Bilateral Fasciotomies Research Articles

Bilateral lower extremity compartment syndrome after prolonged gynecological surgery in lithotomy position: a case report

BackgroundAcute compartment syndrome is a rare but serious complication following gynecological surgery in the lithotomy position, potentially resulting in permanent neuromuscular dysfunction or limb loss, making early recognition and prompt management essential.Case presentationA 41-year-old woman underwent a laparoscopic myomectomy for uterine fibroids, during which she was positioned in the high lithotomy and head-down position for 118 min. Six hours post-surgery, she experienced spasmodic pain and swelling in both lower extremities. Thirteen hours after surgery, her symptoms worsened, leading to the diagnosis of acute compartment syndrome in both legs. An emergency bilateral fasciotomy was performed, and the patient fully recovered within two months without any neuromuscular dysfunction.ConclusionsACS should be an important differential diagnosis for lower extremity pain after gynecologic surgery, especially with prolonged lithotomy positioning. Gynecologists should be vigilant for ACS signs and symptoms to prevent delayed diagnosis.

Perineural Injection Therapy forChronic Exertional Compartment Syndrome Refractory to Initial Compartment Release: A Case Report.

This is a case of a 26-year-old active duty male with a 1-year history of distal anterolateral leg pain and numbness which would persist following activity cessation. He was referred to physical therapy and eventually orthopedic surgery for bilateral anterior exertional compartment syndrome and underwent bilateral anterolateral fasciotomies. One year after surgery, he continued to have pain along the posterior aspect of his lower legs with residual numbness over his left dorsomedial foot. He was referred to sports medicine for further evaluation and Botox injections without significant symptomatic changes. He subsequently underwent diagnostic ultrasound of his lower legs which showed multiple entrapment points of the left superficial peroneal nerve along the fasciotomy scar. An additional electrodiagnostic study showed left superficial peroneal sensory mononeuropathy. Eighteen months following surgery, he received his first perineural injection therapy (PIT) treatment. A mixture of lidocaine and D5W was prepared to achieve 1 mg/cc which was then injected along his tibial, saphenous, and sural nerves. Following four PIT sessions, the patient's overall lower extremity pain, weakness, and functionality had improved. This case demonstrates potential benefit with PIT in patients with refractory symptoms following surgery for chronic exertional compartment syndrome. These symptoms may be due to chronic irritation of cutaneous nerves and they may benefit from treatment with PIT. Our case may represent a possible paradigm shift in the conservative treatment of chronic exertional compartment syndrome, especially when refractory to surgical compartment release.

ID: 219034 Heterotopic Ossification Masquerades as CRPS in the Inpatient Setting

31-year-old male admitted with gunshots to bilateral lower extremities. He sustained right femur fracture, underwent open reduction/internal fixation and nailing. His hospitalization was complicated by compartment syndrome status-post bilateral fasciotomy and by infection, requiring multiple incision and drainage. Additionally, he developed left foot drop, and electromyography (EMG) showed sciatic nerve neuropathy affecting the tibial and peroneal division.

Chronic Exertional Compartment Syndrome Requiring Bilateral Fasciotomy: An Atypical Complication of Familial Stiff Skin Syndrome in a Father and Son.

Stiff skin syndrome (SSS) is a rare cutaneous disorder characterized by cutaneous fibrosis resulting in the early onset of thickened and indurated skin, joint mobility restrictions, and contractures. We describe a father and son with familial SSS who presented with bilateral exertional pain and a confirmed diagnosis of chronic exertional compartment syndrome on 4-compartment pressure testing. Patients experienced restored functionality with bilateral 4-compartment fasciotomy. Chronic exertional compartment syndrome should be considered in the differential diagnosis of patients with SSS and chronic pain of the lower limbs.

Atraumatic Bilateral Acute Compartment Syndrome of the Lower Legs: A Review of the Literature.

