Category: Clinical Cases

Posted on

Case 43: Shortness of Breath

Molly Chou

An 83-year-old male presented to our emergency department with shortness of breath. He woke up that morning with symptoms and called EMS. On arrival, the patient was alert and oriented with SpO2 90% on room air. The patient had a recent admission for right middle and lower lobe pneumonia. He also reported a history of heart failure with mildly reduced ejection fraction, coronary artery disease, and chronic kidney disease.

Vitals: BP 122/71, HR 92, RR 30, T 98.8F, spO2 90% on room air, 99% on 4LNC

Exam: Normal heart sounds, tachypnea, rhonchi in bilateral lower lobes, non-tender abdomen, >4mm pitting lower extremity edema

Labs: Cr 2.23 (from 1.98), BNPP 34,591 (from 19,366), WBC 31

EKG: new left bundle branch block

CXR: pulmonary edema, bilateral pleural effusions, and opacities that may represent atelectasis, though cannot rule out pneumonia or aspiration.

A bedside ultrasound was performed:

Figure 1: Right-sided pleural effusion, atelectasis, and pneumonia in seen right lower lobe

Figure 2A: During exhalation. Left-sided pleural effusion, atelectasis. 2B: During inhalation. Pneumonia becomes more visible as air fills alveoli adjacent to consolidated lung tissue (also known as “dynamic air bronchogram”)

Discussion: Bedside ultrasound demonstrated persistent pneumonia as a likely contributor to his shortness of breath. While other clinical indicators directed the diagnosis toward acute on chronic heart failure, POCUS was instrumental in also identifying persistent pneumonia. The patient was ultimately started on antibiotics and admitted to Cardiology for pneumonia and diuresis.

Learning points:

  • Pneumonia is among the leading causes of hospitalization, and it can be detected on ultrasound if the pleural line is involved, which is in about 99% of cases.
  • Ultrasound can detect inflammation and lung-tissue thickening of lobar pneumonias and consolidations. Interstitial pneumonias more often manifest as B-lines or white lung areas. Complications such as empyema and lung abscess can also be detected [1].
  • POCUS is highly sensitive (estimated around 93%) and specific (estimated around 98%) for pneumonia, particularly if done by a skilled sonographer [2,3].
  • Classic ultrasound findings:
    • “Hepatization” of lung parenchyma, when multiple hypoechoic areas give the tissue a “liver-like” or “spleen-like” appearance.
    • “Shred sign” (Figure 1), when a clear margin can be detected separating a consolidation with aerated parenchyma.
    • Air bronchograms (hyperechoic, linear punctate spots) can be detected within a consolidation in over 90% of pneumonia patients, though they are non-specific, as they may indicate any form of airway obstruction [1].
      • However, “dynamic air bronchograms” (Figure 2) where air-filled bronchograms move with respiration, are highly specific (94%) to pneumonia and have a high positive predictive value (97%) when seen [4]. An example can be seen below [5]:

References:

  1. Boccatonda A, Cocco G, D'Ardes D, et al. Infectious Pneumonia and Lung Ultrasound: A Review. J Clin Med. 2023;12(4):1402. Published 2023 Feb 10. doi:10.3390/jcm12041402
  2. Reissig A, Copetti R, Mathis G, et al. Lung ultrasound in the diagnosis and follow-up of community-acquired pneumonia: a prospective, multicenter, diagnostic accuracy study. Chest. 2012;142(4):965-972. doi:10.1378/chest.12-0364
  3. Chavez MA, Shams N, Ellington LE, et al. Lung ultrasound for the diagnosis of pneumonia in adults: a systematic review and meta-analysis. Respir Res. 2014;15(1):50. Published 2014 Apr 23. doi:10.1186/1465-9921-15-50
  4. Lichtenstein D, Meziere G, Seitz J. The Dynamic Air Bronchogram: A Lung Ultrasound Sign of Alveolar Consolidation Ruling Out Atelectasis. Chest. 2009;135(6):1421-1425. Published 2009 Jan 8. doi:10.1378/chest.08-2281
  5. Hailey Hobbs, MD. Dynamic Air Bronchograms. NephroPOCUS. Published 2019 Jul 1. Accessed 2024 Dec 13.
Posted on

Case 42: Nephrolithiasis

Alex Liang, Rachna Subramony

A 48 year old male with past medical history of Crohn’s Disease, cryptogenic cirrhosis, pancytopenia, portal vein thrombosis, Factor V Leiden, and prior history of kidney stones presenting with right sided flank pain, dysuria, and hematuria worsening over the past 4 days. He reports similar symptoms in the past associated with his previous findings of kidney stones. He denies fever, nausea, vomit, diarrhea, chest pain, shortness of breath, or anuria.

