Month: November 2024

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Case 38: Painless Worsening Vision

Liz Volochyna-Farber

A 37-year-old male with a past medical history of retinal detachment (RD) of the left eye (OS), left eye cataract surgery and retinal tear in the rigth eye (OD) s/p laser presents to Emergency Department (ED) on a Sunday with painless worsening right eye vision. It started with a floater in the eye 2 days prior. The patient went to an outside ED, has been given a diagnosis and was told to see ophthalmology, but was unable to do that over the weekend. Meanwhile his symptoms worsened, so he came to our ED. He endorsed mild itching to the eye but denied trauma, pain, foreign body sensation, fever and neurologic changes.

Eye exam: PERRL, EOMI, no injection/discharge, no nystagmus, no corneal abrasion or fluorescein uptake b/l, left superior field defect present OD, visual acuity OD 20/400 pinhole corrected to 20/40, OS 20/20-2, IOP L13, R13

An ocular ultrasound is performed and the images below are seen. What do you see, and what is his most likely diagnosis? What is your management?

Figure 1: Right eye.

Figure 2: Right eye kinetic scan. Retinal detachment (arrows) is demonstrated by a bright, echogenic membrane tethered to the optic disc (star) in image B. The optic nerve and disk can be seen in the lower right corner of image A, while in image B, the disk is positioned more medially, with tethering observed, though the retina is detached to the left of the optic disc.

Ophthalmology was consulted at the bedside. On a dilated fundoscopic exam of the right eye, a mac-off retinal detachment (RD) was noted temporally between 6:00 and 10:30, extending onto the temporal macula next to the fovea, with a hole at the 8:00 position, likely the causative break. Surgery was recommended within the next few days. Records from an outside emergency department were not obtained, but it is possible that the patient initially presented with a mac-on RD, and if treated immediately, could have had a better prognosis.

Learning points

  • Retinal detachment is a serious ocular condition that can lead to permanent vision loss and can be directly visualized using point-of-care ultrasound (POCUS) and diagnosed with sensitivity of 96.9% and specificity of 88.1%. [1]
    • In a normal eye, the vitreous cavity appears as a circular hypoechoic structure, with the hyperechoic retina indistinguishable from the underlying hyperechoic choroid. In retinal detachment, the neurosensory retina separates from the choroid and appears on ultrasound as a distinct hyperechoic line still tethered to the optic disc.
    • Proper ultrasound technique involves placing a high-frequency linear transducer over a gel-covered closed eyelid. Both static and kinetic images should be obtained, with scanning done in transverse and longitudinal planes. In the static exam, the patient holds the eye still while the examiner fans through the orbit. In the kinetic exam, the examiner holds the probe steady while the patient moves the eye left and right.
      • It's crucial to determine whether the macula is attached (mac-on) or detached (mac-off) as this affects treatment urgency. The macula, located lateral to the optic nerve, is vital for central, high-acuity vision. In mac-on detachment, where only the peripheral retina is detached, urgent treatment ideally within 24 hrs is required to prevent central vision loss.[2,3] In mac-off detachment, visual prognosis is worse, but treatment within 7 to 10 days shows no difference in outcomes compared to treatment within 24 hours.[1] While there are no large-scale studies on utilizing POCUS to differentiate between mac-on vs. mac-off RD, diagnosing RD alone should prompt an urgent ophthalmology evaluation that will expedite the urgent surgery when needed. Progression from mac-on to mac-off can occur in hours to days, depending on factors such as pseudophakia, retinal break location, vitreous liquefaction, and age.[3,4]

      References:

      1. Lahham, S., Shniter, I., Thompson, M., Le, D., Chadha, T., Mailhot, T., Kang, T. L., Chiem, A., Tseeng, S., & Fox, J. C. (2019). Point-of-Care Ultrasonography in the Diagnosis of Retinal Detachment, Vitreous Hemorrhage, and Vitreous Detachment in the Emergency Department. JAMA network open, 2(4), e192162. https://doi.org/10.1001/jamanetworkopen.2019.2162
      2. Blair K, Czyz CN. Retinal Detachment. [Updated 2024 Feb 12]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK551502/
      3. Wiedemann P. (2024). When to repair a retinal detachment?. International journal of ophthalmology, 17(4), 607–609. https://doi.org/10.18240/ijo.2024.04.01
      4. Mundae, R., Velez, A., Sodhi, G. S., Belin, P. J., Kohler, J. M., Ryan, E. H., & Tang, P. H. (2022). Trends in the Clinical Presentation of Primary Rhegmatogenous Retinal Detachments During the First Year of the COVID-19 Pandemic. American journal of ophthalmology, 237, 49–57. https://doi.org/10.1016/j.ajo.2021.11.017
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      Case 37: Forearm Fracture