Bilateral acute compartment syndrome of the legs is a very rare presentation that requires emergency surgical intervention. Atraumatic bilateral cases are almost unheard of in medicine. There is currently no link between compartment syndrome and cognitive impairment or mental health.A systematic literature search was performed in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines using the following keywords in multiple databases: compartment syndrome, atraumatic, spontaneous, bilateral, both, lower leg, acute, compartmental pressure, and fasciotomy. Atraumatic, bilateral, acute, and confirmed compartment syndrome cases were included.In total, 33 cases of atraumatic bilateral acute compartment syndrome (ABACS) were identified, of those 72.7% of cases were males. A form of cognitive impairment was found in 66% of cases. The medical history of the cases included substance abuse (nine patients), mental health illness (seven patients), and hypothyroidism (four patients). Within the reports, there was evidence of a misdiagnosis or delayed management in 19 cases (57.6%). Creatinine kinase (CK) was measured in 28 cases with a mean CK of 110,893 IU/L. Compartment pressure measurements were used in only 12 cases. A total of 29 cases were managed with bilateral four-compartment fasciotomy.This review highlights that ABACS is a condition with high rates of misdiagnosis or delay in treatment. Associations found included patients with cognitive impairment on presentation, mental health conditions, substance misuse, and elevated levels of CK. In addition, this review demonstrates that this condition is less rare than previously thought with serious morbidity and mortality.

Intraoperative Transesophageal Echocardiographic Detection of Large Mobile Aortic Thrombus in a Patient with Iron Deficiency Anemia Presenting as Acute Limb Ischemia

Quantitative and qualitative abnormalities in red blood cells are associated with arterial thrombosis. We report a case of a middle-aged female with iron deficiency anemia (IDA) presenting as bilateral acute limb ischemia (ALI) and on evaluation with transesophageal echocardiography (TEE) a large mobile thrombus was detected in the descending thoracic aorta. Her limbs were salvaged with successful bilateral surgical embolectomy and fasciotomies. The aortic thrombus was resolved with anticoagulation and correction of iron deficiency. We conclude that TEE evaluation of aorta is warranted in middle age females with IDA presenting as ALI.

Compartment syndrome and suicide attempt

IntroductionThe compartment syndrome is a pathological condition characterized by a decrease, or even interruption, of the microcirculation within a soft tissue compartment. There have been a few cases reported about compartment syndrome due to a suicide attempt.ObjectivesTo present an unusual complication of an autolytic attemptMethodsA descriptive study of a clinical case and literature reviewResultsA 49-year-old woman, divorced. With no psychiatric history and no somatic antecedents. Comes to the hospital after been found lying face down on the bathroom’s floor for 48 hours, next to her two empty blister packs of lorazepam and naproxen. Her partner says they argued two days ago. Brain CT: with no abnormalities. Blood analysis: metabolic acidosis with rhabdomyolysis and kidney failure. She presents ischemic injuries in both inferior extremities with right food ischemia and with no pedal pulses. Compartment syndrome is diagnosed, being necessary a bilateral fasciotomy and later a right lower extremity amputation. Initiates referral from Vascular Surgery for self-poisoning. She refers to low mood and mild anxiety due to work and relationship issues/problems. She accepts that she self-poisoning only to attract her partner’s attention after the argument. The examination shows logical thought, emotional lability, good judgement, future-oriented without suicidal ideation. Clinical judgement: acute stress reaction.ConclusionsThe compartment syndrome is a rare complication of the suicide attempt. Our patient suffered a compartment syndrome lying on the bathroom’s floor for 48 consecutive hours without apparent trauma and no somatic antecedents. This syndrome could be developed by high naproxen and lorazepam intake.DisclosureNo significant relationships.

