BackgroundWe report a case of severe upper airway obstruction due to a retropharyngeal hematoma that presented nearly one day after a precipitating traumatic injury. Retropharyngeal hematomas are rare, but may cause life-threatening airway compromise.Case presentationA 50 year-old man developed severe dyspnea with oropharyngeal airway compression due to retropharyngeal hematoma 20 hours after presenting to the emergency department. The patient also had a fractured first cervical vertebra and was diagnosed with a left brachial plexopathy. The patient underwent emergent awake fiberoptic endotracheal intubation to provide a definitive airway.ConclusionRetropharyngeal hematoma with life-threatening airway compromise can develop hours or days after a precipitating injury. Clinicians should be alert to the potential for this delayed airway collapse, and should also be prepared to rapidly secure the airway in this patient population likely to have concomitant cervical spinal or head injuries.

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Morphine sulfate is often administered for patients requiring surgical intervention for the control of hemorrhage. Recent data implicate morphine as an immune modulator that affects white blood cells and increases infection rates. In addition, morphine releases histamine, an inflammatory mediator that increases microvascular permeability. Both of these actions of morphine could aggravate the inflammatory progress after hemorrhagic shock. In this study, we evaluated the role of morphine sulfate on microvascular permeability and its effects on leukocyte adherence after hemorrhagic shock. After a control period, blood was withdrawn to reduce the mean arterial blood pressure to 40 mm Hg for 1 h in urethane-anesthetized Sprague-Dawley rats. Mesenteric postcapillary venules in a transilluminated segment of small intestine were examined to quantify changes in permeability and leukocyte adherence. The rats received an IV injection of fluorescein isothiocyanate-bovine albumin during the control period. The fluorescent light intensity emitted from the fluorescein isothiocyanate-bovine albumin was recorded with digital microscopy within the lumen of the microvasculature and compared with the intensity of light in the extraluminal space over time. These images were downloaded to a computerized image analysis program that quantitates changes in light intensity. This change in light intensity represents albumin extravasation. In addition, bright-field images were recorded on compact disk for playback to determine leukocyte adherence. Leukocytes stationary for more than 30 s or longer in a 100-micron segment of venule was considered adherent. Our results demonstrated a marked increase in fluorescein isothiocyanate-bovine albumin leakage into the extravascular space after hemorrhagic shock. Hemorrhagic shock was also associated with an increase in leukocytes adhering to the postcapillary venular endothelium. Morphine sulfate 10 microg/kg given before the shock period, attenuated both the hyperpermeability (P < 0.05) and the increase in leukocyte adherence (P < 0.05) after hemorrhagic shock. These results suggest that instead of aggravating the inflammatory response after hemorrhagic shock, morphine may provide protection to the microvasculature.

Reactivation of latent varicella-zoster virus can occur when the immune system is weakened leading to the typical presentation seen with herpes zoster or shingles. In a small percentage of these patients, motor paralysis can be seen in the affected myotomal distribution. Zoster sine herpete, or shingles without the typical vesicular rash, is an uncommon variant of zoster. Systemic steroids are known to weaken the immune response. Two previous case reports have implicated epidural steroid injections as a precipitating cause of zoster. We present a case of serologically verified zoster sine herpete producing an abdominal wall bulge, which occurred 1 wk after thoracic epidural steroid injection. Electromyography documented the presence of abdominal wall denervation. Given the low incidence of serologically proven zoster sine herpete--especially with thoracic motor paralysis--and the equally rarely documented incidence of zoster related to epidural steroids, we present what we believe to be the first reported case of zoster sine herpete with a neuropathic abdominal wall bulge occurring in close temporal association to receiving epidural steroids.

Our data demonstrated an increase in vascular hyperpermeability after inhibition of adenylate cyclase via SQ22536, a nonreceptor inhibitor. This increase in hyperpermeability was attenuated when treated with MS. Morphine did not attenuate hyperpermeability after blockage following PKA with H89 suggesting the action of MS is upstream of PKA and PKA dependent.