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A 69-Year-Old Man With Dyspnea Following Lung BiopsyPost-Lung Biopsy Dyspnea FREE TO VIEW

Christian B. Laursen, MD, PhD; Bill Frederiksen, MD; Stefan Posth, MD
Author and Funding Information

From the Department of Respiratory Medicine and Center for Thorax Oncology (Dr Laursen), Department of Rheumatology (Dr Frederiksen), and Department of Emergency Medicine (Dr Posth), Odense University Hospital; and Institute of Clinical Research (Drs Laursen and Posth), University of Southern Denmark, Odense, Denmark.

CORRESPONDENCE TO: Christian B. Laursen, MD, PhD, Department of Respiratory Medicine, Odense University Hospital, Sdr Blvd 29, 5000 Odense C, Denmark; e-mail: christian.b.laursen@rsyd.dk


Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2015;148(5):e139-e141. doi:10.1378/chest.14-3152
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Published online

A 69-year-old man with COPD and ischemic heart disease was admitted with dyspnea to the ED. Nine hours prior to the admission, the patient had been seen in an outpatient clinic where a CT scan-guided biopsy of an opacity in the right lung had been performed. After the biopsy, the patient did not have any complaints. A control CT scan of the chest following the biopsy as well as a control chest radiograph 4 h after the biopsy had been performed did not have signs of pneumothorax or other complications. The patient was allowed to go home without any further observation.

Within the following hours, the patient developed progressive dyspnea and a dry cough and was subsequently readmitted to the ED. On admission, the patient was found to be awake, but in respiratory distress. The respiratory rate was 45 breaths/min; saturation was 95% on 2 L/min oxygen delivered with nasal cannulae. BP, heart rate, and Glasgow coma score were normal. Heart and lung auscultation were without any abnormal findings. The bandage at the site where the needle had been inserted in the chest was dry with no signs of bleeding. No subcutaneous emphysema was present when palpating the chest of the patient. Initial blood sample analysis showed a hemoglobin level of 9.7 g/dL and a C-reactive protein level of 7.9 mg/L; these were unaltered when compared with blood samples performed during the stay in the outpatient clinic earlier on the same day. No major abnormalities were detected in the other blood sample results. An ECG taken upon arrival was without signs of ischemia or arrhythmia.

Video 1 demonstrates lung ultrasound (LUS) findings from the right anterior chest surface (clip 1), the right lateral chest surface corresponding to the biopsy puncture site (clip 2), and the right posterolateral chest surface (clip 3).

Video 1.

Case presentation video. Clip 1: Lung ultrasound (LUS) of the right anterior chest surface. Clip 2: LUS of right lateral chest surface corresponding to the biopsy puncture site. Clip 3: LUS of the right posterolateral chest surface.

Running Time: 01:24

Question: Based on Video 1 and the patient’s clinical history and physical examination, what is the most likely diagnosis?
Diagnosis: Intrapulmonary hemorrhage

Based on the sonographic findings, iatrogenic complications such as pneumothorax and hemothorax can be ruled out. LUS of the right posterolateral surface of the chest reveals an area of lung consolidation. In this case, the rapid development of lung consolidation following lung biopsy makes intrapulmonary hemorrhage the most likely diagnosis.

Point-of-care LUS can be used to assess patients who develop respiratory symptoms following invasive procedures in the chest. Known iatrogenic complications following transthoracic lung biopsy include pneumothorax, hemothorax, and intrapulmonary hemorrhage.1 This case demonstrates how point-of-care LUS can be used to assess patients who develop respiratory symptoms following invasive procedures in the chest for the presence (or absence) of these complications.

In the presented case, the first clinical question would be whether the patient had developed a postinterventional pneumothorax. In Video 2, clips with inserted markings demonstrating LUS findings are shown. In the first clip, from the right anterior chest surface, lung sliding (marked LS) is present; the diagnosis of pneumothorax can be ruled out in the assessed area. The first area assessed was, hence, the right anterior surface of the chest. The next area scanned corresponded to the needle puncture site. This was done to assess the presence of a localized pneumothorax in that area and whether any intrapulmonary pathology was present. The findings are demonstrated in the second clip of Video 2, from the right lateral chest surface corresponding to the biopsy puncture site. Lung sliding was absent and the pleura line (marked PL in the clip) was irregular with small subpleural consolidations. Additionally, localized multiple B lines (one of which is marked B in the clip) was also present. Due to these findings, localized pneumothorax at the puncture site could be ruled out.

Video 2.

Discussion video. Clip 1: LUS of the right anterior surface of the chest. Lung sliding (LS) is present, the diagnosis of pneumothorax can ruled out in the assessed area. Clip 2: LUS of right lateral chest surface corresponding to the biopsy puncture site. Lung sliding is absent but since multiple B-lines are present, localized pneumothorax at the puncture site can be ruled-out. Clip 3: LUS of the right posterolateral chest surface. No pleural effusion is present, thus ruling out a hemothorax. An area of consolidated lung tissue (LC) is present; the consolidation appears more hyperechogenic than the liver tissue (Lvr) which can be visualized below the diaphragm. The hyperechoic lung consolidation was suspected as representing intrapulmonary hemorrhage.