Ergotism with acute limb ischemia, provoked by HIV protease inhibitors interaction with ergotamine, rescued by multisite transluminal balloon angioplasty

Acute limb ischemia induced by arterial vasospasm remains an exceptional situation, favoured by the use of arterial vasoconstrictors. The risk of these substances is largely underestimated in the general population, especially with the co-administration of strong cytochrome inhibitors like human immunodeficiency virus (HIV) protease inhibitors. A 33-year-old woman, who used to take dihydroergotamine for orthostatic hypotension, was prescribed a post-exposure HIV prophylaxis including lopinavir and ritonavir. One day later, she presented an acute bilateral limb ischemia with a sudden pain in both calves, initially while walking and then at rest with bilateral ischemic toes. Angiography confirmed diffuse arterial vasospasm of the lower limb arteries. A first-line therapy with isosorbide dinitrate and amlodipine was ineffective, with rapid clinical worsening. A combination of intra-arterial injections and intra-venous infusions of vasodilators, transluminal balloon angioplasty and bilateral 4-Compartment fasciotomies permitted rapid improvement and finally resulted in both lower limbs rescue. This case and literature review illustrate ergotism due to ergotamine overdose after taking HIV protease inhibitors. It also demonstrates the benefit of an interventional procedure besides medical therapy with vasodilators in severe arterial vasospasm. All along the lower limb arterial tree, transluminal balloon angioplasty restored the blood flow, without vasospasm recurrence. CONCLUSION: In case of ergotism with acute lower limbs ischemia, combining medical vasodilator therapy with interventional procedure can restore the arterial blood flow, thus allowing to save lower limbs.

Surgical Management of Chronic Exertional Compartment Syndrome of the Lower Extremity: Outcome Analysis and Return to Sport.

To evaluate patient-reported outcomes and return to sport after open fasciotomy for lower extremity chronic exertional compartment syndrome (CECS). Retrospective case series. Foot and ankle specialty service at a large multisite academic medical center. All patients undergoing lower extremity fasciotomy for CECS from 2009 to 2017 by one surgeon were eligible. Patients that underwent a fasciotomy for trauma, infection, or an acute pathologic process were excluded. Fifty-nine patients that underwent 63 procedures were included. The average age was 26.6 years, and 35 (59%) patients were women. Thirty-seven patients underwent simultaneous bilateral fasciotomies, 4 had staged bilateral fasciotomies, and 18 underwent unilateral fasciotomy. Four-compartment fasciotomy was performed 15 times. Retrospective email/telephone follow-up. Return to sports questionnaire, the Foot and Ankle Ability Measure-Sports subscale, and visual analog scale for pain. At a mean follow-up of 58.8 months, significant postoperative improvement was seen in patient-reported outcome scores compared with preoperative scores (P < 0.0001). Overall, 55 (93%) patients were able to return to sport, 42 (76%) returned to the same level of sport, and 13 (24%) returned to a lower level of competition. Bivariate regression analysis demonstrated that a higher preoperative body mass index [odds ratio: 0.829 (95% confidence interval: 0.688, 0.999); P = 0.049] was associated with a lower likelihood of return to sport. This study demonstrates that lower extremity fasciotomy for CECS results in improvement of patient-reported outcomes and a high rate of return to sport.

Surgical Management of Chronic Exertional Compartment Syndrome of the Lower Extremity: Outcome Analysis and Return to Sport