      Teini Elisara

      Case

      An 82 year old female with a past medical history of anemia of chronic disease, breast cancer, diabetes mellitus, hypertension, osteoporosis, rectal adenocarcinoma, scleroderma with pulmonary involvement, and systemic lupus erythematosus presented to the emergency department after a mechanical fall the night prior. Patient reported that she was getting into bed when she tripped and fell on the left side of her body landing on her left arm and hit in the side of her head on the floor. Patient endorsed severe pain to her left wrist. She was able to move her fingers; however had severe pain doing so. In addition, unable to supinate due to severe pain. Sensation was intact throughout the hand and wrist.

      Vitals: BP 162/64 | Pulse 67 | Temp 98 °F (36.7 °C) | Resp 16 | Wt 53 kg (116 lb 13.5 oz) | SpO2 98% | BMI 22.08 kg/m²

      On physical exam of the left wrist, there was significant swelling and overlying bruising. Wrist did not appear grossly displaced laterally or medially. Decreased range of motion secondary to pain; sensation intact and able to move digits. There were no open wounds.

      A bedside ultrasound was performed on the patient’s distal forearm, the following images were obtained:

      Figure 1: Left distal ulna

      Figure 2: Left distal radius

      Discussion

      In this case, we identified fractures in both the distal radius and ulnar styloid of our patient. The joint capsule was visualized and negative for signs of effusion. We visualized the joint capsule by identifying Lister’s tubercle, the extensor carpi radialis brevis tendon and extensor carpi radialis longus. We then rotated the transducer into a longitudinal plane and looked for signs of anechoic fluid between the distal radius and scaphoid bone.

      The right wrist also scanned for anatomy comparison. We were able to identify fractures quickly and with minimal discomfort to the patient. Left distal radius and ulnar styloid fractures were confirmed by two-plane x-ray.

      Cortical fractures are a common presentation to the emergency department, with distal forearm fractures being amongst the most common in both adult and pediatric populations. Wrist fracture prevalence in the United States is 12% in adults over the age of 50, with significant increases over the last 20 years [1,2]. As x-ray is the gold standard for diagnosing fractures, ultrasound is not typically thought of as an option for identification. However, it is a possible alternative for fracture identification in the emergency department, with high specificity and sensitivity [3]. In addition, ultrasound can be used to assess the healing phases of fracture using grayscale and color doppler [4]. With increased prevalence and use of ultrasound, it is a reasonable alternative for patients where reduction of exposure to ionizing radiation is preferred, such as pediatrics or pregnant peoples. It also may provide benefit for those with significant pain, when further MSK or vasculature evaluation is needed, or when x-ray is not easily accessible.

      References

      1. Ye J, Li Q, Nie J. Prevalence, Characteristics, and Associated Risk Factors of Wrist Fractures in Americans Above 50: The Cross-Sectional NHANES Study. Front Endocrinol (Lausanne). 2022 Apr 25;13:800129. doi: 10.3389/fendo.2022.800129. PMID: 35547001; PMCID: PMC9082306.
      2. Xu B, Radojčić MR, Anderson DB, Shi B, Yao L, Chen Y, Feng S, Lee JH, Chen L. Trends in prevalence of fractures among adults in the United States, 1999-2020: a population-based study. Int J Surg. 2024 Feb 1;110(2):721-732. doi: 10.1097/JS9.0000000000000883. PMID: 37921645; PMCID:PMC10871608.
      3. Douma-den Hamer D, Blanker MH, Edens MA, Buijteweg LN, Boomsma MF, van Helden SH, Mauritz GJ. Ultrasound for Distal Forearm Fracture: A Systematic Review and Diagnostic Meta-Analysis. PLoS One. 2016 May 19;11(5):e0155659. doi: 10.1371/journal.pone.0155659. PMID: 27196439; PMCID: PMC4873261.
      4. Cocco G, Ricci V, Villani M, Delli Pizzi A, Izzi J, Mastandrea M, Boccatonda A, Naňka O, Corvino A, Caulo M, Vecchiet J. Ultrasound imaging of bone fractures. Insights Imaging. 2022 Dec 13;13(1):189. doi: 10.1186/s13244-022-01335-z. PMID: 36512142; PMCID: PMC9748005.
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      Case 36: Retained Shrapnel

      Grace Feng

      Case: A 59-year-old male presented with a chief complaint of retained bullet in his abdomen. He reported a past medical history of multiple gunshot wounds in 2017 and had an exploratory laparotomy related to those injuries. He was uncertain why the bullet was not initially removed, but reported the wound site was stable until several days ago, when it began leaking serous fluid. He denied fevers, chills, and purulent discharge or pain at the wound site.

