SESSION TITLE: Critical Care Student/Resident Case Report Posters III
SESSION TYPE: Medical Student/Resident Case Report
PRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PM
INTRODUCTION: Pulmonary embolism (PE) is a frequently-encountered problem which can be fatal if left untreated. CT pulmonary angiography (CTPA) is the current gold standard for diagnosing PE but sometimes it cannot be done or may not be diagnostic. Alternatively, ventilation-perfusion scan can end up being indeterminate, and conventional pulmonary angiography is invasive and shares similar contra-indications with CTPA. On the other hand, PE may be directly visualized by endobrochial ultrasonography (EBUS). [1, 2]
CASE PRESENTATION: An obese 27 year old male smoker and alcoholic presented with a 3 day history of shortness of breath associated with pleuritic chest pain and hemoptysis. He denied purulent phlegm and fevers. He denied history of blood clots. He was tachycardic, tachypneic, normotensive and afebrile, with decreased breath sounds on the right side and an ulcer on his left leg. Chest X-ray showed bibasilar consolidation, worse on the right side. Labs were significant for leukocytosis of 14,500/cc and PaO2 of 81 mmHg. A CTPA showed consolidation in the right lower lobe and suggested PE but contrast opacification was sub-optimal. Compression ultrasonography did not reveal any deep venous thrombosis. A repeat CTPA was also sub-optimal. Bronchoscopy and EBUS was done. It revealed PE in the right pulmonary artery (Figure 1). This was confirmed with color Doppler. The patient improved with anticoagulation therapy and was subsequently discharged home.
DISCUSSION: PE that is central in location can be visualized directly by endoscopic ultrasonography. Transesophageal echocardiography (TEE) is one such method; however, its use requires expertise and the lobar and distal branches are beyond its reach. EBUS is an alternative method to look for central PE.[1, 2] A growing number of pulmonologists are becoming familiar with this new technology. Unlike TEE, its insertion is not ‘blind’ and it can reach the lobar branches as well. While it is mainly used to sample enlarged lymph nodes and central masses, EBUS appears to be a promising method for detecting central PE, particularly when one is faced with a dilemma similar to ours.
CONCLUSIONS: Given the high quality images obtained by EBUS of the pulmonary artery tree up to its lobar branches, and the option of color Doppler, EBUS could be an emerging new tool to diagnose PE, particularly when CTPA cannot be done (like poor kidney function or allergy to contrast dye), or when the CTPA images are equivocal, or when a rapid bedside diagnosis is warranted in a hemodynamically unstable patient.
Reference #1: Aumiller, J., et al., Endobronchial ultrasound for detecting central pulmonary emboli: a pilot study. Respiration, 2009. 77(3): p. 298-302.
Reference #2: Senturk, A., et al., Diagnostic imaging of pulmonary embolism using endobronchial ultrasound. Arch Bronconeumol, 2013. 49(6): p. 268-71.
DISCLOSURE: The following authors have nothing to disclose: Farah Al-saffar, Saif Ibrahim, Vandana Seeram, Adil Shujaat
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