Am J Emerg Med
· 2026 Jun · PMID 42398236
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Emergency department (ED) triage is a front-door prioritization process intended to identify patients who may require immediate assessment, intensive monitoring, or urgent intervention. Five-level systems such as the Eme...Emergency department (ED) triage is a front-door prioritization process intended to identify patients who may require immediate assessment, intensive monitoring, or urgent intervention. Five-level systems such as the Emergency Severity Index (ESI), Manchester Triage System (MTS), Canadian Triage and Acuity Scale (CTAS), Australasian Triage Scale (ATS), and South African Triage Scale (SATS) are widely used, but their reported performance varies across settings and outcome definitions. This systematic review and meta-analysis evaluated the predictive validity of these triage systems for prespecified surrogate outcomes, including ICU admission, critical intervention, hospital admission, and short-term mortality, rather than assuming that any single endpoint represented a definitive gold standard for true emergency severity. Twenty-five eligible studies were synthesized. In the exploratory composite model across heterogeneous surrogate endpoints, pooled sensitivity was 0.84 (95% CI 0.80-0.88), pooled specificity was 0.72 (95% CI 0.67-0.77), and the HSROC AUC was 0.87. Endpoint-stratified analyses showed clinically important variation: ICU admission/critical intervention yielded sensitivity of 0.87 and specificity of 0.70; hospital admission yielded sensitivity of 0.82 and specificity of 0.74; and short-term mortality yielded sensitivity of 0.79 and specificity of 0.76. System-specific estimates were interpreted as descriptive indirect patterns only, because included studies were not head-to-head comparative trials. Overall, structured ED triage systems demonstrated moderate, context-dependent accuracy for selected surrogate outcomes, but clinically important under-triage remains possible and pooled estimates are influenced by reference-standard choice, case-mix, resource availability, and implementation quality. Future research should prioritize standardized reference outcomes, prospective multicenter validation, and evaluation of calibrated decision-support tools.
Am J Emerg Med
· 2026 Jun · PMID 42398235
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Methyl acetate is an organic solvent used in certain nail polish removers that hydrolyzes in aqueous environments to liberate methanol and acetic acid. This is a case report of a 47-year-old woman who presented to the em...Methyl acetate is an organic solvent used in certain nail polish removers that hydrolyzes in aqueous environments to liberate methanol and acetic acid. This is a case report of a 47-year-old woman who presented to the emergency department intoxicated after an episode of loss of consciousness following recreational huffing of a nail polish remover containing methyl acetate. Laboratory studies demonstrated an elevated anion-gap metabolic acidosis suggestive of methanol toxicity. Diagnosis was confirmed through measurement of the serum methanol concentration, which was 35 mg/dL (reference range < 10 mg/dL). Toxicity was managed in the emergency department with administration of fomepizole (4-methylpyrazole) and initiation of hemodialysis. After a single session of hemodialysis, the patient's acid-base status normalized, visual changes resolved, and mental status returned to baseline. The patient was subsequently discharged on hospital day 2. This is an uncommon case of acute systemic methanol poisoning from inhalation of methyl acetate resulting in profound acidemia requiring hemodialysis. This case underscores the importance of careful product review and ingredient identification in the emergency department.
