The patient subsequently made a Full recovery from the airway burn and was transferred to the department of plastic surgery for continued treatment of the superficial burn.

Tracheal bronchus, which is an aberrant or accessory bronchus, is not rare: the incidence of tracheal bronchus is approximately 2% [1-3]. Almost all cases of tracheal bron- chus arise from the right wall of the trachea, and malfunction of the endotracheal tube in association with tracheal bronchus is rare because almost all cases of tracheal bronchus are branched within 2 cm of the carina [1-3]. Tracheal bronchus detected during Emergency endoscopy has received little attention in the emergency medicine literature. Emergency physicians must be aware, however, that apparent discrep- ancies between the radiological estimation and endoscopic findings can occur because the tracheal bronchus may not be noticed with a portable radiograph.

Naoya Yama MD Kazumitsu Koito MD, PhD Masato Hareyama MD, PhD Department of Radiology School of Medicine

Sapporo Medical University Sapporo 060-8543, Japan

E-mail address: [email protected]

Satoshi Nara MD Hiroyuki Okamoto MD Yoshihiko Kurimoto MD, PhD Eichi Narimatsu MD, PhD Yasufumi Asai MD, PhD Department of Traumatology and

Critical Care Medicine School of Medicine Sapporo Medical University Sapporo 060-8543, Japan

doi:10.1016/j.ajem.2005.04.002

References

1. Setty SP, Michaels AJ. Tracheal bronchus: case presentation, literature review, and discussion. J Trauma 2000;49:943 - 5.
2. Morrison SC. Demonstration of a tracheal bronchus by computed tomography. Clin Radiol 1988;39:208 - 9.
3. Ghaye B, Szpiro D, Fanchamps JM, Dondelinger RF. Congenital bronchial abnormalities revisited. Radiographics 2001;21:105 - 19.

Hypermethemoglobinemia in a substance abuser

To the Editor,

In September 2004, a 44-year-old male substance abuser was admitted in the emergency department after having being found unconscious on the street. On admission, he was deeply cyanotic with normal level of consciousness (Glas-

gow score of 15), free from cardiovascular troubles (blood pressure, 130-80 mm Hg; heart rate, 73 beats per minute). The patient denied have used toxics although he had a known history of substance abuse and chronic obstructive pulmo- nary disease. Arterial blood color was chocolate-brown and blood gases analysis showed a moderate respiratory alkalosis with a decrease in arterial oxygen pressure despite a 6 L/min oxygen mask therapy (pH, 7.46; Pco₂, 35 mm Hg; Po₂, 54 mm Hg; Hco₃, 24 mmol/L; Sao₂, 84.7%). In addition, the biochemistry laboratory Blood gas analyzer co-oximetry module (ABL 725, Radiometer, Copenhagen, Denmark) measured a methemoglobinemia (MetHb) at 38.7%.

When cyanosis is unresponsive to adequate oxygen therapy with fairly normal blood gases, one has to bear in mind dyshemoglobinemia. Because congenital abnormalities in hemoglobin (Hb) structure and inherited deficiencies in enzymes responsible for MetHb reduction are uncommon, nitrite intoxications should be considered especially in substance abuse subjects. Aliphatic nitrites [1] (butyl, amyl, isobutyl), so-called bpoppers,Q are clear liquids usually coming in small glass bottles and sold on the internet or in adult bookstores in France. Legislation varies between countries but poppers are available worldwide with mail- order vendors. Inhalation of nitrite poppers vapors causes muscles around blood vessels to relax, making the heart speed up and leading to a rush sensation and euphoric effects. Aside from the spectrum of acute effects expected by the user, abuse of poppers may lead to intoxication characterized by unconsciousness and anoxia. This observa- tion of hyperMetHb is connected to the general oxidizing property of the nitrites that transform Fe²⁺ of the Hb heme in Fe³⁺ and prevent binding oxygen leading to cyanosis [2]. HyperMetHb is a life-threatening situation (death may occur when MetHb N 70%) that requires fast diagnosis and Antidotal treatment with Methylene blue that quickly reduces MetHb to Hb.

Intoxication of poppers was suspected in this patient because of the high level of MetHb. On requestioning, the patient acknowledged to have inhaled a whole bottle of poppers in the hour before. Immediately after diagnosis, in the intensive care unit, the treatment with intravenous methylene blue (2 mg/kg) was conducted, which rapidly improved the patient’s clinical course and dropped the MetHb level below 1.1% within 1 hour. The day after, blood gases on room air were measured and showed a lowered Po₂ (68 mm Hg) because of his previous lung state but with a normal MetHb.

