Indian Journal of Emergency Medicine

Subarachnoid haemorrhage (SAH) is a life-threatening neurological emergency, most often caused by aneurysmal rupture. However, in patients with multiple systemic comorbidities, including autoimmune disease, coagulopathy, and endstage renal disease, the presentation and outcome may be particularly devastating. We report the case of a 56-year-old male with a background of lupus nephritis, secondary antiphospholipid antibody syndrome, chronic kidney disease on dialysis, and prior cerebrovascular accident who presented with acute headache and subsequently developed spontaneous SAH. Despite timely diagnosis and supportive management, the patient’s condition rapidly deteriorated and he succumbed. This case underscores the multifactorial risks of intracranial haemorrhage in complex autoimmune and renal disease patients, and emphasizes the need for vigilant monitoring and individualized risk-benefit decisions regarding antithrombotic therapy.

Background: Diffuse alveolar haemorrhage (DAH) is a rare but potentially fatal pulmonary complication of SLE. Aims: To describe an unusual presentation of DAH mimicking acute heart failure. Settings and Design: Emergency department case presentation. Methods and Material: Clinical assessment, laboratory testing, imaging (CXR, CT), echocardiography, and renal biopsy. Results: A 34-year-old woman with longstanding SLE presented with acute dyspnoea and hypoxia. CT chest revealed diffuse alveolar haemorrhage. She responded to corticosteroids and supportive therapy. Conclusions: DAH can mimic acute heart failure in SLE and requires rapid recognition for survival.

We present the case of a sixty-one-year-old male with chronic kidney disease (CKD) who developed multi-organ dysfunction characterised by tracheobronchial aspergillosis, hepatocellular carcinoma (HCC), urosepsis, and acute kidney injury (AKI).1,2 The patient initially presented with respiratory distress, haematuria, and sepsis, requiring intensive multidisciplinary intervention. Radiological investigations revealed a fluorodeoxyglucose (FDG)-avid hepatic lesion with features suggestive of HCC3 and widespread bronchial pseudomembranes consistent with invasive aspergillosis.4 Management involved haemodialysis, antifungal therapy, bladder clot evacuation, and supportive care.5 This case underscores the complexity of managing critically ill patients with overlapping infectious and oncological pathologies presenting to emergency services.1,6 Early identification and coordinated multidisciplinary care are critical for optimising outcomes.7 Furthermore, the coexistence of severe fungal airway disease with advanced hepatic malignancy and septic complications highlights the need for heightened clinical vigilance in high-risk CKD populations.8 The integration of serial bronchoscopic assessments, targeted antifungal therapy, and vigilant organ support played a pivotal role in stabilising this patient, demonstrating the importance of comprehensive emergency and critical care pathways in managing such rare and life-threatening presentations.9,10 Key Messages: This case highlights the diagnostic and therapeutic challenges posed by the coexistence of tracheobronchial aspergillosis and hepatocellular carcinoma in a patient with chronic kidney disease and sepsis. Prompt multidisciplinary management is essential to improve survival outcomes in such critically ill patients.

Introduction: Guillain–Barré Syndrome (GBS) comprises a heterogeneous group of acute immune-mediated polyradiculoneuropathies. While the classic ascending pattern is most common, rare variants, such as the pharyngeal–cervical–brachial (PCB) variant and acute motor axonal neuropathy (AMAN), can present diagnostic challenges, particularly when overlapping features are present. Case Report: We report the case of an 18-year-old previously healthy male who presented with rapidly progressive dysphagia, neck weakness, and bilateral upper limb weakness, followed by descending motor involvement without sensory deficits. Neurophysiological studies showed reduced compound muscle action potentials with preserved sensory nerve action potentials, consistent with an axonal motor neuropathy. Discussion: Nerve conduction studies showed AMAN, whereas bulbar and upper limb weakness suggested the PCB variant. The clinical picture, i.e. descending paralysis (hands to feet) indicated a possible descending AMAN or PCB-AMAN overlap. Conclusion: This case underscores the importance of recognizing overlapping GBS variants to facilitate early diagnosis and timely initiation of immunotherapy. Awareness of such presentations can help avoid misdiagnosis, especially when cranial and cervicobrachial weakness predominate.