      Vitals: BP 112/72 | HR 72 | Temp 98.4 ºF (36.9 ºC) | Resp 16 | SpO2 98% on RA

      On physical examination of the abdomen, it was grossly soft, non-tender, and non-distended, with a well-healed exploratory laparotomy scar. There was a keloid scar approximately 4cm lateral to the left of the umbilicus measuring 2x3 cm with minimal serous drainage and a firm, subcutaneous mass palpable underneath.

      Bedside ultrasound was performed to evaluate for foreign body, abscess, and/or cellulitis.

      Figure 1: Longitudinal view of the abdomen using the curvilinear probe.

      Figure 2: Longitudinal view of the abdomen using the curvilinear probe.

      Discussion:

      Retained foreign bodies (FBs) account for 7-15% of patient cases presenting with traumatic wounds and/or lacerations in the emergency department. These FBs are commonly made of glass, metal, and wood, and can serve as a nidus for infection or granulomatous tissue formation.1 Ultrasound is highly sensitive for the detection of FBs, especially superficially, and is also capable of detecting inflammatory and edematous changes in skin and soft tissue associated with cellulitis and abscesses.1,2 While all FBs are hyperechoic on ultrasound, metallic FBs may present with posterior reverberation or posterior acoustic shadowing, depending on its size and curvature.1,3 Inflammation surrounding the FB typically manifests as a hypoechoic halo, which can represent edema, abscess, fibrous tissue, or granulation tissue.1 Infectious processes can cause both edema and abscesses. The former is more characteristic of cellulitis, which typically manifests as hyperechoic areas of soft tissue interspersed with hypoechoic fluid, i.e. subcutaneous edema. This gives a “cobblestone” appearance on ultrasound. Similarly, on ultrasound, abscesses appear as a hypoechoic fluid collection and may have irregular borders, contain debris, and/or swirl with compression.2

      In this case, the patient had a documented retained FB that became newly symptomatic. While the FB was palpable on physical exam, due to extensive scar tissue in the region, it was uncertain how deep the FB was and whether it had provoked an infection. In Figure 1, the FB can be seen just below the probe as a well-circumscribed mass with irregular internal components and significant posterior acoustic shadowing. The irregular internal components likely represent fibrotic tissue and the retained bullet. In Figure 2, the FB briefly appears similarly to an abscess, with a nearly anechoic region. However, the clear posterior acoustic shadowing with continued visualization of deeper visceral structures reassures that there is not fluid within the mass, which would lead to posterior acoustic enhancement. Based on these ultrasound findings, it was determined the patient’s retained FB was very superficial and had no evidence of provoking local or systemic infection. Following local anesthetic injection, a pair of forceps was used to expose and extract the foreign body, and the patient tolerated the procedure very well.

      References:

      1. Carneiro, B. C., Cruz, I. A., Chemin, R. N., Rizzetto, T. A., Guimarães, J. B., Silva, F. D., ... & Nico, M. A. (2020). Multimodality imaging of foreign bodies: new insights into old challenges. Radiographics, 40(7), 1965-1986.

      2. Creditt, A.B., Joyce, M., Tozer, J. (2018). Skin and Soft Tissue Ultrasound. In: Clinical Ultrasound. Springer, Cham. https://doi.org/10.1007/978-3-319-68634-9_15

      3. Rubin, J. M., Adler, R. S., Bude, R. O., Fowlkes, J. B., & Carson, P. L. (1991). Clean and dirty shadowing at US: a reappraisal. Radiology, 181(1), 231-236.

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      Case 35: Intracardiac Mass

      Charlotte Ellberg, MD

      History:
      61-year-old man with a history of asthma, colon cancer s/p hemicolectomy (on Xeloda), COPD, presenting with chief complaint of abdominal pain, non-exertional chest pain, and dyspnea. He denied fever, chills, cough, nausea, vomiting, diarrhea, or dysuria. He was recently hospitalized at an outside hospital for pancreatitis and ascending cholangitis and was treated with antibiotics and underwent an ERCP. He reported that he had completed the antibiotics and was taking rivaroxaban after being told he had a blood clot in his heart. He opted for a patient-directed discharge from that hospital but is re-presenting today for symptoms stated above. His port had been in place since 06/26/2024.

