Serious life-threatening multifocal infection in a child, caused by Panton-Valentine leucocidin-producing Staphylococcus aureus (PVL-MSSA)

Groin pain is a frequently occurring complaint in presentations to the Emergency Department. Muscular sprain is often a differential diagnosis, however serious conditions such as pyomyositis should not be ignored. This case report presents a child with atraumatic right groin pain, which was initially diagnosed as a muscular sprain. The patient later re-presented out of hours to the Emergency Department with what was found to be extensive pelvic abscesses. He was subsequently found to have bilateral pneumonia and later developed a pericardial effusion and osteomyelitis of the right iliac bone, sacroiliac joint and sacrum. With multiple surgical interventions and appropriate antibiotics, he made a full recovery and was discharged home after a total admission time of 41 days. The causative organism was found to be Panton-Valentine leucocidin-positive methicillin-susceptible Staphylococcus aureus.

Hyperthermia and Rigidity Following Overdose of an Unknown Drug; A Case Report and Literature Review

Drug induced hyperthermia is a rare presentation which can rapidly lead to gross metabolic abnormality and death. These presentations are further complicated by the wide range of potentially causative agents. We present a case of rigidity and hyperthermia, following overdose of an initially unknown substance leading to challenging management decisions in the Emergency Department. This case was later identified as Serotonin Syndrome. The patient presented with trismus which was managed with rapid sequence induction of anaesthesia to allow airway protection. On extubation a significant degree of laryngeal oedema complicated weaning, a possible complication of Serotonin Syndrome not previously described in the literature. We discuss the pathophysiology of Serotonin Syndrome, important differentials and practical considerations in managing hypertonicity of unknown origin in a young person.

Compartment syndrome- A rare complication of intraosseous access in adult patients

Background: Intraosseous (IO) access are being widely used in resuscitation of patients with difficult intra-venous (IV) access. The United Kingdom Resuscitation Council guidelines recommend the use of IO access, after two minutes of failed IV access in adult patients or two failed IV attempts in pediatric patients. There are various complications associated with IO access such as extravasation of the infusion fluid or medications, bleeding, infection and pain1. Compartment syndrome is a rare complication associated with IO access. This is reported commonly in children where in certain cases the affected limb required amputation. We report a case where an adult patient developed compartment syndrome secondary to IO access.

Methods: A 52-year-old lady who was on dialysis for renal failure presented to the Emergency Department (ED) with septic shock. She was in peri-arrest and had a difficult IV access. Therefore an IO needle was inserted to her right tibia and resuscitation was carried out with fluids and medications. She required emergency intubation and ventilation and was later admitted to the Intensive Care Unit (ICU). The following day, it was found that she developed a compartment syndrome of the right lower leg where she had the IO access.

Results: Patient was taken to the theatre for an urgent fasciotomy of the affected leg by the orthopedic surgeons with input from plastic surgeons. She made a steady but full recovery and was discharged home later.

Conclusions: Compartment syndrome is a rare complication of IO access (0.6%) 1. Careful monitoring of the IO site is recommended. It is advisable to remove the IO needle once a definitive IV access is established.

1. Complication with Intraosseous Access: Scandinavian Users' Experience. Hallas et al. West J Emerg Med. 2013 Sep; 14(5): 440–443.

Intermittent facial swelling

Intermittent facial swelling is an unusual presentation in the emergency department. The differential diagnosis may range from a variety of causes. Most common differential diagnosis is angio-oedema. However, more serious presentations such as superior venacaval obstruction must not be ignored. This case report presents a patient who was investigated in the hospital for 2 weeks (2 admissions) with intermittent facial swelling. He presented to the emergency department (3rd admission) and was diagnosed to have superior venacaval obstruction secondary to metastatic bronchogenic carcinoma. He underwent emergency endovascular stenting; however, he died within a few weeks.