Running Time: 03:16

The diagnostic accuracy of LUS for pneumothorax is superior to chest radiograph and has been validated as an accurate modality for diagnosing iatrogenic pneumothorax following invasive procedures in the chest.2-4 One could argue that a pneumothorax could have been ruled out using only the assessment of the anterior surface of the chest, but a study conducted in a patient population comprising patients with a variety of chronic pulmonary diseases found that the sensitivity of LUS for diagnosing pneumothorax was lower than what has been reported in studies comprising patients in which the prevalence of chronic pulmonary diseases are low (eg, trauma).4,5 The assessment of the puncture site also revealed signs of localized pathology in the form of multiple B lines. Following the exclusion of pneumothorax, the next important complication to diagnose would be hemothorax. The area subsequently assessed thus corresponded to the lower, posterolateral area of the right lung. The findings are demonstrated in the third clip of Video 2. In this clip, from the right posterolateral chest surface, no pleural effusion was present and hemothorax was ruled out. As an incidental finding in the lower posterolateral area of the right lung, a hyperechoic area of consolidated lung tissue could be visualized (marked LC). The high echogenicity of the area obscured the possible visualization of any air bronchograms. Since lung consolidation was absent in this area on the chest CT scan and radiograph performed after the lung biopsy, the consolidation of the lung tissue in this area had occurred following the biopsy. The consolidation appears more hyperechogenic than the underlying liver tissue (marked Lvr), which can be visualized below the diaphragm; the appearance did not correspond to the typical sonomorphologic patterns in other causes of acutely developed lung consolidations (eg, pneumonia, pulmonary embolism). The visualized lung parenchymal pathology was, thus, believed to represent an acute condition in which a fluid had caused a hyperechoic lung consolidation, which was suspected as representing intrapulmonary hemorrhage.

Point-of-care LUS can be used for the diagnosis of lung consolidation (eg, pneumonia, pulmonary embolism, contusion) and atelectasis.6 To our knowledge, the use of LUS for the diagnosis of lung hemorrhage has yet to be described in studies. In the described case, the two sonomorphologic patterns also seen in other causes of lung consolidation could also be seen, namely focal multiple B lines and visible consolidated lung tissue.6 The B lines located at the biopsy puncture site might have been present prior to the CT scan-guided biopsy as a result of the underlying tumor within the lung tissue. An alternative cause could have been increased density of the lung tissue due to the biopsy causing intrapulmonary hemorrhage. However, the sonomorphologic pattern of the lung consolidation differed from what has been described as the patterns seen in pneumonia and pulmonary embolism. The typical pattern of pneumonia is that of liver-like lung consolidation, presence of air bronchograms, and a serrated margin, whereas that of pulmonary embolism typically is a hypoechoic, well-demarcated lung consolidation without the presence of air bronchograms.6-8 Compared with these two patterns, the visualized consolidation was even more hyperechoic, and, thus, obscured the visualization of any air bronchograms. The hyperechoic appearance could be due to air being admixed with blood within the alveoli causing acoustic enhancement.

Upon arrival at the ED, no obvious signs of intrapulmonary hemorrhage were present, but within the first 24 h after admission, the patient developed hemoptysis, and both BP as well as hemoglobin values decreased. A conservative treatment strategy composed of oxygen therapy, RBC transfusion, and close monitoring was chosen. The patient was discharged 5 days after the admission to the ED.

This case demonstrates the following in patients with dyspnea following lung biopsy: (1) Point-of-care LUS is a fast and accurate tool for ruling out common complications such as pneumothorax and hemothorax; (2) intrapulmonary hemorrhage may present itself as focal B lines, a very hyperechoic lung consolidation, or both; and (3) point-of-care LUS may serve as an imaging modality which in some cases might be able to diagnose intrapulmonary hemorrhage prior to the development of manifest symptoms (eg, hemoptysis) and signs (eg, decreased BP) of active bleeding in the lungs.

  • 1. Point-of-care LUS can accurately diagnose postinterventional pneumothorax.

  • 2. Point-of-care LUS can accurately diagnose postinterventional hemothorax.

  • 3. Point-of-care LUS can in some cases diagnose intrapulmonary hemorrhage following lung biopsy.

  • 4. In some cases, point-of-care LUS is able to diagnose intrapulmonary hemorrhage prior to the development of manifest symptoms and signs.

Conflict of interest: C. B. L. has received payment as an author of e-learn material and as a course director/instructor for courses in ultrasound organized by USabcd A/S. None declared (B. F., S. P.).

Other contributions: CHEST worked with the authors to ensure that the Journal policies on patient consent to report information were met.

Additional information: To analyze this case with the videos, see the online version of this article.

