontaneously within a few moments. He reports no previous episodes of syncope although he says that he has felt lightheaded from time to time, usually when rising from a prone or seated position to a standing position. He also admits to “partying” with his friends the night before the episode, but says that he only drank beer and used no drugs. He also says that he has not felt well for several days, and on the day of the event, he recalls feeling hot.

His grandmother reports that he has been healthy since she began caring for him when he was 4. Specifically, he has no history of seizures and no chronic illnesses. He takes no medications other than a daily multivitamin.

The details of his family history are only partially known. His grandmother reports that some members of her family have experienced adult onset coronary artery disease, but none of her relatives have had a seizure disorder. His father's side of the family has been largely uninvolved in his life, and his maternal grandmother knows nothing of their medical history.

His vital signs are normal as are his cardiac and neurological examinations. In fact, the only significant finding on physical examination is a bruise on the left side of his face where he struck the floor when he fell from his desk. What are the primary considerations in this case?

Syncope is a familiar complaint for most emergency physicians. Although the usual victims are elderly adults, adolescents are sometimes affected. In this case, the most important consideration is whether the event described by the boy and his grandmother represents a first seizure, in which case her concerns about drug abuse (e.g., cocaine) might be justified, or whether there might be another cause for his symptoms. As a part of his evaluation, an electrocardiogram was obtained. What does this EKG tell us about the diagnosis in this patient?

The ST segment elevation noted in leads V1-V3 combined with this patient's history of a sudden syncopal event is strongly suggestive of Brugada syndrome. Brugada is an inherited (auto-somal dominant) disorder of the gene that encodes one of the subunits of the cardiac sodium channel. Patients with this disorder are subject to paroxysmal episodes of polymorphic ventricular tachycardia. Because the incidence of the disease is variable, patients who carry the affected gene may experience an episode of sudden cardiac death at a young age or may never become symp-tomatic. Most patients with Brugada syndrome are diagnosed in early to middle adulthood, but children are not uncommonly affected. As in this case, fever is often a precipitating cause of syncope or sudden cardiac death. Unlike other causes of sudden cardiac death (e.g., hypertrophic cardiomyopathy), most syncopal events in patients with Brugada occurred during rest rather than during exercise. Brugada syndrome can affect men and women. The mutation occurs commonly, but not exclusively, in patients of Asian extraction.

Because Brugada syndrome is an inherited disease, many patients will report a family history of syncope or sudden cardiac death. Given the variable incidence of the disease or an incomplete family history, as in this case, the emergency physician cannot rely on the availability of historical clues.

If a patient presents to the emergency department after a syncopal event or an aborted spontaneous cardiac death episode and has typical EKG findings, he should be admitted to the hospital for further testing and possibly implantation of an internal defibrillator. Additionally, family members, especially siblings, should be tested for the gene mutation. Asymptomatic relatives who possess the gene for Brugada syndrome may still require treatment if arrhythmias can be induced by exposure to a sodium channel blocker.

Suggested Readings