Air and its Sonographic Appearance: Understanding the Artifacts

Emphysematous Pyelonephritis in Cancer Patients: A Case Report With a Literature Review

Emphysematous pyelonephritis (EPN) is a severe necrotising infection of the renal parenchyma which is rarely reported in cancer patients. We present a case of a 92-year-old man with urothelial carcinoma of the bladder who developed EPN after resection of the tumour. Septic shock developed and blood cultures grew extended-spectrum beta-lactamase (ESBL) Escherichia coli. Because of renal function decline with hematuria a non-contrast CT scan of the abdomen showed gas in the kidney and surrounding area consistent with EPN. After receiving appropriate antibiotics according to susceptibility testing, EPN was resolved based on a follow-up CT scan of the abdomen without requiring further surgical intervention. We review the literature and discuss the management of EPN in cancer patients.

Ultrasound-guided percutaneous coil and thrombin embolization of a left gastric artery pseudoaneurysm

Pseudoaneurysms are a commonly encountered pathology, though pseudoaneurysms of the visceral arteries are a less frequent, but potentially deadly entity. Transarterial embolization is the typical treatment of visceral pseudoaneurysms, but success is dependent on anatomy that is conducive to selecting the supplying vessel. Abdominal ultrasound is a viable method to effectively treat visceral pseudoaneurysms when transarterial embolization is not possible. It is also an excellent example of the growing utilization of ultrasound guidance in various interventional radiologic procedures. The usefulness of ultrasound is demonstrated in this case report, where a left gastric artery pseudoaneurysm was embolized through ultrasound guidance.

Pneumoparotid: Practical impact of Surgeon performed Ultrasound in an effective Diagnostic Approach

OBJECTIVES

Pneumoparotid is characterized by air inclusions in the parotid duct system. Use of ultrasound has proved valuable for evaluating air inclusions in various parts of the body; the diagnostics of this condition has not been systematically analyzed, however. The aim of this study was to evaluate the value of ultrasound in the detection of air inclusions along the parotid duct system and its closer characterization.

METHODS

Retrospective analysis was carried out of patients diagnosed with pneumoparotid between 2005 and 2020 in a salivary gland center. Ultrasound was performed in all cases, and features of air inclusions were described. Reference standard was the clinical demonstration of foamy saliva after gland massage and/or sialendoscopic evidence of intraductal air inclusions.

RESULTS

Twenty-one patients were identified (48.8 ± 3.8 years). Two were associated with wind instruments; seven were iatrogenic, following treatment for duct stenosis; one after radiotherapy; four with known bruxism and seven were idiopathic and without associated conditions. On ultrasound examination, pneumoparotid was characterized by three phenomena: flattened, mobile hyperechoic reflexes, dirty shadows with reverberation or "sunbeam effect," and shifting shadows during gland massage.

CONCLUSIONS

Ultrasound was useful for characterizing pneumoparotid in a fast and practical way and could serve as imaging tool of first choice.

Emphysematous thrombophlebitis caused by a misplaced central venous catheter: A case report

BACKGROUND

Central venous catheters (CVCs) often cause life-threatening complications, especially CVC-related bloodstream infection (CVC-BSI) and catheter-related thrombosis (CRT). Here, we report an unusual case of misplaced CVC-induced emphysematous thrombophlebitis, a rare but potentially lethal form of CRT and CVC-BSI characterized by both thrombosis and gas formation.

CASE SUMMARY

A 48-year-old male presented to the emergency room of a local hospital with sudden-onset headache and coma for 4 h. Computed tomography (CT) revealed right basal ganglia hemorrhage, so emergency decompressive craniotomy was performed and a CVC was inserted through the right subclavian vein for fluid resuscitation during anesthesia. Two days later, the patient was transferred to the intensive care unit of our hospital for further critical care. On day 9 after CVC insertion, the patient suddenly developed fever and hypotension. Point-of-care ultrasound (POCUS) demonstrated thrombosis and dilatation of the right internal jugular vein (IJV) filled with thrombosis. Ultrasonography also revealed that the CVC tip had been misplaced into the IJV and was surrounded by gas bubbles, which manifested as hyperechoic lines with dirty shadowing and comet-tail artifacts. Further CT scan confirmed air bubbles surrounding the CVC in the right neck. The final diagnosis was septic emphysematous thrombophlebitis induced by a misplaced CVC and ensuing septic shock. The responsible CVC was removed immediately. The patient received fluid resuscitation, intravenous noradrenaline, and a 10-d ultra-broad spectrum antibiotic treatment to combat septic shock. Both CVC and peripheral venous blood cultures yielded methicillin-resistant Staphylococcus cohnii. The patient was gradually weaned off vasopressors and the symptoms of redness and swelling in the right neck subsided within 7 d.

