VOTW: In the Thick of It

 ·   · 

HPI

A 40-year-old female with a PMH of polycystic kidney disease, HLD, and HTN presents with 1 month of episodic dizziness. She was referred to the ED by her cardiologist for an abnormal EKG, and had previously been told that she had an enlarged heart. 

Her vital signs are unremarkable. Physical exam is notable for a harsh, blowing systolic murmur. Chest X-ray shows cardiomegaly.

Ultrasound Findings

Point-of-care echocardiogram showed no pericardial effusion and was notable for septal thickening to 2.2 cm, concerning for hypertrophic obstructive cardiomyopathy (HOCM).

Echocardiography is the first-line imaging modality for the diagnosis of hypertrophic cardiomyopathy. 

Key findings are wall thickening and intraventricular obstruction. 

  • Wall thickening > 15 mm (or > 13 mm in patients with relatives diagnosed with HOCM). This can be measured in the parasternal long or short axis views. 

  • Interventricular septum to posterior wall thickness ratio of > 1.3 in normotensive patients or > 1.5 in patients with HTN

  • Thickening usually occurs on a focal region of the LV wall

Other associated findings include mitral valve abnormalities, systolic dysfunction, and diastolic dysfunction.

  • Systolic anterior motion of the mitral valve may occur in HOCM due to the Venturi effect. Septal hypertrophy narrows the LVOT, accelerating blood flow and creating a suction force that pulls the mitral valve leaflet into the LVOT. This causes outflow obstruction as well as mitral regurgitation. 

Case Conclusion

Based on these findings, the patient was placed in observation for cardiology evaluation. 

Comprehensive echocardiogram revealed findings consistent with HOCM, including severe asymmetric left ventricular hypertrophy, hyperdynamic LV systolic function (LVEF 76-80%), moderate (grade 2) LV diastolic dysfunction, LV outflow tract obstruction, moderate systolic anterior motion of the anterior leaflet of the mitral valve, and moderate mitral valve regurgitation.

The patient was newly diagnosed with and educated about HOCM. She was discharged with metoprolol 25 mg daily and is anticipated to undergo further treatment with mavacamten and possible septal reduction surgery. 

References & Further Reading

Happy scanning! 


A Cheeky Diagnosis

HPI: 3 yo female with no PMH presenting for L sided facial pain and swelling x 1 day.

POCUS of affected side showed:

Note the hypoechoic spots within the gland that give it a “moth eaten” appearance. This is a classic finding in parotitis. Note the dilated ducts within which may represent a distal sialolithiasis.

Note nearby lymph nodes above.

Contralateral side for comparison:



Signs of parotitis on POCUS:

  • Enlarged, heterogeneous gland compared to contralateral side

  • Increased vascularity/color flow

  • Duct dilation

  • Increased quantity of surrounding lymph nodes

Case conclusion: The patient was diagnosed with likely viral parotitis. She was well appearing with no fever, overlying cellulitis, or trismus and was discharged with Pediatrician follow up!


Happy Scanning!

  • The US Team

Learn more:

  1. https://www.acep.org/sonoguide/advanced/ent

  2. https://ultrasoundpaedia.com/parotid-gland-normal/


VOTW: Intussusception

Today’s VOTW is brought to you by Dr. Fagan, Dr. Davitt and Dr. Lat!

A 2 year old male presented with abdominal pain and vomiting x1 day as well as cough and nasal congestion x2 days. On exam, he was clutching his abdomen in discomfort. A POCUS was performed which showed…

Clip 1 shows an abdominal ultrasound in the RUQ showing the classic “target sign” measureing 3.5cm, concerning for intussusception. You can visualize a smaller circular structure within a larger circular structure representing a part of bowel telescoping into the next part of the bowel. In the center, there are small circular hypoechoic lymph nodes surrounded by echogenic mesenteric fat that serves as the leading point of the intussusception.

Image 1. Target or donut sign

Ultrasound is the test of choice for intussusception and several studies have shown high sensitivity (94%) and specificity (99%) when POCUS is performed by PEM physicians (2).

POCUS for Intussusception

  • Most commonly occurs at the ileo-cecal junction and most commonly found in the right lower or right upper quadrant

  • Look for a target sign or donut sign (in transverse view, see above) or sandwich or pseudokidney sign (in longitudinal view, see below)

  • Diameter > 2cm (remember in-✌-ssusception)

    • May see mesenteric fat and lymph nodes in the center

Image 2. Pseudokidney or sandwhich sign

How to perform the study            

  • Use warm gel, have parents help distract, scan on parent's lap!

  • Use the linear probe

  • Picture frame pattern- start in the RLQ w/ probe marker to pts R scan towards the RUQ, then turn the probe w/ marker to pts head and scan towards the LUQ, then turn the probe w/ marker to pts R and scan down to the LLQ

  • Lawnmower pattern- start in the RLQ and lawnmower the entire abdomen scanning up and down from right to left with the probe marker to the pts R

  • Measure the diameter of the intussusseption if found

Image 3. Picture frame pattern

Back to the patient

Surgery was consulted, the patient underwent an air enema with resolution of the intussusseption. The patient was then discharged home.

References:

  1. Lin-Martore. PEM POCUS Series: Intussusception. https://www.aliem.com/pem-pocus-series-intussusception/

  2. Lin-Martore M, Kornblith AE, Kohn MA, Gottlieb M. Diagnostic Accuracy of Point-of-Care Ultrasound for Intussusception in Children Presenting to the Emergency Department: A Systematic Review and Meta-analysis. West J Emerg Med. 2020 Jul 2;21(4):1008-1016. doi: 10.5811/westjem.2020.4.46241. PMID: 32726276; PMCID: PMC7390574.