Schistosomiasis among travellers returning from Malawi: a common occurrence

Sir, In August 2001, 11 pupils accompanied by four teachers, froma secondary school in London, visited Malawi for 4 weeks. Duringtheir trip they swam in Lake Malawi, having been assured bylocal people that this area was free of schistosomiasis. Five weeks later, one of the pupils, a 17-year-old boy, presentedwith a history     

Wide-complex tachycardia as the presenting complaint in a case of malingering

Fabrications of lethal dysrhythmias are an extremely rare manifestation of malingering, with only one case described more than two decades ago. Recognition of this clinical entity is important because the diagnosis may be difficult to make, therapeutic implications for the patient are significant, and financial consequences of misdiagnosis are considerable. In this case report, we present an unusual example of malingering, in which a patient intentionally mimicked repeated episodes of unstable wide-complex ventricular tachycardia, by tapping on the chest wall cardiac leads, while feigning concurrent episodes of chest pain.     

Persistent hiccups as an atypical presenting complaint of COVID-19

Hiccups (singultus) are reflex inspiratory movements that involve the swallowing reflex arc and can be classified as acute (<48 h) or persistent (>48 h). A 62-year-old man with no history of malignancy or pulmonary disease presented to the Emergency Department with a four-day history of persistent hiccups. Other than episodic hiccupping, his physical examination was otherwise unremarkable. An abnormal chest X-ray led to a CT scan of the chest with IV contrast, which demonstrated regional, peripheral groundglass opacities of the upper lobes with small focal groundglass opacities scattered throughout the lungs. He was tested for COVID-19 per admission protocol, started on hydroxychloroquine, his hiccups improved, and he was discharged to home after 3 days. An emergency medicine physician should keep COVID-19 on the differential and be vigilant of exposure in atypical presentations.     

The Emergency Department presenting complaint as predictor of in-hospital fatality.

BACKGROUND: The relationship between major discharge diagnoses and prediction of in-hospital death has been intensively studied. The relation between the presenting complaint at the Emergency Department (ED) and in-hospital fatality, however, is less well known. OBJECTIVE: To investigate if presenting complaints add information regarding in-hospital fatality risk for nonsurgical ED patients. METHODS: Investigating the relationship of in-hospital fatality rate and presenting complaint by comparing the presenting complaints, discharge diagnoses and in-hospital fatality for all nonsurgical patients visiting the ED during 1 year. RESULTS: Of 12,995 nonsurgical admissions, 40% were treated as in-hospital patients. Among these, 328 in-hospital deaths occurred. Age was the most powerful predictor of death in hospitalized patients (P<0.0001). After adjustment for age, the female sex was found to be protective [odds ratio (OR) 0.73, 95% confidence interval (CI) 0.58-0.92, P=0.007)]. Compared with the largest complaint group, chest pain with an in-hospital fatality rate of 2.5%, there was a significantly increased risk of dying among those with stroke-like symptoms (OR 2.04, 95% CI 1.35-3.08, P=0.0007), dyspnoea (OR 1.95, 95% CI 1.27-3.00, P=0.002) or general disability (OR 1.81, 95% CI 1.17-2.79, P=0.008). CONCLUSIONS: The presenting complaint at the ED carries valuable information of the risk for in-hospital fatality in nonsurgical patients. This knowledge can be valuable in the prioritization between different patient groups in the process of initiating diagnostics and treatment procedures at the ED.     

Painless aortic dissection with bilateral carotid involvement presenting with vertigo as the chief complaint

A 63 year‐old woman was admitted to the emergency department with vertigo, nausea, and vomiting. On arrival ,she was fully oriented and cooperative. She denied any pain in her chest, neck, back, or abdomen. A bruit was heard on both sides of her neck. Cranial computed tomography (CT) revealed no abnormality, while thoracic CT disclosed dissection in the ascending aorta, aortic arch, and bilateral common carotid arteries. After several hours, the patient underwent vascular surgery. She had an uneventful course and was discharged without any sequelae after 10 days.     