Poppers usage is not uncommon. The French ESCAPAD (Enque^te Sante’ et Consummation au cours de l’Appel de Pre’paration a` la De’fense) study recently showed that 5.2% of the 16668 subjects aged 17 to 19 years already experienced poppers [3]. Interestingly, a depressive 28-year-old male substance abuser was admitted to the emergency department 2 weeks after the previous subject after having being found drowsy and vomiting on the street. He was deeply cyanotic and MetHb level was found at 61.1%. The patient was

questioned and finally acknowledged to have inhaled and ingested poppers. He was then treated in the intensive care unit for intravenous injection of methylene blue, which rapidly improved his condition.

Our observations show that inhalation of poppers may be excessive in substance abuse subjects who may not use them moderately. Systematic measurement of MetHb with co- oximetry was the key to diagnosis because none of these subjects acknowledged spontaneously the use of poppers. This emphasizes the usefulness of MetHb measurement in cyanotic patients unresponsive to oxygen therapy to admin- ister the methylene blue antidotal treatment.

Be’ne’dicte Be’ne’teau-Burnat PhD

Pascal Pernet PhD Michel Vaubourdolle PhD Service de Biochimie A Ho^pital St-Antoine, AP-HP

75571, Paris Cedex 12, France E-mail address: benedicte.beneteau-burnat@

sat.ap-hop-paris.fr

Patrick Pelloux MD Laurent Casenove MD

Service d’Accueil des Urgences Ho^pital St-Antoine, AP-HP 75571, Paris Cedex 12, France

doi:10.1016/j.ajem.2005.03.005

References

1. Haverkos HW, Dougherty J. health hazards of nitrite inhalants. Am J Med 1988;3:479 - 82.
2. Ash-Bernal R, Wise R, Wright SM. Acquired methemoglobinemia: a retrospective series of 138 cases at 2 teaching hospitals. Medicine 2004; 5:265 - 73.
3. Beck F, Legleye S. Drogues et adolescence: usages de drogues et contextes d’usage entre 17 et 19 ans, e’volutions re’centes ESCAPAD 2002, OFDT. French Government official report available at http://www.ofdt.fr/BDD/publications/fr/escap02.htm.

nasal ulcers in the ED: from Wegener’s granulomatosis

To the Editor,

Generalized symptoms such as fever, cough, and malaise are common emergency department (ED) complaints. It would be easy for a physician to become complacent about common symptoms. However, bizarre and exotic diseases occur. Therefore, the astute physician keeps a broad differential in mind when evaluating and treating patients.

An 18-year-old Hispanic man presents to our ED with a 1-week history of fever, chills, night sweats, nonproductive cough, and malaise. He began feeling ill 1 month ago with anorexia and fatigue. He denies shortness of breath, chest pain, rash, arthralgias, or hemoptysis. He was recently seen

by his ears, nose, and throat physician and presumptively diagnosed with mononucleosis. His medical history is significant for a Spontaneous pneumothorax 1 year ago and recurrent sinusitis. He has no allergies and takes no medication. The patient denies smoking, drinking, and illicit drug use. He denies recent travel, exposure to tuberculosis, or Sexually transmitted diseases.

On physical examination, the patient is in no acute distress and saturating well on room air, with temperature of 101.08C; heart rate, 92 beats per min; respirations, 18/min; and blood pressure, 116/63 mm Hg; head, eyes, ears, nose, and throat, bilateral nasal septal ulcers and tenderness and erythema on pharynx and soft palate; cardiac, regular rate and rhythm; lungs, clear bilaterally, with decreased breath sounds left upper lobe; abdomen, soft, nontender, positive bowel sounds; neuro, no focal deficits; and skin, warm, dry, and no rash.

Laboratory tests revealed white blood cell count of 13.5 (1000/mL), negative results for influenza And monospot, no acid-fast bacillus in sputum, unremarkable urinalysis, and erythrocyte sedimentation rate of 110 mm/hr. Chest radiog- raphy demonstrated right hilar enlargement, left upper lobe opacities, and a right cavitating lesion (Fig. 1). Empiric antibiotics were started. The ED evaluation concluded with a computed tomographic (CT) scan of the chest and consulta- tions to pulmonology and infectious disease. Computed tomographic scan was preliminarily read as multiple cavitat- ing lesions with infiltration bilaterally (Fig. 2).

The patient was admitted in contact isolation, and antifungal therapy was added. The working differential included infectious etiologies (tuberculosis, histoplasmosis, blastomycosis, human immunodeficiency virus, and nocar- dia) and noninfectious causes (Wegener’s granulomatosis, sarcoidosis, and Goodpasture’s disease). On day 1 of hospitalization, bronchoscopy revealed erythematous bron- chiole walls, with no acid-fast bacilli or fungi observed. A maxillofacial CT scan demonstrated left maxillary mucoper-

Fig. 1 Chest radiograph showing pulmonary destructive lesions.