Transient cortical blindness in fat embolism syndrome—a diagnostic enigma

Fat embolism syndrome(FES)is a serious life-threatening manifestation of the fat embolism phenomenon characterized by Bergman’s triad of dyspnea,petechiae and mental confusion.While fat embolization into systemic circulation is common,FES occurs in a meagre 0.05%e3%of patients having isolated long bone fractures.Though visual symptoms are commonly attributed to fat embolism retinopathy and is a later occurrence,it may not always be the case.Cortical blindness has been seldom reported in association with FES,and less so as a presenting complaint.Furthermore,no previous literature has described the same in context of an isolated tibia fracture.We report a 20-year-old gentleman with an isolated right tibia shaft fracture who developed sudden onset diminution of vision in both eyes less than 24 h following trauma with no other complaints.Lack of any remarkable ophthalmoscopic findings or other symptoms left us with a diagnostic conundrum.He later went on to develop altered mentation,hypoxia and generalized tonic-clonic seizures with subsequent MRI revealing multiple cerebral fat emboli also involving both occipital lobes.Supportive measures were instituted and his general condition as well as vision gradually improved following which he underwent plate fixation of the fracture under spinal anaesthesia.The perioperative period was uneventful and he was discharged following staple removal.At one month of follow-up,the patient had no residual visual field defects or neurological deficits.Though FES is rare among isolated tibia fractures,this clinical catastrophe may strike in any unsuspected setting thereby warranting a high index of suspicion to ensure early diagnosis and improved patient outcomes.

Clinical and laboratory profile in confirmed vs. suspected septic arthritis patients and its relevance in decision making: A comparative cross-sectional study

Purpose:There were 10%e30%of patients with adult-onset septic arthritis(SA)exhibiting sterile synovial fluid(SF),and the uncertainty in the determining diagnosis of these patients posed a challenge in management.The purpose of this study was to investigate the differences between confirmed(Newman A)and suspected(Newman B&C)SA in adults.Methods:This was a descriptive study with a cross-sectional study design conducted at a tertiary referral centre from July 2016 to February 2019.Patients aged over 18 years presented to the emergency department with clinical features suggestive of SA and were scheduled to undergo arthrotomy and joint lavage by the treating surgeon were included in the study.Patients with prosthetic joint infections and open joint injuries were excluded.Patients’demographic data,clinical features and laboratory parameters were collected.The clinical and laboratory profile(blood and SF)of the adult patients presenting with features suggestive of SA based on Newman criteria was statistically analyzed by SPSS version 20 software and Microsoft Excel.The categorical variables were expressed as proportions while the continuous variables were expressed as mean(SD)or median(IQR)depending upon the normality of distribution.The difference between the two groups for categorical variables was assessed using the Chisquare test and the difference for continuous variables was assessed using the unpaired t-test and the Mann-Whitney test depending upon normality.A p value<0.05 was considered significant.Results:Thirty-six patients were divided into confirmed(n¼19)or suspected(n¼17)SA for assessment based on SF culture.The median(IQR)age of the patients was 50 years(37e60 years).There was no significant difference in demographic,clinical and laboratory parameters between the concerned groups.Eight patients presented with fever.Among the confirmed SA cases,8 were negative for C-reactive protein and 6 had synovial white blood cell count<50,000.Staphylococcus species were isolated in 8 cases.The most common risk factors for SA were chronic kidney disease(25.0%),diabetes mellitus(25.0%),pharmacologic immunosuppression(16.7%),recent joint surgery(11.1%)and distant site infection(11.1%).Conclusion:SA is an orthopaedic emergency that needs prompt and aggressive treatment to prevent catastrophic complications.Confirmed and suspected cases of SA exhibit similar demography,clinical features and laboratory parameters at presentation which may mislead the treating surgeon.Management should be based on sound clinical judgment in the event of failure to culture microorganisms.