Szesnat M, Watts A, Tobin MA
… +2 more, Cason TH, Gibbs M
Am J Emerg Med
· 2026 Jun · PMID 42385663
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BACKGROUND: Rocuronium dosing varies in clinical practice, and optimal dosing has yet to be identified. Several studies have investigated differing dosing strategies and have suggested doses ≥1.2 mg/kg may lead to greate...BACKGROUND: Rocuronium dosing varies in clinical practice, and optimal dosing has yet to be identified. Several studies have investigated differing dosing strategies and have suggested doses ≥1.2 mg/kg may lead to greater intubation success. OBJECTIVES: This study aimed to compare the impact of rocuronium dosing on first attempt intubation success during rapid sequence intubation (RSI) with video laryngoscopy in the emergency department (ED) and intensive care units (ICU). METHODS: This was a single-center, retrospective chart review of adult patients undergoing RSI with rocuronium doses ≤1.2 or > 1.2 mg/kg. The primary outcome was successful first attempt intubation. Secondary outcomes included number of intubation attempts, time to successful intubation, 30-day mortality rate, and hospital and ICU length of stay. Subgroup analyses were performed for patients with hypoperfusion states including sepsis and heart failure, and for patients with obesity. RESULTS: Rocuronium doses >1.2 mg/kg were associated with significantly higher first attempt intubation success (100% vs. 89.5%; 95% confidence interval [CI] -0.2 to -0.03; p < 0.01) and fewer mean intubation attempts (1 vs. 1.1; 95% CI 0.01 to 0.20; p < 0.01). No statistically significant differences were observed in any other secondary outcomes or subgroup analyses. CONCLUSION: Rocuronium doses >1.2 mg/kg significantly improved first attempt intubation success. However, no significant differences were observed in secondary clinical outcomes or in subgroup analyses across specific patient populations. Further research into the relationship between rocuronium dosing, first attempt intubation success, and clinical outcomes may inform more effective and evidence-based rocuronium dosing strategies.
Am J Emerg Med
· 2026 Jun · PMID 42385662
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BACKGROUND: Acute leukemia is a life-threatening hematologic malignancy requiring early diagnosis, particularly in the emergency setting. However, initial clinical presentations in the emergency department (ED) remain po...BACKGROUND: Acute leukemia is a life-threatening hematologic malignancy requiring early diagnosis, particularly in the emergency setting. However, initial clinical presentations in the emergency department (ED) remain poorly characterized, resulting in potentially delayed diagnosis. We aimed to describe the initial clinical presentations and major complications of adult patients with previously undiagnosed acute leukemia presenting to the ED. METHODS: We conducted a retrospective descriptive study at a tertiary care ED in Japan from January 2016 to December 2025. We included patients aged 16 years or older who were newly diagnosed with acute leukemia within 14 days of the ED visit. Patients were categorized into uncomplicated and complicated groups based on the presence of febrile neutropenia, intracranial hemorrhage, or leukostasis. We examined the frequency of the three common presenting symptoms (fever, dyspnea, and bleeding tendency) and the presence of major complications at ED presentation. RESULTS: Of 49 patients with acute leukemia, 30 (61%) were in the uncomplicated group and 19 (39%) in the complicated group. Fever was the most frequent presenting symptom but was present in only 43% of uncomplicated patients. Among uncomplicated patients, 20% presented with none of the three common presenting symptoms, and 50% presented with only one. In complicated acute leukemia, chief complaints were frequently pain or altered mental status rather than the common symptoms. CONCLUSIONS: A substantial proportion of adult patients with acute leukemia presenting to the ED had heterogeneous symptoms. Emergency physicians should maintain a low threshold for laboratory evaluation including peripheral blood smear.