Background:Typhoid fever, caused bySalmonella entericaserovar Typhi, is a systemic infection primarily affecting the gastrointestinal tract. Common complications include internal bleeding, intestinal perforation, cholecystitis, bronchitis, and osteomyelitis. Rarely, neurological manifestations such as cerebellitis and bilateral sensorineural hearing loss (SNHL) have been described.1,2 We report a rare case of a 20-year-old female with a prior history of idiopathic intracranial hypertension (IIH) who developed acute ataxia and bilateral SNHL following typhoid fever. Case Presentation: A 20-year-old woman presented with fever, diarrhea, and vomiting, followed by progressive imbalance and hearing loss. She was diagnosed with typhoid fever and started on oral antibiotics. Despite therapy, her neurological symptoms worsened. MRI and CSF studies excluded other etiologies, and audiometry confirmed moderate to severe bilateral SNHL. She received intravenous antibiotics and intravenous immunoglobulin (IVIG), which improved her balance, though hearing loss persisted with only partial audiometric recovery. Conclusion: This case illustrates an uncommon post-infectious complication of typhoid fever and highlights the importance of early recognition and prompt management of neurological sequelae. Clinicians should maintain vigilance for atypical manifestations, particularly in endemic regions.

We present a rare case highlighting the unusual coexistence of single vessel coronary artery disease (CAD) and hypokalemic periodic paralysis (HPP) in a middle-aged male. The patient presented to the emergency department with acute onset chest discomfort, generalized muscle weakness, and difficulty in mobility. Initial evaluation revealed hypokalemia, confirmed on serum electrolyte analysis, alongside electrocardiographic changes suggestive of myocardial ischemia. Subsequent coronary angiography demonstrated significant stenosis of a single major coronary artery. HPP, a channelopathy characterized by recurrent episodes of muscle weakness due to low serum potassium, is rarely reported in conjunction with structural cardiac disease such as CAD. This unique presentation posed a diagnostic and therapeutic challenge, as both conditions required simultaneous yet cautious management to avoid exacerbation of either pathology. Potassium replacement therapy resulted in complete neurological recovery, while percutaneous coronary intervention addressed the underlying ischemic burden. This case underscores the importance of considering concurrent metabolic and structural cardiac disorders in patients with atypical presentations, and highlights the need for integrated, multidisciplinary management to optimize outcomes. To our knowledge, documented reports of such coexistence remain scarce, making this case a valuable contribution to the literature.

Pancreatic cancer is a highly aggressive malignancy with poor prognosis, largely due to its silent onset and delayed diagnosis. Patients typically present with vague symptoms such as abdominal discomfort, jaundice, anorexia, and weight loss. Uncommonly, pancreatic malignancy may initially manifest as upper gastrointestinal bleeding, a presentation that can obscure the underlying diagnosis. One rare but important mechanism for such bleeding is splenic vein thrombosis, which leads to left-sided portal hypertension and the development of isolated gastric varices. Unlike portal hypertension due to chronic liver disease, this condition spares the liver and oesophagus, making recognition challenging. In the emergency setting, patients presenting with melena or hematemesis in the absence of liver dysfunction, ascites, or abnormal liver function tests often prompt diagnostic uncertainty. Cross-sectional imaging with contrast-enhanced CT or MRI plays a crucial role in identifying splenic vein thrombosis and associated pancreatic pathology. Tumours involving the pancreatic tail are particularly prone to causing venous compression or invasion, resulting in thrombosis. Management differs from conventional variceal bleeding, as endoscopic therapy provides only temporary control. Definitive treatment requires addressing the underlying cause, often through distal pancreatectomy with splenectomy in resectable disease. This report highlights pancreatic cancer as a rare but critical cause of isolated gastric variceal bleeding and emphasizes the importance of maintaining a high index of suspicion to enable timely diagnosis and potentially curative intervention.

