Axillary lymph node metastases from papilloma of the breast

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Background: To report a unique case of papilloma of the breast with metastases to the axillary lymph node. Methods: Case report and review of literature. Results: 80 year old Caucasian male presented with right gynacomastia of 3 months duration. The lesion was resected. Pathology was consistent with intraductal papilloma with hyperplasia and no evidence of malignancy. Subsequently, after 2–3 weeks a mass was noted in the right axilla. This mass was resected and was found to be consistent with papilloma of the axillary lymph node and had the pathological characteristics of the original breast papilloma. Conclusion: Solitary papillomas are generally lesions of the large ducts usually located in the subareolar region of the breast. They are among the commonest cause of spontaneous nipple discharge. After resection of the primary lesion, local recurrence is fairly common. Recurrence is especially common if hyperplasia is associated with the papilloma. There is also an increased incidence of carcinoma in the affected breast. Due to the benign nature of papillomas, they do not metastasize. We did an extensive review of literature and did not find any cases of metastatic lesions from a papilloma of the breast. The underlying reason and pathogenesis for the metastases is not known.

No significant financial relationships to disclose.

Oral morphine protocol for sickle cell crisis pain

The painful vaso-occlusive crises that complicate sickle cell anemia can be difficult and frustrating for both patient and physician. We describe our experience using an oral morphine protocol for the treatment of sickle cell crisis pain. The emergency department (ED) visits of nine patients with sickle pain were reviewed for the 12 months before and after implementation of the protocol. The oral morphine regimen was associated with a significant reduction in the number of ED visits, total number of hours spent in the ED, and the proportion of visits that ended in admission to hospital (P < 0.01). The protocol is a useful tool for providing consistent oral analgesia to patients with sickle crisis pain.

High-altitude illness

Acute mountain sickness, high-altitude cerebral edema, and high-altitude pulmonary edema are illnesses associated with acute exposure to altitudes greater than 8000 ft. Although usually self-limiting problems, they can be severe and life threatening. Gradual ascent to allow acclimatization can lessen or prevent symptoms. Acetazolamide is the drug of choice for pharmacologic prophylaxis; descent to lower elevation is the definitive treatment for altitude illness. Individuals who have chronic cardiac, respiratory, or certain other medical conditions may require supplemental oxygen and should be aware of restrictions regarding high-altitude exposure.

Unsuspected heterotopic pregnancy in a woman without risk factors

A 27-year-old woman presented to the emergency department with abdominal pain. One week prior to this she had had an ultrasound which revealed an intrauterine pregnancy (IUP). A second ultrasound performed at our institution revealed an intrauterine pregnancy along with a concomitant ectopic pregnancy which had ruptured. This case emphasizes that coincident pregnancies may occur in women who are without risk of ectopic pregnancy or multiple gestations. In addition, ultrasound must be evaluated fully for heterotopic pregnancy in all women.

The importance of an annual report

An annual report, by summarizing the emergency department's accomplishments, is an effective means of highlighting the vital role of the emergency department within the hospital system and the community. The report should begin with an Executive Summary and proceed to detail the clinical, educational, research, administrative, financial, and other essential aspects of the status and development of the department.

The electrocardiographic features of hypothermia

Hypothermia results in the development of several characteristic electrocardiographic changes. As the core body temperature decreases, several changes in cardiac rhythm occur. Prolongation of the PR, QRS, and QT intervals are also seen. Muscle tremor artifact may be present, even in the absence of clinical shivering. A characteristic secondary deflection on the terminal portion of the QRS complex (Osborn wave) is usually found. All of these features are reversible with rewarming.

Echocardiographic diagnosis of acute pericardial effusion in penetrating chest trauma

Pericardial tamponade persists as a diagnostic challenge to the clinician. The immediate diagnosis is particularly difficult when the patient is well compensated hemodynamically. In contrast to the deceptively stable appearance, the patient is at increased risk due to delayed onset, recognition, and therapy. A case of penetrating thoracic trauma is presented in which the concern about pericardial tamponade was considerable. However, the elements of clinical assessment were inconclusive. Two-dimensional echocardiography was employed in the emergency department to detect a pericardial effusion and thus avoid delayed management. Pericardial tamponade and associated vascular injuries were confirmed at surgery.

Lithium intoxication: manifestations and management

The clinical diagnosis of lithium intoxication can be elusive because of the slow onset and diversity of toxic manifestations. Mental status and neurologic symptoms often predominate. After the diagnosis is made, management depends on the clinical presentation and serum lithium level. Hemodialysis is the treatment of choice for severe lithium intoxication. Two cases of lithium intoxication are presented that demonstrate that predisposing factors and drug interactions play major roles. A review is given of the pathophysiology, presenting signs, symptoms, and approaches to treatment of lithium intoxication.

Late postpartum eclampsia

A case of new-onset seizures occurring 12 days postpartum is described. The patient presented with headache, hypertension, and proteinuria. Postpartum eclampsia was diagnosed and IV magnesium sulfate was administered. The patient had no further seizures and did not require long-term anticonvulsants. Medical and neurologic evaluations failed to reveal any other etiology for the seizures.

Esophageal spasm following propranolol overdose relieved by glucagon

A case of propranolol overdose complicated by esophageal spasm preventing extrication of an orogastric lavage tube and relieved by intravenous glucagon is presented. Esophageal spasm is an infrequent complication of beta-adrenergic over-dose. Possible mechanisms of esophageal spasm and its relief with glucagon are discussed.

Coronary artery spasm. Part II

Coronary artery spasm can occur in several settings, often combined with coronary artery disease and thrombosis. Calcium channel blockers and beta-blockers are primary treatment modalities. The role of alpha-blocking agents remains unconfirmed.

Coronary artery spasm. Part 1: Overview

The syndrome of coronary artery spasm is described. This phenomenon may occur in conjunction with, or in the absence of, fixed atherosclerotic coronary artery disease. ECG manifestations during an attack mimic those seen with acute myocardial injury, but normalization of the ECG following the resolution of the pain is usual. Intravenous ergonovine is a sensitive and specific test for confirmation of the diagnosis. Nitrates and calcium channel blockers are the mainstay of therapy, although other agents are of theoretical benefit. The role of surgery is unclear.