Ferguson K, Badeti J, Zhu M
… +3 more, Yang J, Xiang H, Smith GA
Am J Emerg Med
· 2026 Jun · PMID 42372568
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OBJECTIVE: The objective of this study is to investigate the characteristics and trends of injuries related to racket and paddle sports (RPS) treated in United States (US) emergency departments (EDs). METHODS: Using a re...OBJECTIVE: The objective of this study is to investigate the characteristics and trends of injuries related to racket and paddle sports (RPS) treated in United States (US) emergency departments (EDs). METHODS: Using a retrospective cohort study design, data from the National Electronic Injury Surveillance System were analyzed regarding ED visits from January 1, 2000, through December 31, 2023, by individuals 6 years and older who were injured while playing tennis, paddleball/squash/racquetball, badminton, table tennis, or pickleball. National estimated injury frequencies and annual population-based rates were calculated. RESULTS: An estimated 792,773 RPS injuries among individuals 6 years and older were seen in US EDs from 2000 to 2023. Injuries were more common among males (59.0%) and individuals >39 years old (56.1%). The average age was 43.9 (standard deviation: 23.3) years. Injuries related to tennis were the most frequent (61.7%), followed by paddleball/squash/racquetball (15.6%), pickleball (13.1%), badminton (5.4%), and table tennis (4.2%). Falls were the most common mechanism of injury (36.5%), while a medical event was the mechanism for 25.5% of older adults >64 years old. Sprain/strain was the most common diagnosis (33.0%), followed by fracture (15.4%) and soft tissue injury (11.3%). Overall, 8.7% of injuries resulted in hospital admission. The RPS injury rate per 100,000 US population 6 years and older increased with fluctuation over time by 20.9% from 12.9 in 2000 to 15.6 in 2023, with males experiencing higher rates than females. The rate of RPS injuries among individuals >64 years old increased 55.7% from 10.6 in 2011 to 37.7 in 2023 (P < 0.0001). Additionally, the rate of hospital admission among individuals 6 years and older fluctuated during the study years with a 300.0% increase from 0.7 in 2012 to 2.8 in 2023, with the rate for individuals >64 years old similarly increasing 271.0% from 3.1 in 2013 to 11.5 in 2023. Patients >64 years old were more likely to be admitted than younger patients (RR: 6.32, 95% CI: 4.97-8.04). The admission rate was higher for pickleball injuries (RR: 2.57, 95% CI: 2.03-3.26) compared with injuries associated with other RPS. The admission rate was also higher for RPS-related medical events than other mechanisms of injury (RR: 10.99, 95% CI: 8.22-14.70). CONCLUSIONS: RPS injury-related ED visits increased modestly over the past two decades, while hospital admissions rose substantially, driven primarily by injuries involving older adults and pickleball. As RPS participation continues to grow, targeted, sport-specific, age-specific, and mechanism-informed prevention strategies are warranted to reduce serious morbidity while supporting safe lifelong sport participation.
Chai HS, Park GJ, Kim YM
… +3 more, Kim SC, Kim H, Lee SW
Am J Emerg Med
· 2026 Jun · PMID 42372567
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BACKGROUND: This study investigated the association between prehospital intravenous epinephrine use and outcomes of traumatic cardiac arrest using propensity score matching in a nationwide registry. METHODS: Data of adul...BACKGROUND: This study investigated the association between prehospital intravenous epinephrine use and outcomes of traumatic cardiac arrest using propensity score matching in a nationwide registry. METHODS: Data of adult patients with traumatic cardiac arrest from the Korean Out-of-Hospital Cardiac Arrest Registry (2015-2021) were analyzed. Patients with non-traumatic etiologies or cardiopulmonary resuscitation durations of <1 or >30 min were excluded. Prehospital epinephrine was administered. The primary outcome was survival to hospital discharge, while the secondary outcomes were prehospital return of spontaneous circulation (ROSC) and favorable neurological outcomes (Cerebral Performance Category (CPC) 1-2). Propensity score matching (1:1) and multivariate logistic regression analyses were performed using clinically relevant covariates. RESULTS: Among the 22,105 eligible patients, 809 (3.7%) received prehospital epinephrine. After propensity score matching, 1614 patients (807 matched pairs) were analyzed. Prehospital epinephrine administration was associated with higher rates of survival to hospital discharge (5.1% vs. 2.6%, adjusted odds ratio (OR) 1.38, 95% confidence interval (CI): 1.36-1.39) and prehospital ROSC (12.8% vs. 4.5%, adjusted OR 3.63, 95% CI: 2.39-5.51). The association with favorable neurological outcomes was observed only after multivariable adjustment (1.0% vs. 0.5%, adjusted OR 1.11, 95% CI: 1.10-1.13). CONCLUSION: Prehospital epinephrine administration in patients with traumatic cardiac arrest was associated with increased survival to hospital discharge and prehospital ROSC. However, its association with favorable neurological outcomes remains uncertain. Further studies are required to clarify the optimal timing and patient selection for prehospital epinephrine administration.
