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Atypical presentation of ruptured abdominal aortic aneurysm
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AMERICAN JOURNAL OF EMERGENCY MEDICINE [] Volume 16, Number 4 [] July 1998
about 16 hours after the onset of RLQ pain which woke him from sleep. He was able to drive his cab in the interim. The pain was sharp and well localized from its onset. He was slightly nauseated and complained that he felt constipated, although he had had several small diarrheal bowel movements. His temperature was 36.4°C. He was tender at McBurney's point. There was no rebound, although he had a positive psoas sign. Rectal examination was normal. White blood cell count was 14.5. Urinalysis was negative. He underwent prompt laparotomy at which an enlarged and inflamed, but unruptured appendix was removed. I do not think it is earth-shaking news to most practicing emergency physicians that appendicitis may present in this fashion, although it does run counter to the usual wisdom one learns in training. It is certainly worth reminding ourselves that patients do not usually read the textbooks and may present in unusual ways. KEN ZAFREN,MD Alaska Regional Hospital Anchorage, AK
Reference 1. Wigder HN, Narasimhan K, Shah MR: Acute appendicitis: The myths of migratory pain and the gradual onset of symptoms. Am J Emerg Med 1997;15:111-112 (letter)
ATYPICAL PRESENTATIONOF RUPTUREDABDOMINAL AORTIC ANEURYSM To the Editor:--We read with much interest the recent article by Beach and Manthey t reporting a case of acute thoracic aortic dissection presenting with the chief compliant of unilateral lower extremity numbness. The lack of clinical suspicion and variation in the presentation of aortic dissection and aortic aneurysmal rupture may result in late or missed diagnosis of these entities. We report an unusual case of ruptured abdominal aortic aneurysm presenting as unilateral ureteric colic in a hemodynarnically stable patient. A 65-year-old Caucasian man with medical history of bilateral polycystic kidney disease presented to the emergency department (ED) complaining of sharp left flank pain radiating to the groin. The pain had started 2 hours before the presentation. The patient denied any other complaints. On examination, his blood pressure was 120/80 mm Hg, pulse rate was 92 beats/rain, respiratory rate was 16 breaths/min, and temperature was 98°E The abdomen was soft and nontender with normoactive bowel sounds. There was no rigidity, rebound tenderness, hepatosplenomegaly, masses, or bruit. There was minimal left flank tenderness on deep palpation. The remainder of the examination findings were unremarkable. The laboratory data revealed a white blood cell count of 17,000/laL with normal differential, hemoglobin level of 11.5 g/dL (115 g/L), and a platelet level of 300,000/~tL. Serum electrolyte, blood urea nitrogen, and creatinine levels, as well as coagulation study results, were within normal limits. The urinalysis was remarkable for 15 to 20 red blood cells/high-power field. A kidney/ureter/bladder radiograph was negative and a renal ultrasound showed bilateral polycystic kidney disease without any evidence of calculi. The patient was admitted and urology consultation was obtained. Therapy was started with intravenous antibiotics for a suspected ruptured renal cyst. On the third day of the admission, the patient complained of diaphoresis, shortness of breath, and a persistent, dull left flank pain radiating to the groin. Urgent laboratory investigations showed that the hemoglobin level had decreased to 8.0 g/dL (80 g/L) from 11.5 g/dL (115 g/L) on admission. Retrospective review of the hemoglobin levels revealed a daily decrease of > 1.0 g/dL (> 10 g/L) since admission. The white blood cell count was normal. On examination, his blood pressure was 144/84 mm Hg, pulse was
110 beats/rain, respiratory rate was 22 breaths/min, and the patient remained afebrile. He was not orthostatic. The left flank pain present on admission was elicited. The abdomen was benign and the rectal examination revealed brown guaiac negative stool. No other signs of blood loss were noted. The remainder of the examination did not reveal any positive findings. Computed tomography (CT) of the abdomen showed a 10-cm abdominal aortic aneurysm beginning at the level of the renal arteries and extending to the bifurcation with associated hemoperitoneum and hemorrhage adjacent to the left psoas muscle. The large peritoneal blood collection most likely resulted in compressing the site of aortic rupture and retarding the rate of blood loss into the peritoneum. The patient underwent emergent surgery to repair the ruptured abdominal aortic aneurysm. The recovery was uneventful and the patient was discharged on the 10th postoperative day in stable condition. Ten percent of patients presented with genitourinary symptoms in a series of 400 patients who underwent surgery for abdominal aortic aneurysms.