      Vitals:
      T 98F, HR 87, BP 105/68, RR 16, SpO2 99%

      Physical Exam:
      Physical exam was notable for no apparent distress, port over right anterior chest without tenderness to palpation, warmth, or erythema. Cardiovascular exam with normal rate, regular rhythm without murmurs, rubs, or gallops. Lungs were clear without crackles or wheezing. Abdomen was soft and non-tender. There was no LE edema.

      Labs:
      Labs without leukocytosis or anemia
      ALT 49
      AST 42
      ALP 144
      T bili 1.38
      Troponin within normal limits

      A bedside ultrasound was performed.


      What do you see?


      Figure 1: Apical four chamber view demonstrating hyperechoic mass in right atrium.

      Discussion
      Bedside ultrasound demonstrated a hyperechoic mass in the right atrium, consistent with records from the outside hospital. A CTPE was also performed which showed no evidence of pulmonary embolism, but did demonstrates a 3.2 cm filling defect in the right atrium corresponding to the previously identified right atrial thrombus at the outside hospital. He also had an abdominal ultrasound which demonstrated a surgically absent gallbladder, no hydronephrosis or calculi, patent portal vein, and no ascites or space occupying lesions. Cardiology was consulted, and given improvement in his symptoms he was discharged with return precautions and recommendations to continue anticoagulation with close follow up for a repeat TTE in the outpatient setting.

      Cardiac masses are not common. While they can sometimes present without symptoms, particularly for patients with pacemakers or central lines, they should remain on the differential for patients presenting with unexplained fever, dyspnea, catheter dysfunction, or a new murmur. It is important to recognize catheter associated thrombi as they are associated with increased morbidity and mortality, and can lead to bacteremia, catheter malfunction, SVC syndrome, pulmonary embolism, paradoxical emboli, and prolonged hospitalization and increased cost of care (1).

      Specifically within the right atrium, normal anatomy can mimic tumors. The differential for right atrial masses includes benign or malignant neoplasms, myxoma, fibroelastoma, lipoma, cyst, vegetation, or thrombus (2). As demonstrated in this case, pacemaker leads and indwelling catheters in the right atrium can place patients at risk for thrombi or vegetations.1 While this patient had a history of malignancy, it was not known to be metastatic, and the proximity of the mass to the catheter was more suggestive of catheter associated thrombus. Evaluation of right atrial masses includes chest radiography, TTE, and TEE. POCUS is a non-invasive and useful tool that can aid in identifying and visualizing the size, location, and mobility of masses. POCUS can also be utilized to evaluate presence of obstruction or filling defects. Additional evaluation may involve cardiac MRI, computed tomography (CT), or positron emission tomography (PET) to further characterize masses when the etiology remains unclear (3). Management of atrial masses depends on the etiology. In the case of catheter- associated thrombus, management can include anticoagulation, thrombolysis, thrombectomy and eventual removal of the catheter (4).

      One prior case report demonstrated the utility of POCUS for quickly diagnosing a catheter associated thrombus, allowing for timely initiation of anticoagulation to prevent further complications such as pulmonary embolism (5). Similarly, this case demonstrates the utility of POCUS in the Emergency Department to identify a recently diagnosed catheter associated thrombus without any significant increase in size or subsequent complications. This allowed for the patient to be discharged in a timely manner and avoid repeating further imaging studies.

      1. Geerts W. Central Venous Catheter-Related Thrombosis. http://ashpublications.org/hematology/article-pdf/2014/1/306/1250721/bep00114000306.pdf
      2. Sharma S, Narula N, Argulian E. Solving the Diagnostic Challenge of Right Atrial Mass. JACC Case Rep. 2022;4(4):236-238. doi:10.1016/j.jaccas.2022.01.003
      3. Parwani P, Co M, Ramesh T, et al. Differentiation of Cardiac Masses by Cardiac Magnetic Resonance Imaging. Curr Cardiovasc Imaging Rep. 2020;13(1). doi:10.1007/s12410-019-9522-4
      4. Tran MH, Wilcox T, Tran PN. Catheter-related right atrial thrombosis. Journal of Vascular Access. 2020;21(3):300-307. doi:10.1177/1129729819873851
      5. Nelson EL, Greenwood-Ericksen M, Frasure SE. Point-of-care ultrasound diagnosis of a catheter-associated atrial thrombus. Journal of Emergency Medicine. 2016;50(2):e75-e77. doi:10.1016/j.jemermed.2015.06.063

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