Mavrovounis G, Drivas K, Mermiri M
… +3 more, Papageorgiou K, Tsiotsikas O, Pantazopoulos I
Am J Emerg Med
· 2026 Jun · PMID 42364439
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BACKGROUND: Out-of-hospital cardiac arrest (OHCA) remains a leading cause of death, with survival highly dependent on early cardiopulmonary resuscitation (CPR) and defibrillation. Crowdsourcing technologies that alert ne...BACKGROUND: Out-of-hospital cardiac arrest (OHCA) remains a leading cause of death, with survival highly dependent on early cardiopulmonary resuscitation (CPR) and defibrillation. Crowdsourcing technologies that alert nearby volunteers via text messages or smartphone applications aim to shorten response times and strengthen the chain of survival. A 2021 scoping review highlighted substantial heterogeneity and limited outcome data. This study provides an updated synthesis of the literature. METHODS: A scoping review was conducted in accordance with PRISMA-ScR guidelines. PubMed, Scopus, and ClinicalTrials were searched through 31 December 2024. Randomized and observational studies reporting original data on crowdsourcing technologies alerting lay responders to suspected OHCA were included. Data were extracted on study characteristics, technology features, volunteer participation, OHCA characteristics, and outcomes. RESULTS: Thirty-seven studies met inclusion criteria mainly from Europe (Netherlands, Denmark, Sweden). Smartphone-based systems were evaluated in 22 studies, text message-based in 13, and both in 2. Alerts were triggered by emergency medical services, with location provided via GPS or text. Prior BLS training was required in 65% of studies, and automated role allocation was present in 62%. Reporting of volunteer metrics and patient outcomes was inconsistent. Among 10 studies with detailed data, arrival before EMS, bystander CPR, bystander defibrillation, ROSC and survival rates varied widely. Post-resuscitation outcomes were infrequently reported. CONCLUSIONS: Crowdsourcing technologies may facilitate earlier bystander intervention in OHCA. However, heterogeneity in system design and outcome reporting limits comparability and limits conclusions about clinical effectiveness. Future research should standardize reporting of key volunteer, response, and patient-centered metrics.
Yahya R, Hassoun J, Hamodat O
… +2 more, Rashid A, Hafez W
Am J Emerg Med
· 2026 Jun · PMID 42361705
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INTRODUCTION: Neonates with fluid-refractory septic shock require prompt vasopressor support, including dopamine, epinephrine, and norepinephrine; however, the optimal first-line treatment remains unclear. This meta-anal...INTRODUCTION: Neonates with fluid-refractory septic shock require prompt vasopressor support, including dopamine, epinephrine, and norepinephrine; however, the optimal first-line treatment remains unclear. This meta-analysis assessed the first-line vasopressors for shock reversal and clinical outcomes. METHODS: A comprehensive search of the PubMed, Scopus, Ovid, and CINAHL databases was performed from inception to April 2026. We included randomized controlled trials evaluating first-line vasopressor therapy in neonates (<28 days old) with fluid-refractory septic shock, comparing epinephrine and norepinephrine with dopamine. The primary outcomes were early shock reversal and all-cause mortality, with secondary outcomes including the need for additional vasoactive agents and changes in hemodynamic responses. Analyses were performed using Review Manager (RevMan) version 5.4 software. RESULTS: Four RCTs were included. Compared with dopamine, epinephrine or norepinephrine showed no significant difference in shock reversal within 1h (RR = 1.07; 95% CI = 0.84-1.36; P = 0.57; I = 39%) or mortality (RR = 0.95; 95% CI = 0.80-1.13; P = 0.58; I = 0%). Subgroup analyses showed no significant differences for norepinephrine (RR = 0.97; 95% CI = 0.66-1.44; P = 0.90; I = 73%) or epinephrine (RR = 1.16; 95% CI = 0.86-1.56; P = 0.32; I = 0%), with no difference between subgroups (P = 0.48). Secondary outcomes including the requirement of additional vasoactive agent, mean arterial pressure were not different. CONCLUSION: No substantial changes were observed in the vasoactive therapies used in neonates with fluid-refractory septic shock. Nonetheless, owing to the limited number of trials and considerable clinical heterogeneity within the studies, these results should not be construed as definitive equivalency between treatments. Additional high-quality neonatal-specific research with standardized criteria is essential to determine the most appropriate first-line treatment.