Wang Y, Li W, He X, Li G, Xu L. Computed tomography-guided core needle biopsy of lung lesions: diagnostic yield and correlation between factors and complications. Oncol Lett. 2014;7(1):288-294. [PubMed]
 
Reissig A, Kroegel C. Accuracy of transthoracic sonography in excluding post-interventional pneumothorax and hydropneumothorax. Comparison to chest radiography. Eur J Radiol. 2005;53(3):463-470. [CrossRef] [PubMed]
 
Sartori S, Tombesi P, Trevisani L, Nielsen I, Tassinari D, Abbasciano V. Accuracy of transthoracic sonography in detection of pneumothorax after sonographically guided lung biopsy: prospective comparison with chest radiography. AJR Am J Roentgenol. 2007;188(1):37-41. [CrossRef] [PubMed]
 
Chung MJ, Goo JM, Im JG, Cho JM, Cho SB, Kim SJ. Value of high-resolution ultrasound in detecting a pneumothorax. Eur Radiol. 2005;15(5):930-935. [CrossRef] [PubMed]
 
Soldati G, Testa A, Sher S, Pignataro G, La Sala M, Silveri NG. Occult traumatic pneumothorax: diagnostic accuracy of lung ultrasonography in the emergency department. Chest. 2008;133(1):204-211. [CrossRef] [PubMed]
 
Volpicelli G, Elbarbary M, Blaivas M, et al; International Liaison Committee on Lung Ultrasound (ILC-LUS) for International Consensus Conference on Lung Ultrasound (ICC-LUS). International evidence-based recommendations for point-of-care lung ultrasound. Intensive Care Med. 2012;38(4):577-591. [CrossRef] [PubMed]
 
Weinberg B, Diakoumakis EE, Kass EG, Seife B, Zvi ZB. The air bronchogram: sonographic demonstration. AJR Am J Roentgenol. 1986;147(3):593-595. [CrossRef] [PubMed]
 
Mathis G, Dirschmid K. Pulmonary infarction: sonographic appearance with pathologic correlation. Eur J Radiol. 1993;17(3):170-174. [CrossRef] [PubMed]
 

Figures

Tables

Video 1.

Case presentation video. Clip 1: Lung ultrasound (LUS) of the right anterior chest surface. Clip 2: LUS of right lateral chest surface corresponding to the biopsy puncture site. Clip 3: LUS of the right posterolateral chest surface.

Running Time: 01:24

Video 2.

Discussion video. Clip 1: LUS of the right anterior surface of the chest. Lung sliding (LS) is present, the diagnosis of pneumothorax can ruled out in the assessed area. Clip 2: LUS of right lateral chest surface corresponding to the biopsy puncture site. Lung sliding is absent but since multiple B-lines are present, localized pneumothorax at the puncture site can be ruled-out. Clip 3: LUS of the right posterolateral chest surface. No pleural effusion is present, thus ruling out a hemothorax. An area of consolidated lung tissue (LC) is present; the consolidation appears more hyperechogenic than the liver tissue (Lvr) which can be visualized below the diaphragm. The hyperechoic lung consolidation was suspected as representing intrapulmonary hemorrhage.

Running Time: 03:16

References

Wang Y, Li W, He X, Li G, Xu L. Computed tomography-guided core needle biopsy of lung lesions: diagnostic yield and correlation between factors and complications. Oncol Lett. 2014;7(1):288-294. [PubMed]
 
Reissig A, Kroegel C. Accuracy of transthoracic sonography in excluding post-interventional pneumothorax and hydropneumothorax. Comparison to chest radiography. Eur J Radiol. 2005;53(3):463-470. [CrossRef] [PubMed]
 
Sartori S, Tombesi P, Trevisani L, Nielsen I, Tassinari D, Abbasciano V. Accuracy of transthoracic sonography in detection of pneumothorax after sonographically guided lung biopsy: prospective comparison with chest radiography. AJR Am J Roentgenol. 2007;188(1):37-41. [CrossRef] [PubMed]
 
Chung MJ, Goo JM, Im JG, Cho JM, Cho SB, Kim SJ. Value of high-resolution ultrasound in detecting a pneumothorax. Eur Radiol. 2005;15(5):930-935. [CrossRef] [PubMed]
 
Soldati G, Testa A, Sher S, Pignataro G, La Sala M, Silveri NG. Occult traumatic pneumothorax: diagnostic accuracy of lung ultrasonography in the emergency department. Chest. 2008;133(1):204-211. [CrossRef] [PubMed]
 
Volpicelli G, Elbarbary M, Blaivas M, et al; International Liaison Committee on Lung Ultrasound (ILC-LUS) for International Consensus Conference on Lung Ultrasound (ICC-LUS). International evidence-based recommendations for point-of-care lung ultrasound. Intensive Care Med. 2012;38(4):577-591. [CrossRef] [PubMed]
 
Weinberg B, Diakoumakis EE, Kass EG, Seife B, Zvi ZB. The air bronchogram: sonographic demonstration. AJR Am J Roentgenol. 1986;147(3):593-595. [CrossRef] [PubMed]
 
Mathis G, Dirschmid K. Pulmonary infarction: sonographic appearance with pathologic correlation. Eur J Radiol. 1993;17(3):170-174. [CrossRef] [PubMed]
 
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