Initial chest X-ray (chest X-ray 1) showed a right-sided pleural effusion with compressive atelectasis of the mid to lower right lung. Repeat chest X-ray immediately after evacuation (chest X-ray 2) shows improvement of the pleural effusion and a new trace apical right pneumothorax measuring 6.7 mm. When the patient became tachypneic, a third X-ray (chest X-ray 3) showed persistent trace apical right pneumothorax measuring 6.7 mm.
The ECG shows slurred up-stroking of the QRS complexes characteristic of a delta wave. The PR interval is normal; however, the QT interval is greater than 110ms.
Initial abdominal images demonstrated a dissection flap; therefore, a CTA of the chest was also obtained. These images revealed a Stanford type B aortic dissection beginning just distal to the left subclavian artery and extending to the origin of the inferior mesenteric artery. The right renal artery arose from the true lumen of the dissection while the left renal artery arose from the false lumen. This case is interesting as imaging shows the lack of perfusion to the left kidney, residing in the retroperitoneum, which correlates with her non-descript abdominal and left flank pain.
History of present illness: A 51-year-old male with history of gastroesophageal reflux disease status post multiple endoscopies presented to the […]
The patient’s computed tomography (CT) head demonstrated a deformed left globe, concerning for ruptured globe. The patient had hyperdense material in the posterior segment (see green arrow), consistent with vitreous hemorrhage. CT findings that are consistent with globe rupture may include a collapsed globe, intraocular air, or foreign bodies.
At presentation to the ED, a macular rash was notable on all four extremities, trunk and face, and involved mucous membranes of the oropharynx and vaginal introitus. The rash was painful, erythematous and purpuric with targetoid lesions. There were also multiple areas of sloughing and desquamation with a positive Nikolsky sign. Denudement totaled approximately 2% of total body surface area.
CT of the abdomen and pelvis revealed a normal left kidney and an ectopic, malrotated right kidney located in the pelvis (see white arrow).
CTA demonstrated a ruptured 7.4 cm infrarenal abdominal aortic aneurysm with a large left retroperitoneal hematoma.
