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A 3-Year-Old Child With a History of Persistent Dry Cough and Fever FREE TO VIEW

Emanuele Giovanni Conte, MD; Rafael Emanuele Gerardi, MD; Andrea Smargiassi, MD, PhD; Antonio Gatto, MD; Piero Valentini, MD; Lorenzo Nanni, MD; Riccardo Inchingolo, MD, PhD
Author and Funding Information

E. G. C. and R. E. G. contributed equally to this work.

aDepartment of Pulmonary Medicine, Policlinico Universitario Agostino Gemelli, Rome, Italy

bInstitute of Pediatrics, Policlinico Universitario Agostino Gemelli, Rome, Italy

cInstitute of Pediatric Surgery, Policlinico Universitario Agostino Gemelli, Rome, Italy

CORRESPONDENCE TO: Rafael Emanuele Gerardi, MD, Department of Pulmonary Medicine, Policlinico Universitario A. Gemelli, Rome 00168, Italy


Copyright 2017, American College of Chest Physicians. All Rights Reserved.


Chest. 2017;151(6):e127-e129. doi:10.1016/j.chest.2016.12.036
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Published online

B. K., a 3-year-old child, without past medical history, was accompanied by his parents to our ED after onset of fever (40°C) and dry cough not responsive to 2 weeks of empirical therapy with amoxicillin/clavulanate.

On arrival, the patient was alert and cooperative with oxygen saturation of 97% while breathing room air, a heart rate of 100 beats/min, regular rhythm, blood pressure of 110/60 mm Hg, and body temperature of 36.5°C. The results of physical examination were noncontributory.

Laboratory data revealed a WBC count of 3.8 × 109/L with 20.1% neutrophils and 74.1% lymphocytes and a normal value for C-reactive protein. A posteroanterior chest radiograph (Fig 1) showed a small lung consolidation in the right lower lobe. The patient was admitted to the pediatric care unit of our hospital for further management, and he started empirical antibiotic therapy with ceftriaxone.

Figure Jump LinkFigure 1 Posteroanterior chest radiograph. There is evidence of a small lung consolidation in the right lower lobe.Grahic Jump Location

Because of the radiographic findings, a chest ultrasound (CU) was performed by a pulmonologist (Videos 1 and 2). A MyLab 50 Gold cardiovascular machine (Esaote SpA, Rome, Italy) with a 7.5- to 10-MHz probe was used. Multiple scans were obtained in both sagittal and intercostal planes, in upright and supine positions.

Both videos show multiple supradiaphragmatic subpleural echogenic areas with heterogeneous texture and an ovular/rounded shape along the right mid-clavicular line at the fourth and fifth intercostal spaces. The echogenic areas were characterized by poor Doppler flow, showed no changes during acts of breathing, and resembled intestinal lumen.

Question: Are these ultrasonographic findings suggestive of lung consolidation caused by pneumonia?

Answer: These ultrasonographic findings do not suggest lung consolidation caused by pneumonia, because of the presence of a double curtain sign over the lesion combined with the previously described ultrasonographic findings of the lesion

This pattern is suggestive of intrathoracic extrapulmonary disease, such as a diaphragmatic hernia.

Therefore, the patient underwent a CT scan (Fig 2), which confirmed the diagnosis: Morgagni hernia/congenital diaphragmatic hernia.

Figure Jump LinkFigure 2 Chest CT scan with contrast enhancement. A, Axial scan without contrast. B, Axial scan with contrast. C, Multiplanar reconstruction. There is evidence of intrathoracic herniation of the large bowel (hepatic flexure) suggestive of a Morgagni hernia.Grahic Jump Location

Our next step was to perform laparoscopic diaphragmatic hernia repair. The day before discharge, the patient underwent a new CU evaluation (Video 3).

Postoperative video acquired with a MyLab 50 Gold cardiovascular machine (Esaote SpA) with a 7.5- to 10-MHz linear probe. Longitudinal scans were obtained in the supine position. There is evidence of a small residual sac above the diaphragm and a small right pleural effusion.

The patient in our study presented with symptoms typical of lower respiratory tract infection. Moreover, chest radiography supported the clinical diagnosis.

Chest ultrasound was more informative in terms of morphologic evaluation of the lesion detected by chest radiography. In particular, CU allowed characterization of the lesion as intrathoracic (subpleural and supradiaphragmatic location) and extrapulmonary (double curtain sign) (Discussion Video 4).

In fact, lung consolidation, when imaged by ultrasound, is seen as a subpleural echo-rich region, one with tissue-like echotexture.,,, Various pathologies can generate lung consolidations: pulmonary infection, pulmonary embolism, lung cancer and metastasis, compression atelectasis, obstructive atelectasis, and lung contusion. Independent of the etiology, consolidation of the lung is characterized by a loss of alveolar air and an increase in fluid content. This is responsible for the disappearance of the “normal” artifactual A-lines below the pleural line and the genesis of a discernable image of the lung resulting from a given pathologic process. The consolidated region is visualized as a tissue-like image depending on the various degrees of air loss and fluid accumulation. In the case of pneumonia, the echo texture of the consolidated lung is similar to that of the liver and hence is referred to as lung hepatization.,,

CU played a key role in the clinical management of the patient. In fact, the ultrasonographic pattern of the lesion combined with location, age of the patient, and laboratory data were suggestive of diaphragmatic hernia, confirmed by subsequent chest CT scan.

In our experience, in the pediatric setting, lung ultrasound has demonstrated superior diagnostic accuracy in the differential diagnosis of lung consolidations, in any case not inferior with respect to chest radiography.

  • 1.