CONCLUSION

Emphysematous thrombophlebitis is a fulminant and life-threatening CVC-BSI associated with thrombosis and gas formation in the vein. A misplaced CVC may facilitate the development of emphysematous thrombophlebitis. POCUS can easily identify the artifacts produced by gas and thrombosis, facilitating rapid diagnosis at the bedside.

Ultrasonography and X-ray micro-computed tomography characterization of the effects caused by carrageenin in the muscle of gilthead seabream (Sparus aurata)

The current work aimed to carry out an in vivo study of the λ-carrageenin-induced inflammation in the skin of gilthead seabream (Sparus aurata). The fish were injected intramuscularly with phosphate-buffered saline (PBS, as control) or λ-carrageenin (1% in PBS), and the injection zone was evaluated by real-time ultrasonography (Vevo Lab, VisualSonics) at 1.5, 3, 6, 12, and 24 h post-injection (p.i.). Results demonstrated that the skin thickness was increased in fish injected with λ-carrageenin and sampled at 1.5, 3, and 6 h p.i. However, the skin thickness of the injected area decreased to the normal values in those fish sampled at 12 and 24 h p.i. In addition, fish injected with λ-carrageenin and analysed at 1.5, 3, and 6 h p.i. showed, in the underlying muscle at the injection place, several hyperechoic small foci surrounded by an anechoic area which were not observed in control fish. Furthermore, the fish were analysed by X-ray micro-computed tomography (micro-CT). The analysis of the micro-CT acquisitions revealed also a dark area in the place of the injection with λ-carrageenin at 1.5, 3, and 6 h. These areas were smaller in fish analysed at longer times (12 h p.i.) and were almost disappeared in fish sampled at 24 h p.i. These areas had an average density of -850 to -115 HU, which did not correspond with any tissue density of the rest of the body. Furthermore, similar dark areas at the injection zones were never observed in control fish. Present results support the use of both non-invasive techniques to study the inflammatory process in fish of commercial interest such as gilthead seabream.

Necrotizing fasciitis in Indonesian adult with diabetes mellitus: Two case and review article

Background

Necrotizing fasciitis (NF) is a rare and life-threatening form of infection involving rapidly spreading inflammation and extensive necrosis of the skin, subcutaneous tissue, and superficial fascia.

Case presentation

This study reported two cases of NF in a 56-year-old female and a 38-year-old male who demonstrated typical signs and symptoms of NF. Both presented to the hospital with skin necrosis in the lower extremity, sepsis shock, and multiorgan failure. Based on the clinical presentation, physical examination, and additional examination, a diagnosis of NF was made. The LRINEC score was used to distinguish NF from other soft tissue infections. Both patients were treated with empirical antibiotics, surgical debridement and planned to be amputated, but the patients were hemodynamically unstable and passed away before the amputation proceeded.

Discussion

Delay in the diagnosis of NF increases the risk of mortality and the use of the LRINEC score is very helpful in decision making for health workers.

Conclusion

The key to the management of NF is early diagnosis, debridement, removal of necrotic tissue, amputation, and use of empirical antibiotics.

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Early diagnosis of necrotizing fasciitis (NF) is key in the management of the disease.

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The diagnosis of NF is established using the LRINEC score.

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Debridement and amputation play an important role in preventing the spread of microorganisms in NF.

Point-of-care ultrasound for the early diagnosis of emphysematous pyelonephritis: A case report and literature review

BACKGROUND

Emphysematous pyelonephritis (EPN) is a rare but fatal necrotic infection of the kidney, which usually leads to septic shock. Therefore, early diagnosis and optimized therapy are of paramount importance. In the past two decades, point-of-care ultrasound (POCUS) has been widely used in clinical practice, especially in emergency and critical care settings, and helps to rapidly identify the source of infection in sepsis. We report a rare case in which a “falls” sign on POCUS played a pivotal role in the early diagnosis of EPN.