Vitals: BP 123/80 mmHg | Pulse: 101 | Temp: 98.5 °F (36.9 °C) | Resp: 20 | Wt: 65.8 kg (145 lb) | SpO2: 97%

On physical examination, the patient is alert and uncomfortable but not in acute distress. Abdominal examination reveals a soft, non-distended abdomen with right flank and right costovertebral angle (CVA) tenderness. The remainder of the physical exam, including cardiac, pulmonary, and neurologic exams, was unremarkable.

A bedside ultrasound was performed on the right kidney.

Figure 1: Several renal calculi in the medullary pyramids of the right kidney. The largest measures approximately 6.8mm in diameter.

Discussion

Nephrolithiasis, commonly referred to as kidney stones, is a prevalent condition with an estimated annual incidence rate of approximately 0.5% to 1% in the general population and a lifetime risk of 10%-15% with higher prevalence among men. Risk factors for nephrolithiasis include dehydration, dietary factors (high sodium or oxalate intake), obesity, metabolic syndrome, and recurrent urinary tract infections1,2.

The differential diagnosis for nephrolithiasis includes conditions that present with acute flank pain, hematuria, and urinary symptoms. Such conditions include pyelonephritis, renal infarction, or ureteropelvic junction obstruction. In this patient, the presentation of acute right flank pain with costovertebral angle tenderness accompanied by dysuria and gross hematuria is strongly indicative of nephrolithiasis.

On physical examination, patients with nephrolithiasis typically present with costovertebral angle tenderness on the affected side with otherwise minimal abdominal findings. The clinician should be attentive of systemic signs such as fever and tachycardia, as they may suggest a concurrent urinary tract infection or obstructive pyelonephritis and require further work up. In this case, the patient presented without fever or systemic signs of infection, supporting a diagnosis of uncomplicated nephrolithiasis.

While non-contrast computed tomography (CT) of the abdomen and pelvis is the gold standard for diagnosing nephrolithiasis, ultrasound remains an asset in the detection of stones with a sensitivity of 54% and specificity of 71%. In some cases, such as in pregnant patients, ultrasound is the preferred modality due to its lack of ionizing radiation. In this case, a renal ultrasound revealed several stones in the medullary pyramids of the right kidney, with the largest measuring 6.8mm in diameter. It is important to note that CT does have higher sensitivity (88%) and lower specificity (58%) compared to ultrasound. Despite this, no evidence has shown that increased CT use is associated with improved patient outcomes when compared to ultrasonography 3.

When performing a point-of-care ultrasound (POCUS) exam for nephrolithiasis, the curvilinear or phased-array transducer should be placed in the flank region along the midaxillary line to obtain longitudinal and transverse views of the kidney. The exam focuses on the identification of hydronephrosis, which appears as anechoic dilation of the renal collecting system, and the detection of renal calculi, which appear as echogenic foci with posterior acoustic shadowing.

Management of nephrolithiasis depends on the size and location. Stones that are less than or equal to 5mm are typically managed conservatively with hydration and analgesia. Medication such as tamsulosin can be given to aid in the expulsion of the stones. Stones that are 10mm or greater, causing significant obstruction, or with concurrent infection or renal impairment often require more invasive measures such as extracorporeal shock wave lithotripsy (ESWL), ureteroscopy with laser lithotripsy, or percutaneous nephrolithotomy 4.

Recurrence of nephrolithiasis is common, with a rate of approximately 50% within 10 years. Patients can decrease this risk with preventative strategies such as dietary modifications (increased fluid uptake, reduced sodium and oxalate consumption) and addressing underlying metabolic abnormalities 4.