Category:SportsIntroduction/Purpose:Chronic exertional compartment syndrome (CECS) occurs as the result of increasing pressure in a closed muscular compartment, typically in the leg, as the result of repetitive activity. Physiologic changes in myofibril size during exercise increase muscle volume leading to higher compartmental pressures, which can result in neurologic and vascular changes. CECS has been estimated to cause 27%-33% of exertional leg pain and frequently leads to a decrease in athletic training and competition. CECS affects males and females equally but is especially common in young athletes, particularly competitive runners, as well as soccer, field hockey and lacrosse players and in military personnel. The purpose of this study is to evaluate patient- reported outcomes and return to sport (RTS) after open fasciotomy for lower extremity CECS.Methods:A retrospective review of patients that underwent lower extremity fasciotomy for CECS by a single surgeon was performed. All patients had a diagnosis confirmed by pre- and post-exercise compartment pressure testing. Two-incision technique was used with lateral and anterior compartments released through a lateral incision, while deep and superficial posterior compartments were released through a medial approach when indicated. Patients that underwent a fasciotomy for trauma, infection, or an acute pathologic process were excluded. Patient outcome measures were recorded for each patient including the Foot and Ankle Ability Measure-Sport subscale (FAAM-Sport), FAAM-Sport Single Assessment Numeric Evaluation (SANE), and Visual Analog Scale (VAS) for pain. A novel RTS questionnaire was designed and implemented. Patient demographic information was included. Outcome analysis was performed using Student’s t-test and chi-square testing. RTS was compared using Mann-Whitney U testing, and regression analysis was used to identify independent risk factors for failure to RTS.Results:59 patients that underwent 63 procedures were included. Average age was 26.6 years (range, 15-55), 59.3% were female, and average follow-up was 58.8 months (range, 12-115). 37 patients underwent simultaneous bilateral fasciotomies, 8 had staged bilateral fasciotomies and 18 underwent unilateral fasciotomy. Four-compartment fasciotomy was performed 14 times and 49 fasciotomies involved one or two compartments. Significant postoperative improvement was seen in the FAAM-Sport, Sport SANE and the VAS for pain compared to preoperative scores (p<0.001). Overall 93.2% (55/59) of patients were able to return to sport, 78.1% (43/55) returned to the same level of sport, and 21.9% (12/54) returned to a lower level of competition. Bivariate regression analysis demonstrated that higher preoperative BMI (p=0.049) was associated with a lower likelihood of return to sport.Conclusion:CECS is a relatively common problem seen in young athletes and can cause significant change in athletic participation and ability. This cohort of patients who underwent lower extremity fasciotomies for CECS is larger than any previously published. This study demonstrates that lower extremity fasciotomy for CECS results in improvement of patient-reported outcomes and returns athletes back to competition at a high rate.

ABNORMAL PRESENTATION OF INFLUENZA A-RELATED SYSTEMIC CAPILLARY LEAK SYNDROME

SESSION TITLE: Case Report Semifinalists 9 SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Systemic Capillary Leak Syndrome (SCLS) is a rare and life threatening disorder that can present as fluid-resistant shock in the presence of hemoconcentration, hypotension, and hypoalbuminemia. To date, no cause of SCLS has been confirmed, and mainstays of therapy have been supportive care and IVIG based on limited case reports. CASE PRESENTATION: A 41 year-old man presented with lower extremity swelling and malaise and profound hypotension after a three day viral prodrome. This patient was hospitalized within the past year for similar symptoms of shock with hemoconcentration and hypoalbuminemia without clear etiology. Upon arrival, patient had hypotension resistant to aggressive fluid resuscitation, followed by rapidly progressing renal and cardiac failure and eventually requiring endotracheal intubation due to laryngeal edema. Patient received intravenous immunoglobulin (IVIG) shortly thereafter for possible SCLS. During resuscitation, patient had increasingly tight muscular compartments concerning for compartment syndrome; patient was evaluated by orthopedics and was taken to operating theatre where he received bilateral upper and lower extremity fasciotomies of legs, thighs, forearms. It is known that SCLS presents with a “leak phase” during which extravasation and shock is common, followed by a “post-leak phase” during which extravasated fluid rapidly moves intravascularly. To avoid further compartment syndrome and post-leak volume overload, a goal of normotension with a central venous pressure of 4-8 mmHg was successfully used to guide resuscitation. Due to association of SCLS with oncologic processes, urgent hematology and oncology consult was obtained. Patient underwent evaluation for leukemia and lymphoma without any evidence of malignancy. During this time, patient tested positive for influenza A via PCR. Patient was noted upon workup to have elevated levels of IL-6. The patient was discharged on hospital day 15 to sub-acute rehab with instructions to receive tocilizumab, a biologic targeted at IL-6, if they experienced similar edema and malaise. DISCUSSION: There are scant case reports suggesting influenza A as the inciting factor for SCLS exacerbation. However, this is the first reported case of influenza-associated SCLS with an elevated interleukin-6 level, suggesting a clinical hypothesis that IL-6 may play a role in SCLS. Furthermore, very few of influenza-related SCLS have presented with such acuity, making this a very unusual case. CONCLUSIONS: Difficult to diagnose and manage, SCLS remains poorly understood. Little is known about best management, although IVIG and guided resuscitation may have a role. In this patient, early diagnosis and intervention led to a favorable outcome. Furthermore, an elevated in IL-6 in this patient invokes speculation towards a possible therapy. Reference #1: Ebdrup L, Druey K, Mogensen TH Severe capillary leak syndrome with cardiac arrest triggered by influenza virus infection Case Reports 2018;2018:bcr-2018-226108. Reference #2: Kapoor P, Greipp PT, Schaefer EW, Mandrekar SJ, Kamal AH, Gonzalez-Paz NC, Kumar S, Greipp PR. Idiopathic systemic capillary leak syndrome (Clarkson's disease): the Mayo clinic experience. Mayo Clin Proc. 2010 Oct;85(10):905-12. https://doi.org/10.4065/mcp.2010.0159. Epub 2010 Jul 15. PubMed PMID: 20634497; PubMed Central PMCID: PMC2947962. DISCLOSURES: No relevant relationships by Alexander Croft, source=Web Response No relevant relationships by Rajat Kapoor, source=Web Response

