- Email: [email protected]
Case of the day
The Journal of Emergency Medicine, Vol. 23, No. 4, pp 421– 423, 2002 Copyright © 2002 Elsevier Science Inc. Printed in the USA. All rights reserved 0736-4679/02 $–see front matter
Letters to the Editor
e CASE OF THE DAY
receive thrombolytic medication. A treatment that could allow him to return to normal life but which carried a 6 –10% risk of fatal intracranial bleeding. He told me, “I’m only 54 years old and don’t want to remain paralyzed in bed; I would rather go for TPA and have a normal, healthier life in the future— or else die.” He told me he was essentially the only living person in his family; he still had a distant cousin in Seattle, Washington, but they had not spoken for many years. Then he asked me to hand him the wallet from his pants. I did so, and he took out an old piece of paper with a telephone number on it. “Doc,” he said, “If something happens to me, call this number and let my cousin know that I am no more. Also tell my cousin that even though we have not met or talked for many years and have been fighting for a long time, I still love him.” Then he signed the informed consent for the thrombolytic treatment. I was stunned by this statement. And as I looked at this living person, I was suddenly struck by the possibility that he might die after receiving the TPA treatment. All at once, my excitement vanished. I signed the physician’s part of the consent form but with great reluctance. The neurologist arrived, examined the patient, and asked the nurse to administer the TPA. I watched as the TPA began flowing into the patient’s vein. My colleague on the next shift who came to relieve me told me to go home because my shift had ended. But I could not leave. After 1 h, the patient started moving his left upper arm and wriggled the toes of his left foot. His strength kept improving as he kept smiling and talking to staff members. I still held the telephone number in my hand, but seeing the patient’s condition improve gave me some consolation. Before leaving the room, I promised to see him the next day in the intensive care unit. That night, after I spent some time with my family, I went to bed— but I could not sleep well. The next morning, I went to the hospital early and went straight to the
It was 7:30 PM near the end of my shift on a busy day when a person came running into the Emergency Department (ED) screaming, “Someone is having a heart attack outside in the car.” I rushed out with two nurses and found a car with its engine running, which had hit the side wall of our building. A middle-aged man was sitting in the driver’s seat. We approached the window on the driver’s side. The man had his face turned to the left side. With difficulty and with slurred speech he said, “I am having a stroke.” We opened the door and found a 300-lb man who was unable to move the left side of his body. With extra help, we lifted him from the car seat, moved him onto a gurney, and brought him into the ED. The man said that he had been eating a fast-food hamburger 20 min previously, when he suddenly felt weakness on the left side of his body and his speech became slurred. When asked why he did not call the ambulance, he explained. He said that he had called an ambulance 2 years previously, when he had a minor stroke, and that he later had to pay for the ambulance because his insurance did not approve it. This time when he had a stroke, he dragged his feet to the car and drove to (actually, into) the hospital 5 miles away. Physical examination showed that the patient had complete paralysis of the left side of the body and right facial droop. Results of laboratory tests and a computed tomography (CT) scan of the head were normal. I decided to stay late because this stroke patient represented my case of the day, and I was very excited because it was my first case of stroke eligible for thrombolytic treatment. I called the neurologist, who told me to obtain informed consent for thrombolytic treatment [specifically, tissue plasminogen activator (TPA)] and that he would be on his way to see the patient. Without hesitation, I told the patient that he had two options: either to remain paralyzed and bedridden or to
Guidelines for Letters—Letters will appear at the discretion of the editor as space permits and may be subjected to some editing. Three typewritten, double-spaced copies should be submitted. 421
422
Letters to the Editor
intensive care unit, where I saw the patient walking with the help of a nurse. When the patient saw me, he gave me a hug. I took the scrap of paper with the telephone number from my pocket and gave it back to the man, saying that we wouldn’t be needing it anymore. Now it was the patient’s turn to be very excited. He said that he now wanted to live and that he would lose weight and quit smoking. He also told me that he would contact all his relatives now that he suddenly found life to be beautiful. As I returned to the ED, I reflected on what for me had been my case of the day. For the patient, it was nothing less than a matter of life and death. Rajesh Gupta, MD, FACEP, FAAEM Department of Emergency Medicine Kaiser Permanente Medical Center Fresno, California PII S0736-4679(02)00584-X Acknowledgment—The Medical Editing Department of Kaiser Foundation Hospitals, Inc., provided editorial assistance.
e TWO FATAL CASES OF INFANTS WITH CONGENITAL LEUKEMIA PRESENTING WITH SKIN LESIONS
e Letter to the Editor: Congenital leukemia (CL) is an extremely rare hematologic disorder that comprises only 0.5-1% of the leukemias in the first year of life. Specific skin lesions are frequent (25 to 30% of cases) and sometimes (7%) precede anomalies in peripheral and medullary smears (1-6). Herein we report two cases of CL with skin lesions (one with reddish purple nodules on the extremities and the other with a widespread petechial and purpuric rash on the trunk) because of their rare presentation.
