Classical Lemierre's syndrome is characterized by severe sepsis with metastatic abscess formation in young, previously fit people from a primary head or neck focus. The causative organisms are the anaerobic fusobacteria, most commonly Fusobacterium necrophorum. We describe the evaluation, therapeutic interventions and management of a patient with Lemierre's syndrome who presented in septic shock with multiple organ dysfunction. The patient required immediate interventions including endotracheal intubation and mechanical ventilation, fluid resuscitation, inotropic support, bilateral thoracostomy tube drainage of empyemata and antimicrobial therapy. The unexpected isolation of Fusobacterium necrophorum from blood cultures and empyema fluid necessitated a change of antibiotic regime to provide anaerobic cover. The patient required 4 weeks of intensive support including prolonged antimicrobial therapy, and after a further 2 weeks was discharged home from hospital. This case highlights the need to raise the awareness of 'the forgotten disease': Lemierre's syndrome. Its diagnosis may, as in this case, be confounded by a lack of symptoms of pharyngitis at the time of presentation, and end-organ dysfunction associated with severe sepsis, possibly suggesting an alternative source of infection. As appropriate antibiotics reduce mortality dramatically, clinicians need to be alert to Lemierre's syndrome and include it in the differential diagnosis in young but otherwise healthy patients presenting with severe sepsis.
Amphetamine induced ischaemic colitis is an exceedingly rare presentation of amphetamine toxicity. The cases reported in the literature have described mild or transient disease. We present a fatal case of ischaemic colitis induced by amphetamine use in a 44-year-old woman who presented in extremis after a cardiac arrest en route to the emergency department. A short history of headache, abdominal pain, vomiting and agitation preceded her admission. Imaging revealed changes consistent with ischaemic colitis. Emergency laparotomy revealed widespread colonic necrosis necessitating a subtotal colectomy. Despite aggressive resuscitation and inotropic support from arrival, the patient deteriorated intraoperatively and died in the immediate postoperative period. Histology showed arterial type ischaemia/reperfusion injury of the area supplied by the superior mesenteric artery. The patient's serum amphetamine level was 0.52mg/l (peak therapeutic levels <0.2mg/l). The postmortem examination concluded that amphetamines were the likely cause of the vasospasm, leading to profound colonic ischaemia.
Background
Abdominal pain is a common presentation in all age groups with 7-10% of emergency department admissions.
Method
This registered audit looks at male children (aged <16), admitted with abdominal pain during this period. Approximately 2,877 children under the age of sixteen were admitted, 1,582 males. This equates to 55% of children admitted within 3 months. Manual note analysis from ED records identified 53 males <16 years of age with abdominal pain for inspection of documentation.
Results
45% of inspected notes had documented genital and scrotal examination, none of which had a documented consent. In addition, 21% had a documented chaperone for the intimate examination. None of the cases had BOTH consent and presence of chaperone documented.
Conclusions
A common presentation in children lacks significant elements of documentation. This is noted in multiple specialties. Potentially overlooked aspects of examination can lead to missed or delayed identification of time sensitive diagnosis namely testicular torsion, with possible substantial legal, professional, and financial consequences.
To improve the quality of documentation, education at junior doctor level has been carried out, with further analysis to take place and with the view to incorporate the three elements of an intimate examination: consent, chaperone, and findings.
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