IMAGES
IN THE
MEDICAL SCIENCES
Bergman’s Triad: Fat Embolism Syndrome René Rodríguez-Gutiérrez, MD,* Mario Rodarte-Shade, MD, José Gerardo González-González, MD, PhD and Fernando Javier Lavalle-González, MD *Department of Internal Medicine, “Dr. José E. González” University Hospital, Universidad Autonoma de Nuevo León, Monterrey, Mexico (E-mail: [email protected]) The authors have no financial or other conflicts of interest to disclose.
FIGURE 1
A
25-year-old man with no medical history arrived to our emergency department 2 hours after a motor vehicle accident. On physical examination, he had multiple scars and bruises on his head, altered consciousness with a Glasgow Coma Scale of 13 points, a left pneumoneumothorax and a left lower-extremity deformity. The x-ray showed a closed left femur and 2 left rib fractures. He was treated with a left-side thoracic tube, early immobilization of the femur fracture and supportive care. After 16 hours, he suddenly developed dyspnea, having a room air oxygen saturation of 86%, which improved to 94% with 3 L/min of nasal oxygen. At the same time, he developed confusion with a Glasgow Coma Scale that dropped to 10 points. A petechial rash appeared all over his body (Figure 1). After presenting the characteristic Bergman’s triad (dyspnea, neurologic impairment and petechial rash), a clinical diagnosis of fat embolism was made and a magnetic resonance imaging was done. The results showed the classical diffuse hyperintensity and the star in field pattern that confirmed the diagnosis (Figure 2). He was managed with supportive care and was discharged having a full recovery without neurological deficit 3 weeks after admission. Fat emboli syndrome is a rare and life-threatening emergency that remains until now a diagnostic challenge for clinicians. It is more often related to trauma especially, as in this case, of long closed bone fractures. It has also been described
186
FIGURE 2
in diabetes mellitus, pancreatitis, osteomyelitis and bone tumor lysis. The incidence after a single long bone fracture is 1% to 2%. Microembolism of fat that enters the bloodstream is the common physiopathology theory. The diagnosis of fat embolism syndrome remains clinical, and the Bergman’s triad of dyspnea, neurological impairment and petechial rash in a concordat scenario is pathognomonic. Petechial rash is only present in 20% to 50% of the cases.1 Scotomata (Purrtscher retinopathy) and lipiduria can also be present but are not necessary for diagnosis. The magnetic resonance imaging finding of multiple diffuse foci of hyperintensity on the T2-weighted axial images in the white matter and star in field pattern on diffusion-weighted images is characteristic.2 Treatment is mainly supportive, although glucocorticoids have been used in life-threatening cases. Mortality is up to 15%, and as in this case, complete recovery is common. REFERENCES 1. Mellor A, Soni N. Fat embolism. Anaesthesia 2001;56:145–54. 2. Takahashi M, Suzuki R, Osakabe Y, et al. Magnetic resonance imaging findings in cerebral fat embolism: correlation with clinical manifestations. J Trauma 1999;46:324–7.
The American Journal of the Medical Sciences
Volume 349, Number 2, February 2015
IN THE
MEDICAL SCIENCES
Bergman’s Triad: Fat Embolism Syndrome René Rodríguez-Gutiérrez, MD,* Mario Rodarte-Shade, MD, José Gerardo González-González, MD, PhD and Fernando Javier Lavalle-González, MD *Department of Internal Medicine, “Dr. José E. González” University Hospital, Universidad Autonoma de Nuevo León, Monterrey, Mexico (E-mail: [email protected]) The authors have no financial or other conflicts of interest to disclose.
FIGURE 1
A
25-year-old man with no medical history arrived to our emergency department 2 hours after a motor vehicle accident. On physical examination, he had multiple scars and bruises on his head, altered consciousness with a Glasgow Coma Scale of 13 points, a left pneumoneumothorax and a left lower-extremity deformity. The x-ray showed a closed left femur and 2 left rib fractures. He was treated with a left-side thoracic tube, early immobilization of the femur fracture and supportive care. After 16 hours, he suddenly developed dyspnea, having a room air oxygen saturation of 86%, which improved to 94% with 3 L/min of nasal oxygen. At the same time, he developed confusion with a Glasgow Coma Scale that dropped to 10 points. A petechial rash appeared all over his body (Figure 1). After presenting the characteristic Bergman’s triad (dyspnea, neurologic impairment and petechial rash), a clinical diagnosis of fat embolism was made and a magnetic resonance imaging was done. The results showed the classical diffuse hyperintensity and the star in field pattern that confirmed the diagnosis (Figure 2). He was managed with supportive care and was discharged having a full recovery without neurological deficit 3 weeks after admission. Fat emboli syndrome is a rare and life-threatening emergency that remains until now a diagnostic challenge for clinicians. It is more often related to trauma especially, as in this case, of long closed bone fractures. It has also been described
186
FIGURE 2
in diabetes mellitus, pancreatitis, osteomyelitis and bone tumor lysis. The incidence after a single long bone fracture is 1% to 2%. Microembolism of fat that enters the bloodstream is the common physiopathology theory. The diagnosis of fat embolism syndrome remains clinical, and the Bergman’s triad of dyspnea, neurological impairment and petechial rash in a concordat scenario is pathognomonic. Petechial rash is only present in 20% to 50% of the cases.1 Scotomata (Purrtscher retinopathy) and lipiduria can also be present but are not necessary for diagnosis. The magnetic resonance imaging finding of multiple diffuse foci of hyperintensity on the T2-weighted axial images in the white matter and star in field pattern on diffusion-weighted images is characteristic.2 Treatment is mainly supportive, although glucocorticoids have been used in life-threatening cases. Mortality is up to 15%, and as in this case, complete recovery is common. REFERENCES 1. Mellor A, Soni N. Fat embolism. Anaesthesia 2001;56:145–54. 2. Takahashi M, Suzuki R, Osakabe Y, et al. Magnetic resonance imaging findings in cerebral fat embolism: correlation with clinical manifestations. J Trauma 1999;46:324–7.
The American Journal of the Medical Sciences
Volume 349, Number 2, February 2015