References

  1. Pearle MS, Calhoun EA, Curhan GC. Urologic Diseases in America Project: Urolithiasis. J Urol. 2005;173(3):848–857. doi:10.1097/01.ju.0000152082.14384.d7.
  2. Scales CD, Smith AC, Hanley JM, Saigal CS. Prevalence of Kidney Stones in the United States. Eur Urol. 2012;62(1):160–165. doi:10.1016/j.eururo.2012.03.052.
  3. Smith-Bindman R, Aubin C, Bailitz J, et al. Ultrasonography versus Computed Tomography for Suspected Nephrolithiasis. N Engl J Med. 2014;371(12):1100-1110. doi:10.1056/NEJMoa1404446.
  4. Curhan GC. Epidemiology of Stone Disease. Urol Clin North Am. 2007;34(3):287–293. doi:10.1016/j.ucl.2007.05.003.
Posted on

Case 41: Abdominal Aortic Aneurysm

Skyler Sloane, Benjamin Supat

An 83-year-old man presented to the emergency department with a chief complaint of acute onset lower abdominal pain radiating to the right groin. The patient reported a history of hypertension, coronary artery disease, and nephrolithiasis. 

Vitals: BP 71/51 | Pulse 84 | Temp 98.0 °F (36.6 °C) | Resp 20 | SpO2 99% on RA 

On physical exam, the patient appeared to be in obvious discomfort. There was diffuse abdominal tenderness though no rebound or guarding was observed.

A bedside FAST exam was performed. What do you see? 

Figures 1-3: This 3-view FAST exam was negative for intra-abdominal free fluid.

Next, we performed an ultrasound of the aorta.

Figure 4: Transverse aorta view. Here we can see a fusiform aneurysm. The hyperechoic vessel wall contains a less dense ring of clot surrounding the anechoic blood in the vessel.

Figure 5: Labeled image showing intramural thrombus.

The patient was given a 1L fluid bolus, 2 ultrasound-guided peripheral 14g IVs, and 2 units of emergency-release blood. The patient also got a CT angiogram which showed a large ruptured fusiform infrarenal abdominal aortic aneurysm measuring 9.2 cm by 6.0 cm with a large hematoma in the right flank and iliac fossa, which explained the patient’s symptom of flank pain. Diffuse moderate atherosclerotic vessel wall changes were also present. The patient underwent emergent endovascular aneurysm repair.

Discussion: 

An abdominal aortic aneurysm (AAA) is defined by the parameter of aortic dilation of 3 cm or greater, measured outer wall to outer wall (1). This risk of developing a AAA increases with age and is more common in males than in females. Primary relationship to a family member who has had an AAA, hypertension, and coronary artery disease are predisposing factors. Smoking and poor lifestyle are also common risk factors (2). 

There are three types of AAAs: fusiform aneurysms, saccular aneurysms, and mycotic aneurysms. Fusiform aneurysms comprise 94% of aneurysms, and they present as bulging or ballooning on all sides of the aorta. Saccular aneurysms are less common and become symptomatic at smaller sizes (on average of 5.5 cm) and present as an outpouching on one side of the aorta. Saccular aneurysms can result from a tear on the tunica media of the aortic wall, due to injury or ulceration. Mycotic aneurysms are formed due to an infection of the vessel wall that can be bacterial, viral, or fungal in nature. They can occur as a complication of endocarditis and have an increased risk of rupture. AAAs are most commonly infrarenal (80%), but some may be pararenal (3,4).

Most patients with AAAs are asymptomatic, and diagnosis is often incidental as a result of imaging with MRI, CT, or ultrasonography. AAAs can present with life-threatening complications such as thrombosis, embolization, and rupture (3). The risk of rupture increases with the size of the aneurysm. A ruptured AAA is a catastrophic medical emergency, and left untreated the mortality approaches 100%. 50% of patients die prior to hospital arrival, and another 25-50% die during surgery.  Most AAAs rupture in the retroperitoneal cavity, creating symptoms of pain, lightheadedness, and a pulsing sensation in the abdomen. Notably, up to 50% of patients with AAAs have aneurysm rupture as their primary presentation of having a AAA, and only some patients are diagnosed prior to a catastrophic event and thus have preventative measures taken (5). 

Due to the emergent need to address potential AAA and AAA ruptures, rapid diagnosis in an emergency setting is necessary. Aortic ultrasound is the primary diagnostic method for diagnosing AAAs or ruptured AAAs in an emergency setting (6). Non-radiologist-performed ultrasound for AAA is estimated to have a sensitivity of 0.975 [95% confidence interval (CI), 0.942-0.992] for AAA detection and a specificity of 0.989 (95% CI, 0.979-0.995), making it an effective diagnostic tool (7). Computed tomography angiogram is also commonly used for diagnosis and surgical planning of AAAs. However, CT is not always feasible in unstable patients (8). 