Concurrent Exertional Compartment Syndrome and Functional Popliteal Artery Entrapment Syndrome: A Case Report

Exertional leg pain is a common and disabling condition in athletes with challenging diagnosis and management. We report the case of a 29-year-old rugby player with a history and clinical examination consistent with chronic exertional compartment syndrome (CECS). Compartment pressure measurement was supportive of the diagnosis. However, magnetic resonance angiography (MRA) with provocative maneuvers showed functional popliteal artery entrapment syndrome (PAES). For the treatment of CECS, bilateral fasciotomy of the anterolateral compartments permitted return to full sport participation in 8 weeks. A follow-up MR angiogram at 12 months showed resolution of the popliteal entrapment leading us to hypothesize a possible relationship between CECS and functional PAES.

Open fracture of tibia mid-shaft associated with the contralateral leg acute compartment syndrome without fracture

The acute extremity compartment syndrome is caused by increased compartment volume or restriction of compartment size. There are 23% of all compartment syndrome is caused by isolated soft-tissue injury especially in crushing injury. We report a 30-year-old male with the initial diagnosis of the right tibia open fracture, Gustilo Type II, due to a motor-vehicle accident. Besides the right leg condition, he was continually suffered from left leg pain, where the X-ray revealed no apparent fracture since the collision. The physical examination showed no skin lesion and deformity; however, numbness and tightness were noted, toe stretching pain+, Pedis Dorsalis Artery+, Posterior Tibialis Artery+. Doppler showed the presence of PDA and PTA blood flow. Nine hours after the injury, pain and numbness of his left leg and foot still persisted and also pale and pulseless developed. Doppler for his left leg was done again and showed the negative result of PTA and PDA. Emergent bilateral side fasciotomy for his left leg was arranged, and the cardiovascular department was consulted for intraoperative angiography. The fasciotomy wound was cared with sterilized saline wet dressing for 3 days. Medial fasciotomy was closed with delayed primary method, and the lateral sides were treated with split-thickness skin graft. Acute compartment syndrome is diagnosed by the interpretation of a collection of clinical signs and symptoms. In a patient with a swollen limb, in the absence of a fracture and for whom, there is a suspicion of an acute compartment syndrome, methods, technology, and application for the early detection of acute compartment syndrome is important and also provides promising opportunities for the clinicians to perform early interventions.