Lawson C, Rech MA, Sun J
… +13 more, Celmins L, Sindelar M, Van Wert E, Fletcher AA, Coralic Z, Zimmerman DE, Howington GT, Woolum JA, Krenz J, Mattson AE, Brown CS, Zepeski A, Faine B
Am J Emerg Med
· 2026 Jun · PMID 42349235
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STUDY OBJECTIVE: The objective of this study was to describe the proportion of emergency department (ED) patients with traumatic brain injury (TBI) or spontaneous intracranial hemorrhage (sICH) who demonstrated a positiv...STUDY OBJECTIVE: The objective of this study was to describe the proportion of emergency department (ED) patients with traumatic brain injury (TBI) or spontaneous intracranial hemorrhage (sICH) who demonstrated a positive neurologic response to sugammadex-mediated reversal of rocuronium, and to compare outcomes between responders and non-responders. METHODS: This was a multicenter, retrospective, observational cohort study of 11 US Emergency Departments. Adult patients, aged ≥18 years, who were intubated using rocuronium and subsequently received sugammadex and had a primary diagnosis of TBI or sICH between December 15, 2015, to June 30, 2024 were screened for inclusion. The primary outcome of this study was the proportion of patients who had a positive response (defined as an increase in GCS of ≥1 point) within 30 min of sugammadex administration. The secondary outcomes included change in analgosedation requirements during the first 30 min post-sugammadex administration, and the rate of neurosurgical procedures. RESULTS: The primary outcome analysis included 362 patients. An increase in GCS within 30 min post-sugammadex administration occurred in 54% (n = 196), with a median GCS change of 3 (IQR: 2-4, range 1-9). A positive response was associated with the addition of a new analgesic agent (30.6% 13.9%, difference = 16.8%, 95% confidence interval 8.4 to 25.1), sedation agent (33.7% vs. 14.5%, difference = 19.2%, 95% confidence interval 10.7 to 27.7), and a non-significant increase in neurosurgical procedures (43.4 vs. 33.7%, difference = 9.6%, 95% confidence interval -0.4 to 19.7). CONCLUSION: Sugammadex administration to reverse rocuronium in the ED was associated with a significant change in GCS and analgosedation requirements.
Koh HP, Chen MSY, Tan S
… +12 more, Abdul Ghani F, Selvaratanam M, Mah GY, Ong AG, Mustapa AH, Hanan NA, Abu Bakar UZ, Lim TM, Pan HC, Tan SSA, Chuah SM, Mat Idris MAZ
Am J Emerg Med
· 2026 Jun · PMID 42335572
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INTRODUCTION: Status epilepticus (SE) is a time-critical neurological emergency associated with significant morbidity and mortality. Data on its burden and predictors among patients with established epilepsy presenting t...INTRODUCTION: Status epilepticus (SE) is a time-critical neurological emergency associated with significant morbidity and mortality. Data on its burden and predictors among patients with established epilepsy presenting to the emergency department (ED) remain limited, particularly in Asian settings. This study aimed to determine the incidence of SE, its association with in-hospital mortality, and its predictors. METHODS: This multicentre prospective observational study was conducted across 34 public hospitals in Malaysia. Epilepsy patients presenting to the ED with seizures were recruited using convenience sampling. The primary endpoints were SE and in-hospital mortality. Predictors were identified using logistic regression analysis. RESULTS: A total of 521 patients were included, of whom 119 (22.8%) had SE. In-hospital mortality rate was 3.5%. SE was independently associated with mortality (aOR 9.17, 95% CI 3.14-26.78; p < 0.01), along with prior ischaemic stroke (aOR 5.75, 95% CI 2.13-15.56; p = 0.01). Independent predictors of SE included age ≥ 60 years (aOR 1.79, 95% CI 1.03-3.11, p = 0.04), hyperglycaemia (aOR 2.08, 95% CI 1.10-3.91, p = 0.02), hypocalcaemia (aOR 2.50, 95% CI 1.06-5.90, p = 0.04), central nervous system infections (aOR 7.80, 95% CI 2.80-21.78, p < 0.01), and phenytoin use (aOR 1.98, 95% CI 1.16-3.37, p = 0.01). CONCLUSION: SE occurred in nearly one-quarter of epilepsy patients presenting to the ED and was strongly associated with increased in-hospital mortality. These findings may assist clinicians in identifying patients at increased risk of SE and support early risk stratification and appropriate monitoring, particularly among older patients and those presenting with metabolic abnormalities or suspected CNS infection.