In this case, point-of-care ultrasound was a vital component in diagnosing this patient. Given a patient presentation concerning for AAA, ultrasound is a rapid and effective method to reach an early diagnosis and expedite treatment. 

References

  1. Hirsch AT, Haskal ZJ, Hertzer NR, et al. ACC/AHA 2005 Circulation. 2006; 113: e463-e654. doi:10.1161/CIRCULATIONAHA.106.174526
  2. Altobelli E, Rapacchietta L, Profeta VF, Fagnano R. Risk Factors for Abdominal Aortic Aneurysm in Population-Based Studies: A Systematic Review and Meta-Analysis. Int J Environ Res Public Health. 2018 Dec 10;15(12):2805. doi: 10.3390/ijerph15122805. PMID: 30544688; PMCID: PMC6313801.
  3. Farber, M. A.; Parodi, F. E. Abdominal Aortic Aneurysms (AAA), 2023, 2023. https://www.merckmanuals.com/professional/cardiovascular-disorders/diseases-of-the-aorta-and-its-branches/abdominal-aortic-aneurysms-aaa.
  4. Aggarwal S, Qamar A, Sharma V, Sharma A. Abdominal aortic aneurysm: A comprehensive review. Exp Clin Cardiol. 2011 Spring;16(1):11-5. PMID: 21523201; PMCID: PMC3076160.
  5. Jeanmonod D, Yelamanchili VS, Jeanmonod R. Abdominal Aortic Aneurysm Rupture. [Updated 2023 Aug 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK459176/
  6. Abdominal aortic aneurysm: diagnosis and management. London: National Institute for Health and Care Excellence (NICE); 2020 Mar 19. (NICE Guideline, No. 156.) Available from: https://www.ncbi.nlm.nih.gov/books/NBK556921/
  7. Concannon E, McHugh S, Healy DA, Kavanagh E, Burke P, Clarke Moloney M, Walsh SR. Diagnostic accuracy of non-radiologist performed ultrasound for abdominal aortic aneurysm: systematic review and meta-analysis. Int J Clin Pract. 2014 Sep;68(9):1122-9. doi: 10.1111/ijcp.12453. Epub 2014 May 18. PMID: 24837590.
  8. Moxon JV, Parr A, Emeto TI, Walker P, Norman PE, Golledge J. Diagnosis and monitoring of abdominal aortic aneurysm: current status and future prospects. Curr Probl Cardiol. 2010 Oct;35(10):512-48. doi: 10.1016/j.cpcardiol.2010.08.004. PMID: 20932435; PMCID: PMC3014318.
Posted on

Case 40: Rare Ocular Condition Diagnosed by Point-of-Care Ultrasound

Skyler Sloane & Andre Velazquez

A 73-year-old male presented to our emergency department with a chief complaint of new intermittent double vision for the past two weeks. The patient noticed that he saw double when looking at signs on the freeway. These were new symptoms he had not experienced in the past. The patient reported a history of hypertension, hyperlipidemia, and recently diagnosed prostate cancer. The patient also confirmed a history of ocular migraine. The patient denied current headaches, new floaters or flashes, curtains, or clouds in his vision.

Upon arrival, vital signs were: BP 131/91 | Pulse 107 | Temp 97.8 °F (36.6 °C) | SpO2 98% 

Visual acuity: OD 20/20 and OS) 20/20. Pupil light reaction from 3 mm to 2 mm bilaterally. Extraocular movement was full and normal in both eyes. Finger counting was normal in both eyes. The right eye had an intraocular pressure of 13 mmHg and the left eye had an intraocular pressure of 14 mmHg. The bedside anterior segment exam was normal. 

We performed a bedside ultrasound while waiting for an ophthalmology consult and obtained the following images of the left eye. 

Figure 1: Ultrasound of the left eye. 

Figure 2: Labeled ultrasound of the left eye showing asteroid hyalosis (hyperechoic free-floating particles in the vitreous chamber). 