Macroglossia is a rare but classical manifestation of systemic amyloidosis and may progress gradually over time. In advanced stages, it can precipitate sudden and life-threatening airway obstruction. Airway management in such patients is particularly challenging because of distorted anatomy and limited visualization of oropharyngea tructures. We report the case of a 77-year-old female with biopsy-proven systemic amyloidosis who presented with acute respiratory distress secondary to massive tongue enlargement. Conventional airway assessment and orotracheal intubation were not feasible due to complete obstruction of the oral cavity by the swollen tongue. Fibreoptic-guided nasal intubation was successfully performed, securing the airway and preventing further deterioration. This case highlights the importance of early recognition of airway compromise in patients with amyloidosis and underscores the critical role of fibreoptic techniques in managing anticipated difficult airways. Emergency physicians should maintain a high index of suspicion and prepare advanced airway strategies when encountering patients with progressive macroglossia.

Background: Myasthenic crisis is a life-threatening neurological emergency characterized by respiratory failure due to neuromuscular weakness. Diagnosis may be delayed in elderly patients with overlapping cardiopulmonary comorbidities. Case Summary: A 73-year-old male with hypertension, diabetes mellitus, and recently diagnosed bronchial asthma presented with progressive dyspnea. Despite relatively stable vital signs, clinical examination revealed bulbar dysfunction and neck flexor weakness. Arterial blood gas analysis demonstrated hypercapnic respiratory failure. Electrophysiological studies and serology confirmed previously undiagnosed myasthenia gravis presenting as myasthenic crisis. The patient required invasive mechanical ventilation and was treated with intravenous immunoglobulin, acetyl-cholinesterase inhibitors, and corticosteroids, resulting in full clinical recovery. Conclusion: This case highlights the importance of early recognition of myasthenic crisis in elderly patients presenting with respiratory failure and emphasizes the value of careful neurological examination in the emergency setting.

Snake envenomation is a common medical emergency in tropical regions and is typically associated with neurotoxic, hemotoxic, or myotoxic manifestations. Cardiovascular complications are rare but potentially life-threatening. Acute myocardial infarction (AMI) following snakebite is an uncommon and poorly understood phenomenon, often leading to diagnostic and therapeutic challenges in emergency settings. We report a rare case of acute myocardial infarction occurring after snake envenomation, which showed significant clinical improvement following timely administration of polyvalent snake antivenom along with standard supportive care. A middle-aged male patient presented to the emergency department with a history of snakebite, followed by chest pain, diaphoresis, and hemodynamic instability. Electrocardiography revealed ST-segment elevation consistent with acute myocardial infarction, while cardiac biomarkers were markedly elevated. The patient had no prior history of coronary artery disease or traditional cardiovascular risk factors. Early administration of snake antivenom resulted in rapid stabilization, improvement in electrocardiographic changes, and normalization of cardiac enzymes. This case highlights the importance of recognizing acute coronary events as a possible complication of snake envenomation. Early diagnosis and prompt antivenom therapy may play a crucial role in reversing myocardial injury and improving outcomes. Clinicians in snakebite-endemic regions should maintain a high index of suspicion for cardiac involvement in such patients.

Anti-GQ1b syndrome, a rare autoimmune neurological disorder, presents a diagnostic challenge due to its overlapping central and peripheral nervous system features. We report a case of a 21-year-old male who presented with binocular diplopia, cranial nerve involvement, and limb weakness following a recent febrile illness. Despite initial unresponsiveness to steroid therapy, the patient showed remarkable improvement with intravenous immunoglobulin (IVIg), and a delayed anti-GQ1b antibody test confirmed the diagnosis. This case emphasizes the importance of early clinical suspicion and aggressive immunotherapy to prevent long-term complications.

Penetrating thoracic injuries from impalement are rare but potentially catastrophic due to the concentration of vital structures within the chest cavity. We report the case of a 24 year old male who sustained a trans thoracic impalement from a metallic rod following a road traffic accident. The entry wound was located 6 cm below the right nipple on the anterolateral chest wall, with an exit point just lateral to the left nipple. Despite the dramatic mechanism of injury, the patient arrived hemodynamically stable with a GCS of 15. Prompt trauma team activation, targeted imaging and emergency thoracotomy enabled successful removal of the rod, with no injury to cardiac or major vascular structures. Post-operative intensive care involved mechanical ventilation, targeted analgesia and gradual mobilization. The patient was discharged in stable condition. This case underscores the critical role of rapid, coordinated trauma care and highlights the possibility of positive outcomes even in seemingly critical injuries.