CASE SUMMARY

A 57-year-old man presented with fever and lumbago for 3 d prior to admission. He went to the emergency room, and the initial POCUS detected gas bubbles in the hepatorenal space showing a hyperechoic focus with dirty shadowing and comet-tail artifacts. This imaging feature was like a mini waterfall. His blood and urine culture demonstrated Escherichia coli bacteremia, and EPN associated with septic shock was diagnosed. The patient did not respond to broad-spectrum antibiotic treatment and a perirenal abscess developed. He subsequently underwent computed tomography-guided percutaneous catheter drainage, and fully recovered. We also review the literature on the sonographic features of POCUS in EPN.

CONCLUSION

This case indicates that a “falls” sign on POCUS facilitates the rapid diagnosis of severe EPN at the bedside.

Managing uncommon and unexpected findings during neuromuscular ultrasound

One barrier to widespread adoption of neuromuscular ultrasound by clinical neurophysiologists is concern over how to identify and manage non-neuromuscular findings. This review addresses this concern by describing the sonographic appearance of a variety of commonly observed pathologies and anatomic variants in dermal, subcutaneous, bony, glandular, lymphatic, vascular, and other superficial tissues. Additionally, it outlines techniques to ensure proper clinical and ultrasound evaluation of unexpected or uncommon findings. Finally, it highlights strategies to manage unexpected findings, including how to best communicate findings to patients and referring clinicians to avoid unnecessary testing and ensure appropriate follow-up. Ultrasound extends the ability of the neuromuscular sonographer-clinician to contribute to patient care.

Emphysematous Pyelonephritis Presenting as Pneumaturia and the Use of Point-of-Care Ultrasound in the Emergency Department

Emphysematous pyelonephritis (EPN) is a rare form of pyelonephritis causing a severe infection of the renal system that includes gas in the renal parenchyma, collecting system and surrounding tissue often presenting with sepsis. We report the case of a 60-year-old male with poorly controlled insulin dependent diabetes mellitus who presented with abdominal pain, nausea, vomiting, and “peeing air.” CT scan revealed air extending from the left renal parenchyma, perinephric fat and into the bladder, consistent with emphysematous pyelonephritis. Bedside point-of-care ultrasound (POCUS) subsequently revealed dirty shadowing and reverberation artifacts in the left kidney and the bladder consistent with gas in the urinary collecting system. By understanding the identifying artifacts seen with EPN, reflective shadow and reverberation artifact, the emergency physician may be alerted to the diagnosis sooner. Often this illness presents similarly to simple, acute pyelonephritis or undifferentiated sepsis. Therefore, POCUS allows for real time consideration of this condition while in the emergency department and thus prompter time to treatment.

Can Ultrasound Identify Traumatic Knee Arthrotomy in a Cadaveric Model?

BACKGROUND

Traumatic arthrotomy of the knee (TAK) involves the violation of the knee capsule. TAK differs from simple lacerations because it requires operative management to prevent resultant septic arthritis. The diagnostic test of choice in the emergency department is the saline load test (SLT). SLT sensitivity ranges from 34% to 99%, depending on volume used. Computed tomography (CT) is a possible alternative, using intra-articular air as a diagnostic marker. Ultrasound can identify air in various tissues, given its highly echogenic nature.

OBJECTIVE

We sought to determine the sensitivity and specificity of ultrasound for detecting intra-articular air in cadaveric knee joints.

METHODS

Soft embalmed cadavers were utilized. The knees were block randomized to having 1 mL of air injected into the joint or sham skin injection. Two blinded, expert operators scanned the knees with a high-frequency linear transducer. The sensitivity and specificity were calculated.

RESULTS

Twenty knees were included. Knees that had any prior dissection were excluded from analysis. Ten knees were randomized for air injection. The pooled sensitivity was 0.65 (95% confidence interval [CI] 0.41-0.85) with a specificity of 0.75 (95% CI 0.48-0.93). Mean time taken was 143 s.

CONCLUSIONS

Ultrasound may have utility in evaluation of TAK. There were limitations. Some knees had effusions with echogenic material present, which could have led to false-positive results. It is also unknown how much air is typical of TAK. One milliliter was used based on previous work with CT. The use of ultrasound for diagnosis of TAK warrants further study.