In the obtained images, we see hyperechoic free-floating particles in the vitreous chamber as we scan through the eye. From these images, we reached a diagnosis of asteroid hyalosis. This was later confirmed by ophthalmology through a dilated fundus exam. 

Asteroid hyalosis (AH) is an uncommon degenerative condition that is characterized by the formation of asteroid bodies (AB), comprised of calcium and phospholipids within the vitreous chamber (1). The greatest prominent risk factor is age (2). 

Asteroid hyalosis is benign and asymptomatic in most cases and is not a viable cause for the diplopia that our patient presented with (1). Ophthalmology reported no evidence of strabismus or nystagmus. Additionally, the optic nerve was observed to be sharp and perfused. They postulated that the complaints could be explained by superior oblique myokymia vs retinal hemifield slide. Given the patient’s history of recently diagnosed prostate cancer, brain imaging was recommended to rule out intracranial pathology. Brain imaging revealed no evidence of acute infarct, hemorrhage, or mass. A follow-up with ophthalmology revealed ocular misalignment with a small esotropia in the left eye and a left abduction deficit. The ophthalmologist postulated that this could be due to minor six nerve palsy. This esotropia was found to be the cause of the ocular diplopia.

Asteroid hyalosis can mimic vitreous hemorrhage on ultrasound. Both conditions may show hyperechoic echogenicities swirling in the vitreous chamber in a washing machine or snow globe motion (3). Asteroid particles are composed of calcium linked to phospholipids and often take on an intensely hyperechoic appearance on ultrasound due to their density (2). Conversely, vitreous hemorrhage often appears less hyperechoic than asteroid particles and can have a less granular appearance (4). Differentiating between asteroid hyalosis, a benign and largely asymptomatic condition, and vitreous hemorrhage, a more serious condition that may require emergent intervention is critical. 

Figure 3: Vitreous Hemorrhage: diffuse mobile opacity often referred to as a “snow globe” appearance that is made apparent by side-to-side movement of the eye.

We presented this case to raise awareness of the utility of point-of-care ultrasound in rapidly diagnosing rare ocular diseases. Furthermore, this case is significant because asteroid hyalinosis is a relatively rare disease that is infrequently observed in the emergency department. 

References: 

  1. Scott, D. A. R., Møller-Lorentzen, T. B., Faber, C., Wied, J., Grauslund, J., & Subhi, Y. (2021). Spotlight on Asteroid Hyalosis: A Clinical Perspective. Clinical Ophthalmology, 15, 2537–2544. https://doi.org/10.2147/OPTH.S272333
  2. Duong R, Abou-Samra A, Bogaard JD, Shildkrot Y. Asteroid Hyalosis: An Update on Prevalence, Risk Factors, Emerging Clinical Impact and Management Strategies. Clin Ophthalmol. 2023 Jun 20;17:1739-1754. doi: 10.2147/OPTH.S389111.
  3. Gros EC, Mccafferty LR. Asteroid Hyalosis: A Mimicker of Vitreous Hemorrhage on Point of Care Ultrasound: A Case Report. POCUS J. 2023 Nov 27;8(2):113-115. doi: 10.24908/pocus.v8i2.16391.
  4. De La Hoz Polo M, Torramilans Lluís A, Pozuelo Segura O, Anguera Bosque A, Esmerado Appiani C, Caminal Mitjana JM. Ocular ultrasonography focused on the posterior eye segment: what radiologists should know. (2016) Insights into imaging. 7 (3): 351-64. doi:10.1007/s13244-016-0471-z
Posted on

Case 39: Superficial Thrombophlebitis

Aastha Shah

A 57-year-old male with a past medical history of HIV, hyperlipidemia (on a statin), chronic obstructive pulmonary disease (COPD), lumbar stenosis, and chronic diastolic heart failure presented with a chief complaint of pain and swelling in the right inguinal region for the past 3 days. The patient reported a similar presentation in the past, during which he was told that he had a hernia. He denies associated symptoms such as fever, chills, nausea, vomiting, abdominal distention, constipation, or urinary changes. He passed stool normally this morning and has no history of prior abdominal surgeries.

