cinnat Cin i M f ed o i y c t a i l s C r e e n v i t n e r U - - D e e n p i a c r i t d m e IV IX Issue Volume e 2016 Issue summer M n t NNALS OF OD y c o n f A B P e E g m r e Since 1970 - Leadership - Excellence - Opportunity TAKE A LOOK... #beneaththesurface 2 Mycotic Aneurysm 4 Necrotizing Fasciitis 6 Erythroderma also available at tamingthesru.com EMERGENCY MEDICINE Mycotic aneurysm: ANNALS OF B POD A rare cause of lower SUMMER 2016 2 Mycotic Aneurysm Whitford extremity DVT 4 Necrotizing Fasciitis Sabedra 6 Erythroderma Harrison Robert Whitford, MD 7 Continuous Ketamine Garber University of Cincinnati R1 8 Pediatric Abdominal Pain Ostro/ LaFollette History of Present Illness 10 Fingertip Injuries Ostro 11 Seymour Fracture Derks The patient is a middle-aged male with a and swelling. He reports taking his rivar- 12 Patella Alta Shaw past medical history of a recent right pop- oxaban as prescribed as well as oxycodone, Back EKG Focus: Brugada Lagasse liteal deep vein thrombosis who presents but states that despite this the pain is wors- Cover with worsening pain and swelling of his ening and preventing him from sleeping. #beneaththesurface right lower extremity. He denies chest pain, shortness of breath, It’s that time: the academic year has numbness, weakness, fevers, or cough. He come to a close. Interns are spending The patient was seen three days ago at an has no history of prior deep vein thrombo- their last few shifts in B Pod, and the R2s outside hospital for acute onset right lower sis or pulmonary embolisms. He denies a are testing their taming skills in the SRU. extremity pain and swelling. A venous dop- personal history of cancer or recent unin- The R3s are stepping up to the educator pler was performed and showed a right tentional weight loss. He smokes one pack role, and the R4s are looking onwards to popliteal deep vein thrombosis. He was per day, reports moderate alcohol use, and their future careers. We spend these last started on rivaroxaban and discharged. He admits to injecting IV drugs, although de- few weeks balancing the excitement of presented to our ED for worsening pain nies use in the last three years. our transitions and the purpose of our Past Medical History Past Surgical History Medications job: somewhere between the hustle and noise of B Pod, there is a critical illness None None Rivaroxaban waiting to be found, #beneaththesurface. Physical Exam In this issue, we look at the difference T100.2 HR 105 RR 16 BP 153/95 O2 Sat 97% between how something appears on the surface and its true nature. A simple DVT hides something more. A chronic wound takes a patient to the ICU. Our patients challenge us every day to keep our skills fresh and our index of suspicion high, because #beneaththesurface, your patient may be hiding something more. EDITORS RYAN LAFOLLETTE, MD BENJAMIN OSTRO, MD Image 1: Venous distention in the right lower extremity of a patient previously diagnosed with a DVT. RILEY GROSSO, MD GRACE LagaSSE, MD KARI GORDER, MD The patient is an alert, well-developed male in no acute distress. He is tachycardic but has a normal S1/S2 with no murmurs, rubs or gallops. He has clear and unlabored breath sounds FACULTY EDITORS bilaterally. His neurologic exam is normal. His skin exam reveals no rashes or lesions. He has 2+ pulses in all four extremities. His right lower extremity is notable for 1+ non-pitting WILLIAM KNIGHT, MD edema from the shin to the mid-thigh with visibly dilated superficial veins without ery- NATALIE KREITZER, MD thema when compared to the left lower extremity (Image 1). ROBBIE PAULSEN, MD Labs EDITORS EMERITUS WBC: 13.9 H/H: 11.6/35.7 INR 1.8 AARON BERNARD, MD BMP: 131/4.0/97/27/17/0.8/129 CHRISTOPHER MILLER, MD 2 ANNALS OF B POD Hospital Course ther work up for an occult malignancy. #bpodcase Given the patient’s worsening symptoms de- In our patient, the cause of his deep vein spite being on appropriate medical therapy thrombosis was likely compression of the for his known deep vein thrombosis, the de- popliteal vein by his mycotic right popliteal cision was made to obtain a repeat right lower artery aneurysm. Causes of arterial aneu- extremity venous ultrasound to evaluate for rysms include atherosclerosis, hypertension, proximal spread of the clot. The ultrasound trauma, congenital anomalies, infection, and was concerning for a mid to distal thigh pseu- syphilis. do-aneurysm, as well as an acute occluding deep vein thromboses of the right popliteal, The term mycotic aneurysm was coined by gastrocnemius, soleal, posterior tibial, and William Osler in 1885 to describe the mush- peroneal veins. room shaped aneurysms associated with bac- terial endocarditis. Today, the term is used To better characterize this vascular abnormal- more generally to refer to all