Ill weed grows fast

Just when I thought the sun would set behind the mountain, it rose and made yet another run across the valley. Time to step out of the twilight zone and get back on the donkey. Three hours away from the closest hospital and with an ultrasound probe in hand, I made another run for it.

A peculiar case this middle aged man was, bearing a captivating odor of fermented fish. Priorly morbidly obese with OSAS and CPAP night-time, he’d undergone laparoscopic gastric bypass a year previously, lost massive amounts of weight and was now carrying his skin like a half-empty sack of potatoes. His main complaint was tiredness and impaired life-lust. Family and friends had noticed his indifference. For the past months he’d slept most of the days, experienced muscle- and joint aches and some dizziness. I wasn’t immediately alarmed. Might as well have prescribed him antidepressants. I persisted and he answered question after question.

His apathy had almost rubbed off on me when I heard “visual disturbance, night-sweats” and snapped back. Two days ago he had suddenly gone blind on one eye. Five minutes later he regained vision only to be followed by another similar episode. This was a clear-cut case of…
Vitals were fine and he was afebrile. CRP 110. No cutaneous changes. But upon cardiac auscultation a pan-systolic and diastolic murmur was discovered! And wouldn’t you know, he’d had periodontitis for the past 20 years and root canal fixed three months ago. So what was in the Chinese fortune cookie?

Infective endocarditis. A dancing vegetation is present on the aortic valve non-coronary cusp and anterior mitral leaflet. There is an aortic regurgitation. And the crown jewel? Fistula between the aortic root and left atrium. Anatomically the aortic- and mitral annuli are fused at the fibrous trigone predisposing any vegetation to travel between one another sometimes producing an apparent abscess or fistula.

He was immediately admitted to the hospital. Antibiotics were prescribed and the patient planned for subacute surgery due to high risk of embolization. Blood cultures grew Streptococcus mitis, an inhabitant of the oral cavity. The cause of amaurosis fugax proved to be what we expected unfortunately. MR brain showed two small infarcts caused by septic embolization. Neurologic function remained intact however. And like any other success story, christmas didn’t arrive a day too early. The diseased valves were replaced by two intracardiac Philippe Pateks working around the clock keeping his life ticking.

A liver in the lung

65-yo female with COPD presents to the ED severely distressed and dyspneic. Oxygen saturation 70%. Breathing frequency 45/min. Obstructive breath sounds with spread rhonchi. The patient is heavily dependent on accessory respiratory muscles. 120BPM. BP 100/70. Afebrile. COPD with acute exacerbation is suspected. Corticosteroids, bronchodilators and oxygen are administered. A bloodgas shows PCO2 retention and respiratory acidosis. Vitals slightly improved but oxygen saturation is not adequate. Higher levels of oxygen therapy will cause carbon dioxid narcosis. BIPAP is started with progressive improvement. Bedside ultrasound:

Left lateral thoracic- and upper abdominal view plus zoom. Significant for consolidations and hence a high suspicion of severe pneumonia/pneumosepsis. Fluids and antibiotics are administered. Bloodpanel returns showing Lactate 4,5, CRP 200 and WBC 18 with a left shift. A central venous catheter is placed.

The patient is taken to the ICU where a new bedside ultrasound is done. Consolidations are again visualized. In addition the following is seen.

What do you think? Please comment below. All intercostal spaces look the same. The pleura is statically prolapsed intercostally. My guess:the intercostal muscles have been through a marathon of strain. Currently flaccid and off-loaded by a well-deserved non-invasive ventilation. Additionally we see a flattened diaphragm which signifies severe COPD/emphysema.

Three days into treatment inflammatory parameters and oxygen saturation have been improved and NIV discontinued.

Left lateralt thoracic- and upper abdominal view. Interestingly enough the consolidation has changed. What we see now is an air bronchogram/hepatization of the lung which simply means that the lung takes on the appearance of a liver. The bronchi appear white. Causes may vary, but in short it implies lung consolidation or atelectasis. In contrast to chest x-ray, ultrasound can divided air bronchograms into either static with no movement in the bronchi or to dynamic with movement in the bronchi (see youtube). The dynamic form has a very high specificity and positiv predictive value for pneumonia. In our case the air bronchogram is static but the clinical scenario implies an infectious process.

Furthermore the intercostal space and pleura seem to have normalized.

References
1. The dynamic air bronchogram. A lung ultrasound sign of alveolar consolidation ruling out atelectasis. 2009. Lichtenstein D, Mezière G, Seitz J.
2. Radiopaedia.orgAir bronchogram
3. Introduction to Bedside Ultrasound: Volume 1 by Matthew Dawson och Mike Mallin (free at Itunes)