Vitals: BP: 135/84 mmHg | Pulse: 84 bpm | Temp: 97.4 °F (36.3 °C) | Resp: 16 | Wt: 75.7 kg (166 lb 14.2 oz) | SpO2: 98%

On physical examination, the patient appeared in no acute distress. Cardiovascular exam revealed a regular rate and rhythm without murmurs. Lungs were clear to auscultation and the abdomen was soft, nondistended, and non-tender. A firm, localized swelling and tenderness was noted in the right inguinal region. There was no redness, induration, or drainage at the site. No testicular swelling or tenderness was observed. The remainder of the physical exam, including neurologic and extremity exams, was unremarkable.

A bedside ultrasound was performed over the area of swelling.

Figure 1: Non-occlusive superficial venous thrombus in the right inguinal region.

Discussion

Deep vein thrombosis (DVT) is a common condition, with an annual incidence rate estimated at about 1 in 1,000 adults. The risk of DVT increases with age, and other risk factors include immobility, recent surgery, trauma, malignancy, and certain medical conditions like HIV, COPD, and heart failure, which this patient has.

The differential diagnosis for DVT includes a variety of conditions that may present with
unilateral leg pain and swelling. These include cellulitis, muscle strains, Baker's cyst, venous
insufficiency, or even superficial thrombophlebitis, which was seen in this patient. Superficial venous thrombosis (SVT) is generally considered less dangerous than DVT, as SVT does not carry the same risk of pulmonary embolism, but it can still cause significant discomfort and complications if left untreated.

On physical exam, patients with DVT typically present with unilateral leg swelling, pain, and
tenderness. Other findings can include warmth, erythema, and distended superficial veins. In this case, the patient had localized swelling and tenderness in the right inguinal region without any associated redness or warmth, which is consistent with superficial venous thrombosis rather than DVT.

Ultrasound is the gold standard for diagnosing both DVT and SVT. Bedside ultrasonography
performed by emergency physicians can achieve sensitivities of 95% and specificities of 96%, making it a highly reliable tool for assessing DVT at the point of care (1). However, variability in ultrasound protocols has been noted across institutions. As reported by the Society of Radiologists in Ultrasound, discrepancies between protocols can lead to underdiagnosis or unnecessary testing, as highlighted in one case where a patient presented with calf DVT that was missed on initial imaging but later identified during follow-up scans (2). This underscores the need for standardized, comprehensive duplex ultrasound protocols to ensure accurate diagnosis.

When performing a point-of-care ultrasound (POCUS) exam for DVT, compression should be applied to the femoral vein just above and below the saphenofemoral junction, above and below the bifurcation of the common femoral vein into the deep femoral vein and femoral vein, and to the popliteal vein extending up to the trifurcation into the calf veins (3-point compression protocol). In this patient, the femoral vein was visualized during the POCUS, but the clot was superficial and located away from the femoral vein.

Treatment for DVT typically involves anticoagulation to prevent clot extension and pulmonary embolism. For superficial venous thrombosis, treatment is less aggressive and usually involves conservative management, such as compression stockings, nonsteroidal anti-inflammatory drugs (NSAIDs) for pain relief, and in some cases, anticoagulation if the thrombus is near a deep vein or extensive. If the thrombus extends or becomes symptomatic, more aggressive measures, such as surgical intervention or thrombolytic therapy, may be required.

References:

  1. Baker M, Anjum F, dela Cruz J. Deep Venous Thrombosis Ultrasound Evaluation.
    StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available
    from: https://www.ncbi.nlm.nih.gov/books/NBK470453/.
  2. Needleman L, Cronan JJ, Lilly MP, et al. Ultrasound for Lower Extremity Deep Venous
    Thrombosis: Multidisciplinary Recommendations From the Society of Radiologists in
    Ultrasound Consensus Conference. Circulation. 2018;137(14):1505-1515.
    doi:10.1161/CIRCULATIONAHA.117.030687.

Posted on

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
      Posted on

      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.
      Posted on

      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.

      Posted on

      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

      Posted on

      Case 34: Rare Cause of Knee Pain

       

      A 58-year-old female presented with a chief complaint of focal lateral knee pain and swelling. She had a remote history of anterior cruciate ligament repair, as well as medial collateral ligament injury and meniscal injuries. The patient stated that she had a history of recurrent intermittent effusions. However, that day she noted focal swelling. She reported playing tennis a few days before and noted a pain in her knee with pivoting. No knee instability. No fever.

