Acquired methemoglobinemia is an uncommon hemoglobinopathy that results from exposure to oxidizing agents, such as chemicals or medications. Although, as reported in the adult population, it happens most often due to prescribed medication or procedural anesthesia and not due to easily accessed over-the-counter medications, the authors will describe an otherwise healthy male adult with no known medical history and no prescribed medications, who presented to the emergency department reporting generalized weakness, shortness of breath, headache, dizziness, and pale gray skin. In addition, the patient reported that he also had a severe toothache for several days, which he had been self-treating with an over-the-counter oral benzocaine gel. Ultimately, the diagnosis of methemoglobinemia was made by clinical history, physical examination, and the appearance of chocolate-colored blood and arterial blood gas (ABG) with cooximetry. After 2 mg/kg of intravenous methylene blue was administered, the patient had complete resolution of all signs and symptoms. This case illustrates that emergency physicians should be keenly aware of the potential of toxic hemoglobinopathy secondary to over-the-counter, nonprescribed medications. Discussion with patients regarding the dangers of inappropriate use of these medicines is imperative, as such warnings are typically not evident on product labels.

There was no statistical evidence that application of the OFARs decreases the number of imaging orders or decreases LOS. This observation suggests that even when clinicians are being observed and instructed to use clinical decision rules, their evaluation bias tends toward recommendations for testing.

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Since marijuana legalization, pediatric exposures to cannabis have increased.1 To date, pediatric deaths from cannabis exposure have not been reported. The authors report an 11-month-old male who, following cannabis exposure, presented with central nervous system depression after seizure, and progressed to cardiac arrest and died. Myocarditis was diagnosed post-mortem and cannabis exposure was confirmed. Given the temporal relationship of these two rare occurrences – cannabis exposure and sudden death secondary to myocarditis in an 11-month-old – as well as histological consistency with drug-induced myocarditis without confirmed alternate causes, and prior reported cases of cannabis-associated myocarditis, a possible relationship exists between cannabis exposure in this child and myocarditis leading to death. In areas where marijuana is commercially available or decriminalized, the authors urge clinicians to preventively counsel parents and to include cannabis exposure in the differential diagnosis of patients presenting with myocarditis.

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BACKGROUND:The Chikungunya (CHIK) virus was recently reported by the CDC to have spread to the United States. We report an early documented case of CHIK from the state of Pennsylvania after a patient recently returned from Haiti in June of 2014. METHODS:A 39-year-old man presented to the emergency department complaining of fever, fatigue, polyarthralgias and a diffuse rash for two days. Four days before, he returned from a mission trip to Haiti and reported that four of his accompanying friends had also become ill. A CHIK antibody titer was obtained and it was found to be positive. During his hospital stay, he responded well to supportive care, including anti-infl ammatories, intravenous hydration and anti-emetics. RESULTS:His condition improved within two days and he was ultimately discharged home.CONCLUSIONS: Manifestations of CHIK can be similar to Dengue fever, which is transmitted by the same species of mosquito, and occasionally as a co-infection. Clinicians should include Chikungunya virus in their differential diagnosis of patients who present with fever, polyarthralgia and rash with a recent history of travel to endemic areas, including those within the United States.