= Thus, unilateral flank pain with distal radiation to the genitalia, hip, and thigh is a rare presenting feature of aneurysmal rupture, which may be misdiagnosed as a ureteric colic. 3 The presumed mechanism of this pain is the irritation of the ureteric pain fibers in the sympathetic plexus by the retroperitoneal hematoma.=,3 In conclusion, our case reiterates the fact that the manifestations of abdominal aortic aneurysmal rupture constitute a wide constellation of clinical features. Timely diagnosis accompanied by prompt surgical intervention significantly reduces the mortality rate in patients with aortic dissection and aortic aneurysm rupture.l,2 Early recognition may be facilitated by a high index of clinical suspicion accompanied by the knowledge of variable manifestations of aortic dissection and aortic aneurysmal rupture. We suggest that ruptured abdominal aortic aneurysm must be included in the differential diagnosis while evaluating a hemodynamically stable patient presenting with ureteric colic. MANSOORAHMAD,MD FAIAZM. RASUL,MD Department of Medicine Shands Hospital at Lake Shore Lake City, FL References 1. Beach C, Manthey D: Painless acute aortic dissection presenting as left lower extremity numbness. Am J Emerg Med 1998;16: 49-51 2. Culp OS, Bematz PE: Urologic aspects of lesions in the abdominal aorta. J Urol 1961 ;86:189-195 3. Moran CG, Edwards AT, Griffith GH: Ruptured abdominal aortic aneurysm presenting with uretedc colic. BMJ 1987;294:1279
AIRBAG-RELATEDLOWER EXTREMITY BURNS IN A PEDIATRIC PATIENT To the Editor:--A federal mandate currently requires all new passenger cars built after September 1997 to provide driver-side and passenger-side airbags, in addition to 3-point restraint seat belts. As a result, fewer fatalities and injuries are experienced in moderate to severe frontal collisions.1 However, airbag deployment results in new patterns of injury that present different risks to the pediatric population. We report the following case to emphasize the specificity of alrbag-related injuries in the pediatric population, and we discuss several differences between the effects of this restraint system in child injuries and its effects in adult injuries. A 10 year-old Hispanic boy was restrained in the front passenger seat of a sport utility vehicle that collided into a stationary ear at a speed of approximately 30 mph. Damage to the front bumper and
AMERICAN JOURNAL OF EMERGENCY MEDICINE [] Volume 16, Number 4 [] July 1998
about 16 hours after the onset of RLQ pain which woke him from sleep. He was able to drive his cab in the interim. The pain was sharp and well localized from its onset. He was slightly nauseated and complained that he felt constipated, although he had had several small diarrheal bowel movements. His temperature was 36.4°C. He was tender at McBurney's point. There was no rebound, although he had a positive psoas sign. Rectal examination was normal. White blood cell count was 14.5. Urinalysis was negative. He underwent prompt laparotomy at which an enlarged and inflamed, but unruptured appendix was removed. I do not think it is earth-shaking news to most practicing emergency physicians that appendicitis may present in this fashion, although it does run counter to the usual wisdom one learns in training. It is certainly worth reminding ourselves that patients do not usually read the textbooks and may present in unusual ways. KEN ZAFREN,MD Alaska Regional Hospital Anchorage, AK
Reference 1. Wigder HN, Narasimhan K, Shah MR: Acute appendicitis: The myths of migratory pain and the gradual onset of symptoms. Am J Emerg Med 1997;15:111-112 (letter)
ATYPICAL PRESENTATIONOF RUPTUREDABDOMINAL AORTIC ANEURYSM To the Editor:--We read with much interest the recent article by Beach and Manthey t reporting a case of acute thoracic aortic dissection presenting with the chief compliant of unilateral lower extremity numbness. The lack of clinical suspicion and variation in the presentation of aortic dissection and aortic aneurysmal rupture may result in late or missed diagnosis of these entities. We report an unusual case of ruptured abdominal aortic aneurysm presenting as unilateral ureteric colic in a hemodynarnically stable patient. A 65-year-old Caucasian man with medical history of bilateral polycystic kidney disease presented to the emergency department (ED) complaining of sharp left flank pain radiating to the groin. The pain had started 2 hours before the presentation. The patient denied any other complaints. On examination, his blood pressure was 120/80 mm Hg, pulse rate was 92 beats/rain, respiratory rate was 16 breaths/min, and temperature was 98°E The abdomen was soft and nontender with normoactive bowel sounds. There was no rigidity, rebound