aneurysms of ity, a CT angiogram of the lower extremities infectious etiology. Popliteal vein thrombo- was ordered. It showed a large pseudo-aneu- sis secondary to popliteal artery aneurysm is rysm or contained rupture of the distal right most often seen in patients with aneurysms superficial femoral artery measuring up to 2.8 due to atherosclerosis.2 Although less fre- cm (Image 2). Vascular surgery was consulted quent, they have also been seen secondary to and they admitted the patient with plans for mycotic aneurysms. Mycotic aneurysms are operative repair. an uncommon but known complication of IV drug abuse with a rate amongst IV drug Shortly after admission, the patient devel- users of 0.14%.4 oped a fever to 102.2 F. Blood cultures were drawn and he was started on vancomycin and Mycotic aneurysms are most commonly ampicillin/sulbactam. The patient was taken caused by septic emboli from endocarditis. Image 2: Mycotic aneurysm of the right distal superficial femoral artery. to the operating room on hospital day 1 and However, they have also been observed in was found to have a 3 cm ruptured mycotic IV drug users without endocarditis and are right popliteal artery aneurysm. This was re- thought to be due to direct needle trauma their potential to provoke deep vein throm- paired and the patient underwent a femoral and inoculation of the vessels. They have bosis. Vascular surgery consultation is inte- to below knee popliteal bypass graft. Intra- been described in the popliteal, femoral, ra- gral to the management of these patients. operative culture swabs of the aneurysm were dial, brachial, and subclavian arteries, as well negative for bacteria, fungus, anaerobes, and as intracranially.⁵ The predominant causative 1. Miller KB, Hribar LJ, Sanders LJ. Human myiasis mycoplasma. Ultimately, the aneurysm was organism is methicillin resistant Staph aure- caused by Phormia regina in Pennsylvania. J Am Podiatr believed to be secondary from injecting intra- us, but other organisms have been identified, Med Assoc. 1990;80(11):600-2. venous drugs. including Strep viridians, Staph epidermis, 2. Giustra PE, Root JA, Mason SE, Killoran PJ. Popliteal Campylobacter, E. Coli, and Mycobacterium vein thrombosis secondary to popliteal artery aneurysm. 6, 7 AJR Am J Roentgenol. 1978;130(1):25-7. During his hospital course he had a negative tuberculosis. Diagnosis of popliteal arte- 3. Denis Spelman, Overview of Infected (Mycotic) Arte- workup for endocarditis including a normal rial aneurysms can be difficult. Findings may rial Aneurysm, updated Oct 12, 2015. trans-throracic echocardiogram and negative include a pulsatile popliteal fossa mass or 4. Tsao JW, Marder SR, Goldstone J, Bloom AI. Presen- serial blood cultures. He was discharged on swelling, fever, leukocytosis, limb ischemia, tation, diagnosis, and management of arterial mycotic pseudoaneurysms in injection drug users. Ann Vasc hospital day 10 with a PICC line for six weeks DVTs, elevated ESR or CRP, and foot drop.⁸ Surg. 2002;16(5):652-62. of antibiotics. Complications include aneurysm rupture, 5. Lewis ES, Singh I, Patel R, Purcell R. Mycotic aneu- rysms in intravenous drug abuse. J Natl Med Assoc. Discussion thrombosis, embolization, compartment syn- drome, limb ischemia, need for amputation, 1986;78(4):273. 6. Jayaraman S, Richardson D, Conrad M, Eichler C, When diagnosing a patient with a deep vein and death from exsanguination.⁹ Schecter W. Mycotic pseudoaneurysms due to injec- thrombosis, the provider should attempt to tion drug use: a ten-year experience. Ann Vasc Surg. determine if the clot was provoked or un- In summary, when evaluating a patient with 2012;26(6):819-24. provoked. A provoked deep vein thrombosis a deep vein thrombosis, careful attention 7. Killeen SD, O’Brien N, O’Sullivan MJ, Karr G, Red- mond HP, Fulton GJ. Mycotic aneurysm of the popliteal should have an inciting factor such as pro- should be paid to eliciting a provoking factor, artery secondary to Streptococcus pneumoniae: a case longed immobility, recent surgery, trauma, as venous obstruction from an unrecognized report and review of the literature. J Med Case Rep. vascular anomalies, or active malignancy. A arterial aneurysm is associated with high 2009;3:117. deep vein thrombosis without a clear incit- morbidity and mortality. IV drug use may 8. Sachdeva A, Paul B, Bhatia N, Kumar V. Mycotic popliteal artery aneurysm. J Assoc Physicians India. ing factor is classified as unprovoked, and lead to the development of vascular abnor- 2014;62(5):413-4. may merit further evaluation for a primary malities that provoke deep vein thrombosis. 9. Brown SL, Busuttil RW, Baker JD, Machleder HI, clotting disorder such as protein C or S defi- In light of the ongoing national opioid epi- Moore WS, Barker WF.