was noted one week after the birth, and widespread skin lesions, respiratory distress, and fever arose when she was 3 weeks old. Because the severity of the symptoms gradually increased, she was admitted, diagnosed with leukemia, and referred to our hospital for further investigation and management. On physical examination, the weight, height and head circumference were within the normal ranges. She had numerous reddish purple nodules clustered on the face and the upper and lower extremities, particularly on the right inguinal and left thigh regions, and some of the skin lesions looked infected. Respiratory examination revealed inspiratory rales in the middle zone of the right lung. She also had tachycardia and a 2nd degree systolic murmur sound on all foci of the heart. The enlarged liver was palpable 7 cm below the right costal margin, and the spleen, 6 cm below the left costal margin. Other systemic findings were normal. Laboratory studies disclosed a hemoglobin of 10.2 g/dL, leukocyte count of 150,000/mm3 and platelet count of 219,000/mm3. In the peripheral blood smear, myeloblasts were predominant (90%). In the bone marrow aspirate, almost all the cells were myeloblasts: PAS staining was negative and SUDAN staining was positive. Serum electrolytes and renal and liver function tests were normal. A thoracic X-ray study showed pneumonic infiltration on the right side. Abdominal ultrasonography showed massive hepatosplenomegaly. The patient was hospitalized with the diagnosis of CL and lower respiratory tract infection. Aside from supportive therapy, cefazolin plus gentamicin were initiated. On the second day of admission, an exchange transfusion was performed because of the very high leukocyte count. However, her respiratory distress and fever did not subside and the patient died on the fourth day after admission. Postmortem blood and cerebrospinal fluid (CSF) cultures were found to be sterile, but Pseudomonas aeruginosa was isolated from the skin lesions. Cytological examination of the CSF showed class IV. At autopsy, leukemic cell infiltration was observed in the liver, lung, larynx, and skin.
CASE 2 CASE 1 A 28-day-old female presented with abdominal swelling, widespread skin lesions, respiratory distress and fever. She was the product of a 40 week term uncomplicated gestation and labor. No maternal uses of medication or antepartum illnesses were reported. Abdominal swelling
The work has been carried out in Department of Pediatrics, Erciyes University Faculty of Medicine, Kayseri, Turkey.
A 35-day-old female was admitted with abdominal swelling, bloody diarrhea, and fever. Ten and 5 days before admission to our hospital, abdominal swelling and fever were recorded, respectively. On the day of admission to the hospital, bloody diarrhea developed. The personal and family histories were noncontributory. Physical examination revealed normal weight, height, and head circumference. A widespread petechial and purpuric rash was noted on the trunk, and she also had oozy bleeding at the injection sites. Abdominal examination revealed 5-cm hepatomegaly and
Letters to the Editor
e CASE OF THE DAY
receive thrombolytic medication. A treatment that could allow him to return to normal life but which carried a 6 –10% risk of fatal intracranial bleeding. He told me, “I’m only 54 years old and don’t want to remain paralyzed in bed; I would rather go for TPA and have a normal, healthier life in the future— or else die.” He told me he was essentially the only living person in his family; he still had a distant cousin in Seattle, Washington, but they had not spoken for many years. Then he asked me to hand him the wallet from his pants. I did so, and he took out an old piece of paper with a telephone number on it. “Doc,” he said, “If something happens to me, call this number and let my cousin know that I am no more. Also tell my cousin that even though we have not met or talked for many years and have been fighting for a long time, I still love him.” Then he signed the informed consent for the thrombolytic treatment. I was stunned by this statement. And as I looked at this living person, I was suddenly struck by the possibility that he might die after receiving the TPA treatment. All at once, my excitement vanished. I signed the physician’s part of the consent form but with great reluctance. The neurologist arrived, examined the patient, and asked the nurse to administer the TPA. I watched as the TPA began flowing into the patient’s vein. My colleague on the next shift who came to relieve me told me to go home because my shift had ended. But I could not leave. After 1 h, the patient started moving his left upper arm and wriggled the toes of his left foot. His strength kept improving as he kept smiling and talking to staff members. I still held the telephone number in my hand, but seeing the patient’s condition improve gave me some consolation. Before leaving the room, I promised to see him the next day in the intensive care unit. That night, after I spent some time with my family, I went to bed— but I could not sleep well. The next morning, I went to the hospital early and went straight to the