Chronic Exertional Compartment Syndrome in a Healthy Young Man

ObjectiveThe purpose of this case report is to describe a patient who presented with symptoms of exercise-induced compartment syndrome and was later referred for bilateral fasciotomy surgery. Clinical FeaturesA 21-year-old patient presented for chiropractic care with the inability to run due to foot paresthesia and weakness. An exertion test and compartment pressure test diagnosed exercise-induced compartment syndrome. Exertion test and compartment pressure test were used to identify and diagnose exercise-induced compartment syndrome. Intervention and OutcomeThe patient was diagnosed with exercise-induced compartment syndrome. He was treated conservatively and referred for additional testing. The orthopedic surgeon requested that 12 weeks of conservative care be provided prior to testing; treatment consisted of chiropractic care and rehabilitation exercises. Following the 12 weeks of treatment, the patient did not significantly respond to conservative care. A compartment pressure test confirmed the initial diagnosis of exercise-induced compartment syndrome. The patient underwent a unilateral fasciotomy surgery and recovered fully. Following the surgery, the patient returned to the chiropractic clinic with the same presentation in the contralateral leg. The same protocol of management resulted in the same outcome. Two years after surgical intervention, the patient continues to maintain an active lifestyle, able to run 2 to 3 miles per day without any exacerbations or symptomatology. ConclusionClinical awareness, a detailed history, and thorough examination with reproduction of symptomatology are necessary to form a proper diagnosis and treatment plan for these patients. Therefore, multidisciplinary medical communication would prove to be the most beneficial approach for the patient.

Compartment Syndrome as a Result of Systemic Capillary Leak Syndrome.

Objective. To describe a single case of Systemic Capillary Leak Syndrome (SCLS) with a rare complication of compartment syndrome. Patient. Our patient is a 57-year-old male, referred to our hospital due to polycythemia (hemoglobin (Hgb) of 220 g/L), hypotension, acute renal failure, and bilateral calf pain. Measurements and Main Results. The patient required bilateral forearm, thigh, and calf fasciotomies during his ICU stay and continuous renal replacement therapy was instituted following onset of acute renal failure and oliguria. Ongoing hemodynamic (Norepinephrine and Milrinone infusion) and respiratory (ventilator) support in the ICU was provided until resolution of intravascular fluid extravasation. Conclusions. SCLS is an extremely rare disorder characterized by unexplained episodic capillary hyperpermeability, which causes shift of volume and protein from the intravascular space to the interstitial space. Patients present with significant hypotension, hemoconcentration, hypovolemia, and oliguria. Severe edema results from leakage of fluid and proteins into tissue. The most important part of treatment is maintaining stable hemodynamics, ruling out other causes of shock and diligent monitoring for complications. Awareness of the clinical syndrome with the rare complication of compartment syndrome may help guide investigations and diagnoses of these critically ill patients.

A Rare Case of Bleeding - Acquired Factor Inhibitors with Normal Coagulation Tests

