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History: A 65 yr old diabetic woman complains of 1 week of lower anterior molar pain and now with 24 hours of sore throat, difficulty swallowing, and sweats. On physical exam, she is anxious and having difficulty breathing. She has significant trismus and so the pharynx is not visualized. Her tongue appears elevated and she is unable to protrude it beyond her teeth, and the sublingual space is indurated and elevated. What is the next best course of action?

1.  Administer broad-spectrum antibiotics and drain the submandibular abscess.
2. Perform a cricothyroidotomy, administer intravenous fluoroquinolone, order a CT scan, and emergent head and neck surgery consultation.
3. Perform rapid sequence endotracheal intubation, administer intravenous ampicillin–sulbactam, order a CT scan, and emergent head and neck surgery consultation.
4. Perform rapid sequence endotracheal intubation, administer intravenous fluoroquinolone, order a CT scan, and emergent head and neck surgery consultation.
5. Perform awake fiberoptic endotracheal intubation, administer intravenous ampicillin–sulbactam, order a CT scan, and emergent head and neck surgery consultation.

Answer: This patient presents with classic sublingual, submandibular space infection known as Ludwig angina. The tongue can be rapidly displaced posteriorly occluding the airway. The airway of choice is awake fiberoptic endotracheal intubation or awake tracheotomy. A CT of neck and intravenous antibiotics (penicillin, ampicillin–sulbactam and clindamycin) are the preferred choice, and incision and drainage by head and neck surgeon is the appropriate treatment.

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History: A 40 year-old man presents with right neck pain that started while he was wrestling with his friend 2 days ago. Today he also has a right-sided frontotemporal headache and complains that he can hear his heartbeat ringing in his right ear. Vital signs are normal. There is no evidence of head or neck trauma. Neurologic exam shows the abnormalities of the right eye seen. What is the most likely diagnosis?

1. Carotid artery dissection
2. Right third cranial nerve palsy
3. Severe neck strain
4. Temporal arteritis
5.  Vertebral artery dissection

Answer: 1. Carotid artery dissection is uncommon but is a significant
cause of stroke in the young. It usually occurs after major or minor neck trauma. The most common symptom is headache, which is usually frontotemporal, followed by neck pain; pulsatile tinnitus occurs occasionally. Neurologic abnormalities, classically a partial ipsilateral Horner syndrome (no anhydrosis), often occur days after the onset of pain and can be quite subtle. In this case the patient’s right eye miosis is obvious, but the ptosis is very mild.

Neck strain would be a diagnosis of exclusion and is less likely here given the classic presentation of carotid dissection.

Third cranial nerve palsy produces severe ptosis, pupillary dilation, and ophthalmoplegia.

Temporal arteritis occurs almost exclusively in those older than 50 years and is not associated with trauma.

Vertebral artery dissection also occurs after neck trauma but usually causes occipital and nuchal pain and brainstem deficits such as vertigo and ataxia.

Clinical Rounds by ClinicHours

History: A crying child came with his parents to ED with c/o vomiting (nonbilious, nonprojectile), abdominal pain, he was pulling his legs to the chest, and passage of blood per rectum. On physical examination, a sausage-shaped mass was felt in RHC. What’s the diagnosis?

1. Abdominal hernias
2. Volvulus
3. Intussusception
4. Acute gastroenteritis
5. Rectal prolapse

Answer: Intussusception is a medical condition in which a part of the intestine folds into the section immediately ahead of it. It typically involves the small bowel and less commonly the large bowel. MC type is Ileocecal – 77%.

Signs and symptoms:

• Early signs: Periodic abdominal pain, nausea, vomiting, pulling legs to the chest area.
• Later signs: PR bleed, often with “red currant jelly” stool (stool mixed with blood and mucus), lethargy, and sausage-shaped mass.

Etiology: Infections, Anatomical factors, Altered motility, Meckel’s diverticulum, Duplication, Polyps, Appendicitis, Hyperplasia of Peyer patches or Idiopathic.

Diagnosis: USG (target or doughnut sign or pseudokidney), CT, X-ray abdomen.

Treatment: Barium or water-soluble enema, surgical reduction.

Clinical Rounds by ClinicHours

History: A 9 yr child with pruritic and painful rashes on the lower extremities and hands. Arthritis and abdominal pain were also noted. What’s the diagnosis?

1. IgA Vasculitis
2. Hypersensitivity vasculitis
3. Leukocytoclastic vasculitis
4. Meningococcemia
5. Rickettsial diseases

Answer: Henoch Schonlein purpura (HSP) also known as IgA vasculitis is an acute IgA mediated disorder characterized by a generalized vasculitis involving the small vessels of the skin, GI tract, kidneys, joints, and, rarely, the lungs and CNS. IgAV is the most common vasculitis in childhood. The disease is more benign in children than in adults.

Signs & Symptoms: Purpura, arthritis, and abdominal pain are known as the “classic triad” of Henoch–Schönlein purpura.

Headache, Anorexia, Fever, Rash (95-100% of cases), especially involving the legs; this is the hallmark of the disease, Abdominal pain and vomiting (35-85%), Joint pain (60-84%), especially involving the knees and ankles, Subcutaneous edema (20-50%), Scrotal edema (2-35%) or Bloody stools.

Diagnosis: Urinalysis, KFT, CBC, PT-INR, aPTT, Biopsy

DDx: IgAV may mimic an abdominal emergency, Papular urticaria, SLE, meningococcemia, dermatitis herpetiformis.

Treatment: Combination of IV methylprednisolone (steroid), cyclophosphamide and dipyridamole followed by prednisone. IVIG.

Clinical Rounds by ClinicHours

History: A 33 yr female presented with fatigue & flat painless purple lesions on the nose. She had a history of HIV infection and a low CD4 cell count. What’s the diagnosis?
1. Hemangioma
2. Kaposi Sarcoma
3. Bacillary Angiomatosis
4. Purpura

Answer: Kaposi sarcoma (KS) is an indolent angio-proliferative spindle-cell tumor derived from endothelial and immune cells infected with human herpes virus type 8 (HHV-8).

Four sub-types are described:

1. Classic KS tends to affect older men in regions where KSHV is highly prevalent (Mediterranean, Eastern Europe, Middle East), is usually slow-growing, and most often affects only the legs.
2. Endemic KS is MC in Sub-Saharan Africa and is more aggressive in children, while older adults present similarly to classic KS.
3. Immunosuppression therapy-related KS generally occurs in people following organ transplantation and mostly affects the skin.
4. Epidemic KS occurs in people with AIDS and many parts of the body can be affected.

Symptoms: Lesions are nodules or blotches that may be red, purple, brown, or black, and are usually papular. They are typically found on the skin, mouth, gastrointestinal tract, and respiratory tract. Growth can range from very slow to explosively fast, and is associated with significant mortality and morbidity. The lesions are painless, but become cosmetically disfiguring or interruptive to organs.

Diagnosis: KS is diagnosed by tissue biopsy, CD4 count

Treatment: HAART, Combination therapy with regimens such as ABV (actinomycin D, bleomycin, vincristine) or single-agent therapy such as doxorubicin. Cytotoxic agents like doxorubicin, daunorubicin, Paclitaxel or oral etoposide. Radiation therapy, cryotherapy, laser therapy or surgical excision.

Clinical Rounds by ClinicHours