It was 7:30 PM near the end of my shift on a busy day when a person came running into the Emergency Department (ED) screaming, “Someone is having a heart attack outside in the car.” I rushed out with two nurses and found a car with its engine running, which had hit the side wall of our building. A middle-aged man was sitting in the driver’s seat. We approached the window on the driver’s side. The man had his face turned to the left side. With difficulty and with slurred speech he said, “I am having a stroke.” We opened the door and found a 300-lb man who was unable to move the left side of his body. With extra help, we lifted him from the car seat, moved him onto a gurney, and brought him into the ED. The man said that he had been eating a fast-food hamburger 20 min previously, when he suddenly felt weakness on the left side of his body and his speech became slurred. When asked why he did not call the ambulance, he explained. He said that he had called an ambulance 2 years previously, when he had a minor stroke, and that he later had to pay for the ambulance because his insurance did not approve it. This time when he had a stroke, he dragged his feet to the car and drove to (actually, into) the hospital 5 miles away. Physical examination showed that the patient had complete paralysis of the left side of the body and right facial droop. Results of laboratory tests and a computed tomography (CT) scan of the head were normal. I decided to stay late because this stroke patient represented my case of the day, and I was very excited because it was my first case of stroke eligible for thrombolytic treatment. I called the neurologist, who told me to obtain informed consent for thrombolytic treatment [specifically, tissue plasminogen activator (TPA)] and that he would be on his way to see the patient. Without hesitation, I told the patient that he had two options: either to remain paralyzed and bedridden or to
Guidelines for Letters—Letters will appear at the discretion of the editor as space permits and may be subjected to some editing. Three typewritten, double-spaced copies should be submitted. 421
422
Letters to the Editor
intensive care unit, where I saw the patient walking with the help of a nurse. When the patient saw me, he gave me a hug. I took the scrap of paper with the telephone number from my pocket and gave it back to the man, saying that we wouldn’t be needing it anymore. Now it was the patient’s turn to be very excited. He said that he now wanted to live and that he would lose weight and quit smoking. He also told me that he would contact all his relatives now that he suddenly found life to be beautiful. As I returned to the ED, I reflected on what for me had been my case of the day. For the patient, it was nothing less than a matter of life and death. Rajesh Gupta, MD, FACEP, FAAEM Department of Emergency Medicine Kaiser Permanente Medical Center Fresno, California PII S0736-4679(02)00584-X Acknowledgment—The Medical Editing Department of Kaiser Foundation Hospitals, Inc., provided editorial assistance.
e TWO FATAL CASES OF INFANTS WITH CONGENITAL LEUKEMIA PRESENTING WITH SKIN LESIONS
e Letter to the Editor: Congenital leukemia (CL) is an extremely rare hematologic disorder that comprises only 0.5-1% of the leukemias in the first year of life. Specific skin lesions are frequent (25 to 30% of cases) and sometimes (7%) precede anomalies in peripheral and medullary smears (1-6). Herein we report two cases of CL with skin lesions (one with reddish purple nodules on the extremities and the other with a widespread petechial and purpuric rash on the trunk) because of their rare presentation.
was noted one week after the birth, and widespread skin lesions, respiratory distress, and fever arose when she was 3 weeks old. Because the severity of the symptoms gradually increased, she was admitted, diagnosed with leukemia, and referred to our hospital for further investigation and management. On physical examination, the weight, height and head circumference were within the normal ranges. She had numerous reddish purple nodules clustered on the face and the upper and lower extremities, particularly on the right inguinal and left thigh regions, and some of the skin lesions looked infected. Respiratory examination revealed inspiratory rales in the middle zone of the right lung. She also had tachycardia and a 2nd degree systolic murmur sound on all foci of the heart. The enlarged liver was palpable 7 cm below the right costal margin, and the spleen, 6 cm below the left costal margin. Other systemic findings were normal. Laboratory studies disclosed a hemoglobin of 10.2 g/dL, leukocyte count of 150,000/mm3 and platelet count of 219,000/mm3. In the peripheral blood smear, myeloblasts were predominant (90%). In the bone marrow aspirate, almost all the cells were myeloblasts: PAS staining was negative and SUDAN staining was positive. Serum electrolytes and renal and liver function tests were normal. A thoracic X-ray study showed pneumonic infiltration on the right side. Abdominal ultrasonography showed massive hepatosplenomegaly. The patient was hospitalized with the diagnosis of CL and lower respiratory tract infection. Aside from supportive therapy, cefazolin plus gentamicin were initiated. On the second day of admission, an exchange transfusion was performed because of the very high leukocyte count. However, her respiratory distress and fever did not subside and the patient died on the fourth day after admission. Postmortem blood and cerebrospinal fluid (CSF) cultures were found to be sterile, but Pseudomonas aeruginosa was isolated from the skin lesions. Cytological examination of the CSF showed class IV. At autopsy, leukemic cell infiltration was observed in the liver, lung, larynx, and skin.
CASE 2 CASE 1 A 28-day-old female presented with abdominal swelling, widespread skin lesions, respiratory distress and fever. She was the product of a 40 week term uncomplicated gestation and labor. No maternal uses of medication or antepartum illnesses were reported. Abdominal swelling
The work has been carried out in Department of Pediatrics, Erciyes University Faculty of Medicine, Kayseri, Turkey.
A 35-day-old female was admitted with abdominal swelling, bloody diarrhea, and fever. Ten and 5 days before admission to our hospital, abdominal swelling and fever were recorded, respectively. On the day of admission to the hospital, bloody diarrhea developed. The personal and family histories were noncontributory. Physical examination revealed normal weight, height, and head circumference. A widespread petechial and purpuric rash was noted on the trunk, and she also had oozy bleeding at the injection sites. Abdominal examination revealed 5-cm hepatomegaly and