    Chest ultrasonography in the pediatric setting is a useful tool in differentiating lung consolidation from other causes of thoracic pathology.

  • 2.

    Chest ultrasonography allows a bedside and repeatable evaluation, well tolerated in young patients.

  • 3.

    The ultrasonographic pattern of the lesion allowed us to exclude the initial diagnosis of pneumonia and allowed us to characterize the lesion as intrathoracic (subpleural and supradiaphragmatic location) and extrapulmonary (double curtain sign).

Financial/nonfinancial disclosures: None declared.

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

Additional information: The videos can be found in the Supplemental Materials section of the online article.

Gehmacher O. .Mathis G. .Kopf A. .Scheier M. . Ultrasound imaging of pneumonia. Ultrasound Med Biol. 1995;21:1119-1122 [PubMed]journal. [CrossRef] [PubMed]
 
Mathis G. . Thorax sonography. Part II. Peripheral pulmonary consolidation. Ultrasound Med Biol. 1997;23:1141-1153 [PubMed]journal. [CrossRef] [PubMed]
 
Koegelenberg C.F. .von Groote-Bidlingmaier F. .Bolliger C.T. . Transthoracic ultrasonography for the respiratory physician. Respiration. 2012;84:337-350 [PubMed]journal. [CrossRef] [PubMed]
 
Koenig S.J. .Narasimhan M. .Mayo P.H. . Thoracic ultrasonography for the pulmonary specialist. Chest. 2011;140:1332-1341 [PubMed]journal. [CrossRef] [PubMed]
 
Lichtenstein D. .Lascols N. .Mezière G. .Gepner A. . Ultrasound diagnosis of alveolar consolidation in the critically ill. Intensive Care Med. 2004;30:276-281 [PubMed]journal. [CrossRef] [PubMed]
 
Volpicelli G. .Silva F. .Radeos M. . Real-time lung ultrasound for the diagnosis of alveolar consolidation and interstitial syndrome in the emergency department. Eur J Emerg Med. 2010;17:63-72 [PubMed]journal. [CrossRef] [PubMed]
 
Reissig A. .Copetti R. .Mathis G. .Mempel C. .Schuler A. .Zechner P. .et al Lung ultrasound in the diagnosis and follow-up of community-acquired pneumonia: a prospective, multicenter, diagnostic accuracy study. Chest. 2012;142:965-972 [PubMed]journal. [CrossRef] [PubMed]
 
Volpicelli G. .Elbarbary M. .Blaivas M. .Lichtenstein D.A. .Mathis G. .Kirkpatrick A.W. . International Liaison Committee on Lung Ultrasound (ILC-LUS) for the International Consensus Conference on Lung Ultrasound (ICC-LUS)et al International evidence-based recommendations for point-of-care lung ultrasound. Intensive Care Med. 2012;38:577-591 [PubMed]journal. [CrossRef] [PubMed]
 

Figures

Figure Jump LinkFigure 1 Posteroanterior chest radiograph. There is evidence of a small lung consolidation in the right lower lobe.Grahic Jump Location
Figure Jump LinkFigure 2 Chest CT scan with contrast enhancement. A, Axial scan without contrast. B, Axial scan with contrast. C, Multiplanar reconstruction. There is evidence of intrathoracic herniation of the large bowel (hepatic flexure) suggestive of a Morgagni hernia.Grahic Jump Location

Tables

References

Gehmacher O. .Mathis G. .Kopf A. .Scheier M. . Ultrasound imaging of pneumonia. Ultrasound Med Biol. 1995;21:1119-1122 [PubMed]journal. [CrossRef] [PubMed]
 
Mathis G. . Thorax sonography. Part II. Peripheral pulmonary consolidation. Ultrasound Med Biol. 1997;23:1141-1153 [PubMed]journal. [CrossRef] [PubMed]
 
Koegelenberg C.F. .von Groote-Bidlingmaier F. .Bolliger C.T. . Transthoracic ultrasonography for the respiratory physician. Respiration. 2012;84:337-350 [PubMed]journal. [CrossRef] [PubMed]
 
Koenig S.J. .Narasimhan M. .Mayo P.H. . Thoracic ultrasonography for the pulmonary specialist. Chest. 2011;140:1332-1341 [PubMed]journal. [CrossRef] [PubMed]
 
Lichtenstein D. .Lascols N. .Mezière G. .Gepner A. . Ultrasound diagnosis of alveolar consolidation in the critically ill. Intensive Care Med. 2004;30:276-281 [PubMed]journal. [CrossRef] [PubMed]
 
Volpicelli G. .Silva F. .Radeos M. . Real-time lung ultrasound for the diagnosis of alveolar consolidation and interstitial syndrome in the emergency department. Eur J Emerg Med. 2010;17:63-72 [PubMed]journal. [CrossRef] [PubMed]
 
Reissig A. .Copetti R. .Mathis G. .Mempel C. .Schuler A. .Zechner P. .et al Lung ultrasound in the diagnosis and follow-up of community-acquired pneumonia: a prospective, multicenter, diagnostic accuracy study. Chest. 2012;142:965-972 [PubMed]journal. [CrossRef] [PubMed]
 
Volpicelli G. .Elbarbary M. .Blaivas M. .Lichtenstein D.A. .Mathis G. .Kirkpatrick A.W. . International Liaison Committee on Lung Ultrasound (ILC-LUS) for the International Consensus Conference on Lung Ultrasound (ICC-LUS)et al International evidence-based recommendations for point-of-care lung ultrasound. Intensive Care Med. 2012;38:577-591 [PubMed]journal. [CrossRef] [PubMed]
 
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Video 1


Video 2


Video 3


Discussion Video 4

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