What's Your Diagnosis? Dialysis Complications in the ED

Welcome to this month’s What’s Your Diagnosis Challenge!

But before we begin, check to see if you got the previous case on Managing Emergency Department Patients With Opioid Use Disorder correct.

Case Presentation: Emergency Department Management of Patients With Complications of Dialysis

A 63-year-old man on hemodialysis presents to the ED with an area of skin erosion over the fistula…

He was told by his primary care physician that he needed to have his arteriovenous fistula evaluated.
He states the erosion has been present for the past few days. He does not think it is getting worse and he reports no pain.
He is well-appearing, with normal vital signs. On examination, you note some erosion of the skin that appears to have an overlying scab and no surrounding erythema or bleeding, but you think that perhaps the fistula appears enlarged.
You wonder why the patient was sent to the ED and whether the patient needs urgent evaluation of his fistula since the area does not appear infected and is not bleeding…

Case Conclusion

You decided to proceed with getting a duplex ultrasound to evaluate the fistula, and it demonstrated an aneurysm with high flow, located superficially, just below the skin. You consulted vascular surgery, and their team took the patient to the operating room emergently for revision, given concern for impending rupture, even though there were no signs of active bleeding at the AV fistula site.