Am J Emerg Med
· 2026 Jun · PMID 42330722
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INTRODUCTION: Eagle syndrome is a rare condition resulting from elongation of the styloid process or ossification of the stylohyoid ligament. While the classical variant typically presents with cervicofacial pain and dys...INTRODUCTION: Eagle syndrome is a rare condition resulting from elongation of the styloid process or ossification of the stylohyoid ligament. While the classical variant typically presents with cervicofacial pain and dysphagia, the vascular variant may lead to compression or injury of adjacent vascular structures, resulting in transient ischemic attack, arterial dissection, or ischemic stroke. Hemorrhagic vascular complications associated with Eagle syndrome are extremely uncommon. CASE PRESENTATION: A 26-year-old female presented to the emergency department with rapidly progressive swelling on the right side of the neck associated with respiratory distress. Initial assessment revealed stridor and persistent hypoxia with oxygen saturation of 80% despite oxygen supplementation. Physical examination demonstrated a tense, expanding cervical swelling with tracheal deviation, raising concern for impending airway compromise. Intubation was attempted under sedation; however, the patient developed hypoxic bradycardia during the procedure. Oxygenation was restored using a supraglottic airway device while preparation for emergency front-of-neck access was undertaken. CT angiography revealed a fractured elongated styloid process measuring approximately 60 mm, aneurysmal dilatation of the occipital branch of the external carotid artery, and a large cervical hematoma compressing adjacent vascular structures. CT brain demonstrated right subcortical infarction involving the corona radiata and internal capsule. The patient subsequently underwent emergency tracheostomy, evacuation of cervical hematoma, and ligation of the bleeding vessel. She was later discharged with minimal residual neurological deficits. CONCLUSION: This case highlights a rare presentation of vascular Eagle syndrome producing simultaneous hemorrhagic airway compromise and ischemic stroke. Early recognition of airway compromise and prompt multidisciplinary intervention were essential for successful management.
Am J Emerg Med
· 2026 Jun · PMID 42330710
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OBJECTIVE: To describe a case of inferior ST-segment elevation from massive bladder distension resolving with Foley catheterization in the absence of tachycardia, hypertension, or other hemodynamic evidence of sympatheti...OBJECTIVE: To describe a case of inferior ST-segment elevation from massive bladder distension resolving with Foley catheterization in the absence of tachycardia, hypertension, or other hemodynamic evidence of sympathetic activation. CASE PRESENTATION: A 73-year-old man presented with progressive abdominal distension and markedly decreased urination over several days. Vital signs were notable only for mild hypotension (blood pressure 99/75 mmHg) with heart rate 94 beats per minute and temperature 97.6 °F. Examination revealed a bladder palpable to the xiphoid. An electrocardiogram obtained in response to hyperkalemia (potassium 5.5 mEq/L) unexpectedly demonstrated inferior ST-segment elevation in leads II, III, and aVF with reciprocal depression in leads I and aVL. Computed tomography confirmed massive bladder distension extending to the xiphoid with no obstructing lesion. After discussion with interventional cardiology, Foley catheterization drained approximately 2 L of urine; a repeat electrocardiogram immediately after demonstrated complete resolution of ST-segment changes. Serial high-sensitivity troponin (peak 36 ng/L; reference <22 ng/L) showed no dynamic change. Blood cultures grew Escherichia coli, confirming bacteremic urosepsis. DISCUSSION: Unlike prior reports attributing bladder-distension-associated electrocardiographic changes to catecholamine surge with tachycardia and hypertension, this case occurred with entirely normal heart rate and no hypertension. A mechanical diaphragmatic mechanism from a bladder distended to the xiphoid is the more plausible explanation. CONCLUSION: Massive bladder distension can produce inferior ST-segment elevation mimicking ST-elevation myocardial infarction, resolving with decompression even without hemodynamic activation. Emergency physicians should consider this entity in the differential for reversible inferior ST-segment elevation.