Introduction: Acquired Factor XIII deficiency due to an antibody inhibitor (AIFXIII) is a rare but life-threatening bleeding disorder. Factor XIII is a fibrin stabilizing enzyme that crosslinks fibrin monomers. Deficiency of Factor XIII results in destabilization of formed clots within 24-48 hours, resulting in delayed hemorrhage. Because the standard coagulation tests are normal, the diagnosis of this disease requires a high degree of suspicion and specialized testing. We report a case of an 88-year-old female presenting with severe hemorrhage of unknown origin.Goal: We aim to heighten the awareness amongst clinicians of the possibility of acquired FXIII deficiency when a patient presents with bleeding symptoms and normal routine coagulation tests.Case: An 88-year-old female with a recent diagnosis of autoimmune hemolytic anemia (AIHA) on oral Prednisone developed left arm swelling, pain, and ecchymosis. She denied anticoagulation and history of abnormal bleeding. CT scan of the arm showed a biceps muscle hematoma measuring 17cm in length. On day 4, she developed hematoma on the contralateral forearm, which prompted bilateral fasciotomies and evacuation. Patient continued to have bleeding from her right forearm hematoma, requiring further exploration and evacuation of multiple clots.Laboratory Tests: Her Hg dropped from 9.2 g/dl to 6.6 g/dl requiring RBC transfusions. Peripheral blood smear revealed features of chronic hemolysis. She had a normal coagulation profile including PT (11.1 sec), INR (1.05), PTT (24.4 sec), fibrinogen (295mg/dL) and normal platelet function assay. Her D-dimer was elevated at 371 ng/ml. She had a normal CRP (3.3mg/L), ANA antibody (<1:40) and ESR (23 mm/hr). SPEP showed hypoproteinemia without monoclonal bands. The patient's FVIII (307%), VWF ag (307%), VWF activity (369%), VWF collagen binding assay (412%) and alpha-2-antiplasmin (101%) were normal. Patient's Factor XIII levels were measured at 8%. We suspected this to be a case of AIFXIII. Testing for inhibitor with serial dilutions showed an antibody titer of 1:40.Results: She was started on 100 mg/d of Cyclophosphamide and continued on 20mg of Prednisone. No further hematomas developed. Patient was discharged on day 29 with a close follow up. On day 66, patient had AIHA flare (Hg: 6.6g/dL) and was treated with PRBCs, Rituximab 375mg/m^2 for 4 infusions and prednisone 40mg daily. Her Factor XIII activity on day 68 was 12% and inhibitor titer 1:10. On day 98, patient developed large ecchymoses on the right knee, thigh and buttock. Her Factor XIII activity dropped to < 10% again and inhibitor titer went up to 1:20 on serial dilution. She was transfused with PRBCs and was started on IVIG at 1000 mg/kg X 5. Cyclophosphamide was stopped and Prednisone was decreased to 10mg daily. Her Factor XIII is still <10% but inhibitor titer is down to 1:10. Patient is not actively bleeding.Discussion: There are less than 60 reported cases of AIFXIII in the literature. This is the first reported case presenting with warm antibody hemolytic anemia. Various treatments have been employed in the past for AIFXIII. It involves two strategies: hemostasis to treat acute bleeding symptoms and inhibitor eradication. Use of steroids and immunosuppressants such as Cyclophosphamide, Rituximab, and Cyclosporine has been prevalent in most of the cases to obtain inhibitor eradication. It is hard to define what combination of therapy works because most of the cases involve use of combination of these strategies and spontaneous remissions have also been seen. In this case, we suspect that patient presented with higher than expected factor XIII activity (8%) at the onset because she was already on immunosuppression for her AIHA for 2 months prior. She was refractory to first-line therapy with Rituximab and Cyclophosphamide in combination with steroids for complete inhibitor eradication. Second line therapy with IVIG was recently given and we are hopeful of a response.Conclusion: AIFXIII is a rare but life-threatening bleeding disorder that should be suspected especially when elderly patients present with hemorrhage of unknown origin and normal screening coagulation studies. Characterization of the factor XIII activity and detection of antibodies should be undertaken promptly in order to provide the best anti-hemorrhagic and inhibitor eradication treatment. DisclosuresNo relevant conflicts of interest to declare.

Excruciating Low Back Pain After Strenuous Exertion: Beware of Lumbar Paraspinal Compartment Syndrome

BackgroundLow back pain is extremely common and usually a minor self-limiting condition. Rarely, however, it is a harbinger of serious medical illness. Paraspinal compartment syndrome is a rare condition, but its timely recognition is important to allow adequate treatment. Case ReportA 16-year-old boy presented to the Emergency Department (ED) with severe low back pain, necessitating intravenous opioids. Laboratory results showed severe rhabdomyolysis. Magnetic resonance imaging of the lumbar spine showed diffuse edema and swelling in the paraspinal muscles. Aggressive fluid therapy was started but despite narcotic analgesia the pain persisted and creatine kinase (CK) levels increased. Compartment pressures of the erector spinae were found to be increased. The decision was made to proceed with bilateral paraspinal fasciotomies. Postoperatively, the patient noted immediate pain relief with rapid decrease of CK level. The patient is pain free and resumed running and swimming 3 months after admission in the ED. Why Should an Emergency Physician Be Aware of This?Although paraspinal compartment syndrome is a rare condition, its recognition is of paramount importance to allow adequate surgical treatment, preventing muscle necrosis. Although back pain most often has a benign course, a careful history and physical examination in patients presenting with low back pain allows determination of “red flags.” Mandatory further diagnostic tests can identify underlying serious illness.

