On the initial ED visit, an abdominal ultrasound (US) was ordered which showed the classic intussusception finding of a target sign (yellow arrow), or concentric rings of telescoped bowel, on the transverse view of the left lower quadrant (LLQ).
A Case of Community-Acquired Tuberculosis in an Infant Presenting with Pneumonia Refractory to Antibiotic TherapyDOI: https://doi.org/10.21980/J8X07M
Chest radiographs during the initial presentation at seven weeks of life demonstrated right lower lobe (RLL) air space opacity on both PA and lateral views, compatible with pneumonia (referenced by yellow and green arrows, respectively). Repeat chest radiograph performed 12 days after the initial imaging revealed persistent right lower lobe opacity and right hilar fullness, seen as an opacified projection off of the mediastinal border as compared with the prior image, concerning for lymphadenopathy (designated by the aqua arrow). On the third presentation, computed tomography (CT) of the chest with intravenous contrast found persistent right lower lobe consolidation, innumerable 2-3 mm nodules, and surrounding ground glass opacities. This is best visualized as scattered areas of hyperdensity in the lung parenchyma. Axial images confirmed the presence of right hilar as well as subcarinal lymphadenopathy (indicated by white and pink arrows, respectively). Magnetic resonance imaging (MRI) of the brain with IV contrast was performed which showed a punctate focus of enhancement in the left precentral sulcus compatible with a tuberculoma (denoted with red arrow).
The CT of the chest with contrast showed subcutaneous emphysema (green star), pneumomediastinum (yellow arrow), and pneumopericardium (purple asterix) without an identifiable tracheal tear. Extensive air was visualized as hypodense areas within the chest wall within the soft tissue. The image also detailed a hypodense area surrounding the heart consistent with pneumopericardium. No disruption of the trachea was present. Additionally, the CT of the chest also showed bilateral ground glass airspace opacities (red stars) with subpleural sparing that is consistent with EVALI findings.2,5 These specific findings have been seen in many of the EVALI cases.5 This image is interesting because there is extensive pneumomediastinum with no clearly identifiable cause. The imaging shows no esophageal or tracheal or lung injury, so it is important to note relevant information collected during interview regarding patient’s recent history of vaping THC, especially when establishing a differential diagnosis.
Examination of the right ankle demonstrated a large deformity of the superior talus with bruising and blanching of the overlying skin in the area of the Achilles tendon (see images 2,3). The remaining bones of the foot were not tender to palpation and the foot was neurovascularly intact throughout with only mild numbness in the area of the tented skin. Completing the trauma exam, the patient had no signs of head injury and no midline spinal tenderness to palpation. Inspection of the remaining long bones and joints showed no other injuries. There were mild skin scrapes on the right flank from the fall. X-rays of the right foot and ankle showed a longitudinal fracture of the calcaneal tuberosity from the articular surface to the posterior surface (see red outline) with extension into the subtalar joint (blue lines) and roughly 1.8 cm displacement between the fracture segments (yellow double arrow). These findings represented a tongue-type calcaneal bone fracture.
Plain radiographs of the left hand and forearm demonstrated extensive subcutaneous emphysema. The air can be seen as lucent striations tracking along the second and third fingers as well as along the dorsum of the hand and wrist. There is also diffuse soft tissue emphysema surrounding the metacarpophalangeal joints. Lab analysis did not show any significant acute abnormalities.
A Case Report of the Rapid Evaluation of a High-Pressure Injection Injury of a Finger Leading to Positive OutcomesDOI: https://doi.org/10.21980/J8TD2X
On exam the patient was noted to have a punctate wound to the ulnar aspect of his right index finger, just proximal to the distal interphalangeal joint. The finger appeared pale and taut, with absent capillary refill. The patient displayed diminished range of motion with both extension and flexion of the joints of the finger. Sensation was absent and no doppler flow was appreciated to the distal aspects of the finger. X-ray of the hand was obtained and showed many small foreign bodies in the soft tissue and extensive radiolucent material consistent with gas or oil-based material to the palmar aspect of the index finger tracking up to the level of the metacarpal heads.
At the time of presentation to the ED, laboratory results were significant for leukocytosis to 11.8 x 109 white blood cells/L and a partial pressure of carbon dioxide of 52 mmHg on venous blood gas. Computed tomography (CT) of the soft tissue of the neck with contrast showed edematous swelling of the epiglottis and aryepiglottic fold with internal foci of gas (blue arrow) and partial effacement of the laryngopharyngeal airway and scattered cervical lymph nodes bilaterally (Figure 1). Findings were consistent with epiglottitis containing nonspecific air. Additionally, the pathognomonic “thumbprint sign” (yellow arrow) was found on lateral x-ray of the neck (Figure 2). The CT findings as shown in figure 3 illustrate lateral view of the swelling of the epiglottis, gas, and blockage of the airway.
In the image, one can see significant tracheal deviation around the right side of the mass (black arrows). This degree of deviation would make ventilation in a paralyzed patient extremely difficult, if not impossible.
The post intubation chest x-ray (CXR) showed severe rightward displacement of the trachea (purple arrow). The computed tomography angiogram (CTA) showed transection of the left common carotid artery (LCCA), extensive neck hematoma without extravasation and severe tracheal deviation to the right (blue arrow). The intravenous (IV) contrasted chest computed tomography (CT) image showed a lateral contrast projection from the aortic arch at the level of the isthmus (green and pink arrows). There were no other significant injuries reported on the CT scans of the chest, abdomen and pelvis.
Chest X-ray revealed an inferiorly displaced right clavicle at the right sternoclavicular joint (blue arrow). A computed tomography angiogram (CTA) of the chest was therefore obtained and revealed a right posterior sternoclavicular dislocation with resultant compression of the left brachiocephalic vein (purple arrow). Even though the right clavicle is displaced, the anatomy of the brachiocephalic vein is such that it is positioned to the right of midline, placing the left brachiocephalic vein posterior to the right clavicle. The right brachiocephalic and common carotid artery were normal in appearance. The CTA also revealed a comminuted fracture of the left anterior second rib at the costochondral junction that had not been previously seen on the x-ray.