Dhavapalani D, Maloney K, Bouzidi C
… +1 more, Bailey JA
Am J Emerg Med
· 2026 Jun · PMID 42320420
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Diagnosing necrotizing soft tissue infection (NSTI) in the emergency department remains challenging and is primarily a clinical diagnosis despite the availability of decision tools and advanced imaging. In patients with...Diagnosing necrotizing soft tissue infection (NSTI) in the emergency department remains challenging and is primarily a clinical diagnosis despite the availability of decision tools and advanced imaging. In patients with Hidradenitis Suppurativa (HS), baseline skin changes, prior surgical interventions and disrupted tissue planes may obscure early findings, while presentations can mimic less severe conditions such as cellulitis, abscess, or an HS flare. We present the case of a 28-year-old man with HS on adalimumab who presented with left axillary pain and swelling at a prior HS site. He was tachycardic but afebrile with localized erythema on initial examination. On repeat evaluation 50 minutes later, the erythema had rapidly extended along the lateral thoracoabdominal wall, raising concern for NSTI. The patient underwent emergent operative exploration, which revealed copious purulent fluid with disruption of fascial plans and nonviable tissue, consistent with NSTI. His postoperative course was prolonged, requiring surgical intensive care, and he was discharged to subacute rehabilitation on hospital day 25. NSTI in patients with HS may present with subtle or nonspecific findings, and underlying disease-related changes may obscure early diagnosis. These cases require a high index of suspicion, frequent reassessment, and early surgical intervention to optimize outcomes.
Am J Emerg Med
· 2026 Jun · PMID 42320419
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Malignant melanoma is an aggressive skin cancer with a strong tendency to metastasize to distant organs, including the lungs. Pulmonary metastases typically present with nonspecific respiratory symptoms such as cough and...Malignant melanoma is an aggressive skin cancer with a strong tendency to metastasize to distant organs, including the lungs. Pulmonary metastases typically present with nonspecific respiratory symptoms such as cough and dyspnea. Oncoptysis, the expectoration of tumor tissue, has been reported in only two documented cases of melanoma, with less than 50 cases reported in the literature across all malignancies. We present the case of an 88-year-old female complaining of cough and hemoptysis upon arrival to the emergency department. Upon arrival, the patient expectorated abnormal appearing tissue, which was thought initially to be lung tissue. Chest computed tomography (CT) revealed a 8 × 7 cm mass in the right lower lobe. Pathological analysis of the mass confirmed metastatic malignant melanoma in the lungs. Given that she presented with hemoptysis and respiratory distress, antiplatelet therapy was halted to minimize bleeding while bronchodilators were initiated along with supplemental oxygen. While the hemoptysis and patient's respiratory status improved, the patient declined aggressive chemotherapy and requested hospice care at home after discussions regarding her diagnosis. This case highlights a highly unusual presentation of metastatic melanoma and adds to the sparse literature on oncoptysis. The spontaneous expectoration of tumor tissue underscores the potential for central airway involvement in pulmonary metastases. Clinically, this reinforces the importance of considering malignancy in the differential diagnosis of hemoptysis, particularly in patients with a remote history of melanoma and atypical appearing expectorated sputum. Furthermore, it contributes to our understanding of how aggressive malignant progression can manifest in rare but dramatic ways, informing both careful diagnostic evaluation and palliative management strategies.