Molecular diagnosis and species identification of imported malaria in returning travellers in Italy

A new seminested polymerase chain reaction (sn-PCR)-based protocol was developed and used to detect and identify Plasmodium species in 1226 whole-blood samples from patients (872 Italians and 354 foreigners) with at least 1 symptom compatible with clinical malaria. The results were compared with those obtained by microscopy: 187 samples were positive by microscopy for malaria parasites and 196 were positive by sn-PCR. When compared to microscopy, the sn-PCR detected different malaria parasite species in 11 cases. In 4 of 11 cases, the sn-PCR identified 1 additional malaria parasite species not observed microscopically, suggesting increased sensitivity. In 4 samples with levels of parasitemia too low for accurate identification of species by microscopy, the sn-PCR detected 2 P. falciparum, 1 P. ovale, and 1 P. falciparum plus P. ovale. Moreover, 9 negative samples by microscopy were positive by sn-PCR. Follow-up analysis demonstrated a parasite clearance of P. falciparum DNA up to 3 days after the disappearance of parasitemia at microscopy. In conclusion, sn-PCR-based diagnosis of malaria appears to be a useful tool when the results of conventional techniques are negative in the presence of a syndrome consistent with malaria, yielding accurate species identification and consequential correct treatment.     

Cervical Spine pain as a presenting complaint in metastatic pancreatic cancer: a case report

A 48 year-old female presented to her primary care physician with a two-month history of neck pain with negative cervical spine x-rays. During that office visit, the patient was noted to be tachycardic with EKG revealing ST depressions, which led to hospital admission. Acute coronary syndrome was ruled out, however, persistent neck pain warranted inpatient MRI of the cervical spine, which revealed a cervical spine lesion. Extensive investigation and biopsy ultimately confirmed stage IV pancreatic adenocarcinoma with metastases to the bone, liver, and likely lung. In the literature, the findings of a primary metastatic site being bone is rare with only a few case reports showing vertebral or sternal metastasis as the first clinical manifestation of pancreatic cancer. The uniqueness of this case lies in the only presenting complaint being cervical spine pain in the setting of extensive metastases to the liver, bone, and likely lung.     

以发热伴腰痛为主诉的慢性肾脏病合并布氏菌感染1例报告

<正>布氏菌病简称布病,是布氏菌感染引起的一种人畜共患的传染病,属自然疫源性疾病。布病临床表现主要为发热、多汗、关节痛,以及肝脾、淋巴结肿大等,病情轻重不一。中国报告病例最多的省(自治区)为新疆、内蒙古、山西和黑龙江,集中于北方。疫区布病患者诊断并不困难,但非疫区出现的非典型症状患者常易被误诊。本文报告1例在慢性肾脏病基础上以发热伴腰椎疼痛为主要症状的布氏菌病的诊治经过及体会。     

Association between COVID-19 diagnosis and presenting chief complaint from New York City triage data

Background and aimNew York City (NYC) is an epicenter of the COVID-19 pandemic in the United States. Proper triage of patients with possible COVID-19 via chief complaint is critical but not fully optimized. This study aimed to investigate the association between presentation by chief complaints and COVID-19 status.MethodsWe retrospectively analyzed adult emergency department (ED) patient visits from five different NYC hospital campuses from March 1, 2020 to May 13, 2020 of patients who underwent nasopharyngeal COVID-19 RT-PCR testing. The positive and negative COVID-19 cohorts were then assessed for different chief complaints obtained from structured triage data. Sub-analysis was performed for patients older than 65 and within chief complaints with high mortality.ResultsOf 11,992 ED patient visits who received COVID-19 testing, 6524/11992 (54.4%) were COVID-19 positive. 73.5% of fever, 67.7% of shortness of breath, and 65% of cough had COVID-19, but others included 57.5% of weakness/fall/altered mental status, 55.5% of glycemic control, and 51.4% of gastrointestinal symptoms. In patients over 65, 76.7% of diarrhea, 73.7% of fatigue, and 69.3% of weakness had COVID-19. 45.5% of dehydration, 40.5% of altered mental status, 27% of fall, and 24.6% of hyperglycemia patients experienced mortality.ConclusionA novel high risk COVID-19 patient population was identified from chief complaint data, which is different from current suggested CDC guidelines, and may help triage systems to better isolate COVID-19 patients. Older patients with COVID-19 infection presented with more atypical complaints warranting special consideration. COVID-19 was associated with higher mortality in a unique group of complaints also warranting special consideration.     

Severe coronary artery disease presenting with a chief complaint of cervical pain

We present the case of a 49-yr-old man with cervical pain of 14 wk of duration. Physical examination and magnetic resonance imaging of the cervical spine demonstrated no neurologic abnormality or corroborative pathology. Cardiac catheterization demonstrated advanced multivessel disease. The patient underwent successful coronary bypass grafting and was symptom free 12 mo later. Spine practitioners are often consulted by the medical community to determine if a patient's limb or chest complaints might be caused by a spinal pain generator. This atypical case reminds us of the overlap between cardiac and cervical symptom referral. A patient with critical cardiac ischemia can present with predominant cervical complaints.