tenderness, hepatosplenomegaly, masses, or bruit. There was minimal left flank tenderness on deep palpation. The remainder of the examination findings were unremarkable. The laboratory data revealed a white blood cell count of 17,000/laL with normal differential, hemoglobin level of 11.5 g/dL (115 g/L), and a platelet level of 300,000/~tL. Serum electrolyte, blood urea nitrogen, and creatinine levels, as well as coagulation study results, were within normal limits. The urinalysis was remarkable for 15 to 20 red blood cells/high-power field. A kidney/ureter/bladder radiograph was negative and a renal ultrasound showed bilateral polycystic kidney disease without any evidence of calculi. The patient was admitted and urology consultation was obtained. Therapy was started with intravenous antibiotics for a suspected ruptured renal cyst. On the third day of the admission, the patient complained of diaphoresis, shortness of breath, and a persistent, dull left flank pain radiating to the groin. Urgent laboratory investigations showed that the hemoglobin level had decreased to 8.0 g/dL (80 g/L) from 11.5 g/dL (115 g/L) on admission. Retrospective review of the hemoglobin levels revealed a daily decrease of > 1.0 g/dL (> 10 g/L) since admission. The white blood cell count was normal. On examination, his blood pressure was 144/84 mm Hg, pulse was
110 beats/rain, respiratory rate was 22 breaths/min, and the patient remained afebrile. He was not orthostatic. The left flank pain present on admission was elicited. The abdomen was benign and the rectal examination revealed brown guaiac negative stool. No other signs of blood loss were noted. The remainder of the examination did not reveal any positive findings. Computed tomography (CT) of the abdomen showed a 10-cm abdominal aortic aneurysm beginning at the level of the renal arteries and extending to the bifurcation with associated hemoperitoneum and hemorrhage adjacent to the left psoas muscle. The large peritoneal blood collection most likely resulted in compressing the site of aortic rupture and retarding the rate of blood loss into the peritoneum. The patient underwent emergent surgery to repair the ruptured abdominal aortic aneurysm. The recovery was uneventful and the patient was discharged on the 10th postoperative day in stable condition. Ten percent of patients presented with genitourinary symptoms in a series of 400 patients who underwent surgery for abdominal aortic aneurysms.= Thus, unilateral flank pain with distal radiation to the genitalia, hip, and thigh is a rare presenting feature of aneurysmal rupture, which may be misdiagnosed as a ureteric colic. 3 The presumed mechanism of this pain is the irritation of the ureteric pain fibers in the sympathetic plexus by the retroperitoneal hematoma.=,3 In conclusion, our case reiterates the fact that the manifestations of abdominal aortic aneurysmal rupture constitute a wide constellation of clinical features. Timely diagnosis accompanied by prompt surgical intervention significantly reduces the mortality rate in patients with aortic dissection and aortic aneurysm rupture.l,2 Early recognition may be facilitated by a high index of clinical suspicion accompanied by the knowledge of variable manifestations of aortic dissection and aortic aneurysmal rupture. We suggest that ruptured abdominal aortic aneurysm must be included in the differential diagnosis while evaluating a hemodynamically stable patient presenting with ureteric colic. MANSOORAHMAD,MD FAIAZM. RASUL,MD Department of Medicine Shands Hospital at Lake Shore Lake City, FL References 1. Beach C, Manthey D: Painless acute aortic dissection presenting as left lower extremity numbness. Am J Emerg Med 1998;16: 49-51 2. Culp OS, Bematz PE: Urologic aspects of lesions in the abdominal aorta. J Urol 1961 ;86:189-195 3. Moran CG, Edwards AT, Griffith GH: Ruptured abdominal aortic aneurysm presenting with uretedc colic. BMJ 1987;294:1279
AIRBAG-RELATEDLOWER EXTREMITY BURNS IN A PEDIATRIC PATIENT To the Editor:--A federal mandate currently requires all new passenger cars built after September 1997 to provide driver-side and passenger-side airbags, in addition to 3-point restraint seat belts. As a result, fewer fatalities and injuries are experienced in moderate to severe frontal collisions.1 However, airbag deployment results in new patterns of injury that present different risks to the pediatric population. We report the following case to emphasize the specificity of alrbag-related injuries in the pediatric population, and we discuss several differences between the effects of this restraint system in child injuries and its effects in adult injuries. A 10 year-old Hispanic boy was restrained in the front passenger seat of a sport utility vehicle that collided into a stationary ear at a speed of approximately 30 mph. Damage to the front bumper and