Multiloculated pleural effusion detected by ultrasound only in a critically-ill patient

A case report of a 16-year-old male with extrapulmonary tuberculosis presenting as multiloculated mediastinal, pleural, and paravertebral fluid collections with chest pain, Eldoret, Kenya

Key Clinical Message

Extrapulmonary TB presenting as multiloculated pleural fluid collections is rare in persons less than 18 years of age, but it can occur. High index of suspicion is important in establishing early diagnosis and treatment to reduce morbidity and mortality.

Abstract

We present a case report of an immunocompetent African young man who presented with persistent chest pain and fever, and was diagnosed with extrapulmonary tuberculosis (EPTB) following chest CT scan, pleural biopsy histopathology examination, and Ziehl-Neelsen (ZN) staining, and pleural fluid Gene Xpert studies.

Clinical Yield of Routine Chest Radiography after Ultrasound-Guided Thoracentesis

RATIONALE AND OBJECTIVES

To evaluate the clinical yield of routine chest radiography in identifying pneumothorax warranting chest tube decompression in patients undergoing ultrasound-guided thoracentesis.

MATERIALS AND METHODS

All adult patients without pre-existing pneumothorax who underwent ultrasound-guided thoracentesis by a radiologist within a four-hospital large metropolitan academic health system over a 10-year period were identified. Demographic, clinical, and radiographic report information were obtained. Chest radiographic reports were assessed for the presence of pneumothorax and, if positive, manual image and chart review were performed.

RESULTS

Of 2541 consecutive ultrasound-guided thoracentesis procedures, 12 were excluded due to pre-existing pneumothorax, yielding 2529 cases. Mean patient age was 67.7 years; 54.5% were male. Overall, 89 procedures (3.5%) resulted in a postprocedural pneumothorax. Of those, only six (6.7%) had documented changes in patient symptoms. Chest tubes were placed in 15, representing 16.9% (15/89) of cases with postprocedural pneumothoraces and 0.59% (15/2,529) of all procedures. Of these 15, 5 (33.3%) had symptomatic pneumothoraces, most commonly shortness of breath.

CONCLUSION

Following ultrasound-guided thoracentesis, the incidence of pneumothorax requiring chest tube decompression is only 1 in 170. Of the 1 in 30 patients who develop a pneumothorax, only 1 in 6 require a chest tube. This information can inform procedural consent discussions as well as future guidelines about the necessity of routine postprocedural chest radiography.

B-Mode Ultrasound Findings in a Patient With Suspected Pulmonary Gangrene

OBJECTIVES

Lung ultrasound has shown increasing diagnostic value in many lung diseases and has become an efficient tool in the management of dyspnea. In the present case report, we describe a new ultrasound feature of potential interest.

DATA SOURCES

Clinical observation of a patient.

STUDY SELECTION

Case report.

DATA EXTRACTION

Data were extracted from medical records, after obtaining consent from the patient's family. Illustrations were extracted from the imaging software and a video device.

DATA SYNTHESIS

A 56-year-old man was admitted with pneumonia of adverse outcome. Lung ultrasound, a method increasingly considered as a bedside gold standard in critically ill patients due to its overwhelming advantages, was the only tool able to specify the lung injuries. We describe herein a distinctive sign unequivocally evoking a destructive process suggestive of pulmonary gangrene, a variant of the fractal sign combining a lung consolidation with an underlying heterogeneous free fluid.

CONCLUSIONS

Lung ultrasound may help highlight pulmonary gangrene, a poorly-known disease, with this new ultrasonographic description. The next step will be to ascertain the relation between this new ultrasound feature and pulmonary gangrene and to assess how this bedside diagnosis could impact the prognosis of the disease.

Ultrasound of the pediatric chest

Cross-sectional imaging modalities like MRI and CT provide images of the chest which are easily understood by clinicians. However, these modalities may not always be available and are expensive. Lung ultrasonography (US) has therefore become an important tool in the hands of clinicians as an extension of the clinical exam, which has been underutilized by the radiologists. Reinforcement of the ALARA principle along with the dictum of "Image gently" have resulted in increased use of modalities which do not require radiation. Hence, ultrasound, which was earlier being used mainly to confirm the presence of pleural effusion as well as evaluate it and differentiate solid from cystic masses, is now being used to evaluate the lung as well. This review highlights the utility of ultrasound of the paediatric chest. It also describes the normal and abnormal appearances of the paediatric lung on ultrasound as well as the advantages and limitations of this modality.