       

      Vitals: BP 118/60 | Pulse 52 | Temp 97.8 °F (36.6 °C) | Resp 12

       

      On physical examination of the knee, there was a 2 cm x 3 cm firm, immobile round mass at the inferior lateral aspect of the left knee with associated pain, mild warmth, and swelling. Decreased flexion of the joint was observed, with some pain beyond 100 degrees of flexion.

       

       

      A bedside ultrasound was performed. What do you see?

      Figure 1: Ultrasound of the lateral aspect of the knee joint

      Figure 1: Ultrasound of the lateral aspect of the knee joint

      Figure 2: Knee Effusion

      Figure 2: Knee Effusion

      Figure 3: Joint effusion and meniscal cysts

      Figure 3: Joint effusion and meniscal cysts

      Figure 4: Joint effusion

      Figure 4: Joint effusion

      Figure 5: MRI of anterior cyst forming on the meniscus

      Figure 5: MRI of anterior cyst forming on the meniscus

      Discussion

      In these images, we see classic findings of a parameniscal cyst. There is a joint effusion seen superior with Hoffa’s fat pad evident. In the lateral knee, we see extrusion of the meniscus on ultrasound, along with several small fluid collections within the meniscus (meniscal cysts). Beyond the margin of the meniscus, we see the larger parameniscal cyst situated more superficially and featuring a thick wall. Corresponding MRI images from a few months prior also show the anterior cyst forming on the meniscus. Meniscal cysts are found in 1% of MRIs obtained for knee pain [1]. They are a rare pathology most often associated with a synovial leak of fluid through degeneration of the meniscus, secondary to tears of the meniscus. Physical exam findings associated with meniscal cysts include localized pain, with a firm fluid collection at the joint line, anterior or posterior, often accompanied by a joint effusion. However, only 20% of cysts are palpable on examination with the average size being 1-2 cm [2]. Patients will present with local pain, but may also present with peroneal nerve palsy, or foot drop, if the cyst is located inferior and laterally. Point-of-care ultrasound confirms the diagnosis with an accuracy of 94%, a sensitivity of 97%, and a specificity of 86% [3]. The ultrasound appearance of the cyst may be multiloculated and contiguous with the knee joint along the meniscus or within the meniscus. The fluid removed from the cyst is often thick and gelatinous and therefore requires a large gauge needle and ultrasound guidance for successful aspiration [4]. A steroid injection is often performed following fluid aspiration. If there is recurrence, the cyst can be surgically removed. CT or MRI can also confirm diagnosis [5]. Point-of-care ultrasound is a useful tool to distinguish meniscal cysts from other cystic and solid masses at the knee joint [6]. The differential diagnosis of meniscal cysts includes osteophytes associated with degenerative joint disease, traumatic bursitis, lipoma, ganglion cyst, or, rarely, synovial sarcoma.

      References

      1) Anderson JJ, Connor GF, Helms CA. New observations on meniscal cysts. Skeletal Radiol. 2010 Dec;39(12):1187-91. doi: 10.1007/s00256-010-0993-2. Epub 2010 Jul 31. PMID: 20680623.

      2)Crowell MS, Westrick RB, Fogarty BT. Cysts of the lateral meniscus. Int J Sports Phys Ther. 2013 Jun;8(3):340-8. PMID: 23772349; PMCID: PMC3679639.

      3) Chang A. Imaging-guided treatment of meniscal cysts. HSS J. 2009 Feb;5(1):58-60. doi: 10.1007/s11420-008-9098-z. Epub 2008 Nov 7. PMID: 18989726; PMCID: PMC2642552.

      4) Chen H. Diagnosis and treatment of a lateral meniscal cyst with musculoskeletal ultrasound. Case Rep Orthop. 2015;2015:432187. doi: 10.1155/2015/432187. Epub 2015 Feb 5. PMID: 25722908; PMCID: PMC4334430.

      5) Lantz B, Singer KM. Meniscal cysts. Clin Sports Med. 1990 Jul;9(3):707-25. PMID: 2199079.

      6) Rutten MJ, Collins JM, van Kampen A, Jager GJ. Meniscal cysts: detection with high-resolution sonography. AJR Am J Roentgenol. 1998 Aug;171(2):491-6. doi: 10.2214/ajr.171.2.9694482. PMID: 9694482.

      This post was written by Skyler Sloane, Ben Supat MD MPH, and Colleen Campbell MD

      Translate »