Bilateral post-traumatic gluteal compartment syndrome: A case report and review of literature

Gluteal compartment is a rare site for compartment syndrome. Gluteal compartment syndrome has most commonly been described in the literature as occurring after prolonged immobility associated with substance abuse, improper operative positioning, sickle cell-induced infarct, post-traumatic and spontaneous superior gluteal artery rupture, exercise, and post-arterial embolization of the internal iliac artery prior to abdominal aortic aneurysm repair. Trauma is rarely associated with this syndrome. Gluteal compartment syndrome occurs in approximately 0.9% of trauma patients. Posttraumatic gluteal compartment syndrome develops because of edema with traumatic contusions, crush injuries and hematoma formation due to blunt superior or inferior gluteal artery injuries in all compartments of the gluteal region Only 6 previous cases have been reported in the literature. Two previous cases involved positioning for urological procedures, while the other cited causes of bilateral gluteal compartment syndrome include exercise-induced, trauma, and prolonged immobilization from substance abuse. One of the most immediately devastating results of a missed compartment syndrome is the risk of the development of rhabdomyolysis with the resulting squeal of myoglobinuria, hyperkalemia, and acidosis resulting in renal failure, shock, multiple organ failure, disseminated intravascular coagulation, and possibly death. Here we report a case of posttraumatic bilateral compartment syndrome which developed secondary to pressure due to patient being trapped under a vehicle following a vehicular accident. He was operated upon and a bilateral fasciotomy was done. Although he did not develop any renal complications, the sciatic nerve palsy on the left side did not recover. The patient is still under follow up.

Spinning-induced Rhabdomyolysis and the Risk of Compartment Syndrome and Acute Kidney Injury: Two Cases and a Review of the Literature.

Exercise-induced rhabdomyolysis related to military training, marathon running, and other forms of strenuous exercise has been reported. The incidence of acute kidney injury appears to be lower in exercise-induced cases. We present 2 cases of exercise-induced rhabdomyolysis following spinning classes, one of which was further complicated by acute compartment syndrome requiring bilateral fasciotomies of the anterior thigh and acute kidney injury. With vigorous hydration and urine pH monitoring, both patients exhibited good mobility, sensation, and renal function on discharge.

Bilateral Compartment Syndrome of the Thigh in a College Football Athlete: A Case Report.

Whereas acute compartment syndrome is a well-described entity in the leg and forearm, compartment syndrome of the thigh is a much less common phenomenon secondary to the increased compartment compliance of the thigh and the potential for extravasation into the gluteal compartment1-5. The first report of acute compartment syndrome of the thigh attributed to prolonged limb ischemia was presented by Mubarak and Owen in 19756. The first reports of exercise-induced acute compartment syndrome of the thigh are attributed to Kmen et al. (1990)7 and Kahan et al. (1994)1. To date, the diagnosis of acute compartment syndrome of the thigh remains primarily clinical, with measurement of intracompartmental pressures being reserved for patients who are difficult to examine, who are intubated, who are in a comatose state, or who have equivocal findings on physical examination. Additionally, whereas the treatment of acute compartment syndrome of the leg and forearm is well established, the treatment of acute compartment syndrome of the thigh remains controversial. We report the case of a college football athlete who presented with rhabdomyolysis and acute bilateral compartment syndrome of the thigh with secondary acute kidney failure following a strength-training workout. The patient required emergent bilateral three-compartment fasciotomy. The patient discussed in this report was informed that data concerning his case were to be submitted for publication, and he agreed. The patient’s confidentiality was protected according to the Health Insurance Portability and Accountability Act. A twenty-two-year-old otherwise healthy black college football player presented to the emergency department of a level-I tertiary-care center approximately sixty hours after participating in a rigorous strength-training session. The session included a focus on lower-body strength training, and the patient stated that, in addition to the standard workout, he performed 100 squats with use of 280-lb (127-kg) weights. …