Point of Care Ultrasound Diagnosis of Empyema

BACKGROUND

Emergency ultrasonography is an efficient and cost effective tool for patients who are in respiratory distress. Chest radiographs can yield limited information for these patients. Computed tomography scans have long been the criterion standard for advanced imaging in patients with respiratory complaints, but point of care ultrasound (POCUS) can be performed at bedside, does not expose the patient to radiation, and at times may provide more information than a computed tomography scan.

CASE REPORT

A 60-year-old man with a medical history of hypertension presented to the emergency department complaining of a productive cough associated with fever, weakness, and progressively worsening dyspnea on exertion over the previous 1 to 2 weeks. The physical examination was remarkable for rhonchi in the right upper lobe and diminished breath sounds throughout the right lung. POCUS was performed, and the results revealed severe atelectasis and hepatization of the right lung parenchyma with visualized air bronchograms. Complex hypoechoic material with a posterior spine sign was noted, which increased concern for complex consolidation and effusion. The diagnosis of pneumonia with empyema was made. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: POCUS has become a much more commonly used imaging modality within many emergency departments. Ultrasound is more sensitive than chest radiographs for identifying pathologies such as pneumothorax and simple effusions. This case shows how well POCUS can diagnose empyema even in the setting of diagnostic uncertainty of computed tomographic imaging.

Ultrasound in the diagnosis and management of pleural effusions

We review the literature on the use of point-of-care ultrasound to evaluate and manage pleural effusions. Point-of-care ultrasound is more sensitive than physical exam and chest radiography to detect pleural effusions, and avoids many negative aspects of computerized tomography. Additionally, point-of-care ultrasound can assess pleural fluid volume and character, revealing possible underlying pathologies and guiding management. Thoracentesis performed with ultrasound guidance has lower risk of pneumothorax and bleeding complications. Future research should focus on the clinical effectiveness of point-of-care ultrasound in the routine management of pleural effusions and how new technologies may expand its clinical utility.

Sonoelastography--a useful adjunct for parotid gland ultrasound assessment in patients suffering from chronic inflammation

Background

Shear wave elastography (SWE) is widely used in breast, liver, prostate and thyroid evaluations. Elastography provides additional information if used to assess parotid gland pathology. We assessed parotid glands by means of SWE to compare the parenchyma properties in different types of inflammation.

Material/Methods

Prospective analysis included 78 consecutive patients with parotid gland pathology: sialolithiasis (33), Stensen’s duct stenosis (15), chronic inflammation (10), and primary Sjögren syndrome (pSS) (20) treated at the Department of Otolaryngology, Head and Neck Surgery of PUMS. The primary predictor variable was type of parotid pathology, and secondary predictor variables were patient age and the duration and intensity of complaints. Ultrasound pictures were compared with elastography values of parotid parenchyma.

Results

Mean elasticity values for pSS (111 Kilopascals (kPa), Stensen’s duct stenosis (63 kPa), sialolithiasis (82 kPa), and chronic inflammation (77 kPa) were significantly higher than the mean value for healthy patients (24 kPa). Elasticity increased proportionally to the intensity of complaints: mild (51 kPa), moderate (78 kPa), and strong (90 kPa). Increased elasticity did not correspond with ultrasonographic pictures. In pSS the parenchyma was almost twice as stiff as in chronic inflammation (p=0.02), although subjective complaints were mostly mild or moderate, and the ultrasonographic picture did not present features of fibrosis.

Conclusions

Sonoelastography, by improving routine ultrasonographic assessment, might be a useful tool for parotid evaluations during the course of chronic inflammation. An extraordinarily high degree of stiffness was revealed in pSS despite lack of fibrosis by ultrasonography and moderate subjective complaints, suggesting that sonoelastography could be a valuable diagnostic tool.

Pregnancy with bilateral tubercular pleural effusion: challenges

Pulmonary tuberculosis (TB) during pregnancy mimics some of the physiological changes that occur during pregnancy. Diagnosis is challenging, especially when the patient presents with acute respiratory distress. The incidence of pleural effusion in TB is 3-25% and in the majority of patients, is unilateral. We describe the intensive care management of a 27-year-old pregnant woman admitted to our hospital with life threatening respiratory distress and circulatory shock. She continued to have severe metabolic and respiratory acidosis with shock in spite of the resuscitative measures undertaken. At that point, a bedside lung ultrasonography showed bilateral pleural effusion which was followed with therapeutic thoracocentesis of the right side. This resulted in the stabilization of the respiratory mechanics and haemodynamics of the patient. The pleural fluid culture tested positive for acid fast bacilli after 4 weeks in the intensive care unit. Anti-TB therapy was started and she made a rapid recovery with liberation from mechanical ventilation. The early use of bedside lung ultrasonography was instrumental in the successful management of this patient.