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Age: 16

Sex: Male

Indication: Pneumonia

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Case #2


Findings

  • Large, complex, multiseptated left pleural fluid collection
  • Adjacent airspace consolidation in the left lung with air bronchograms
  • No right pleural fluid collection identified


Diagnosis

Pneumonia and empyema

Sample Report

Large, complex, multiseptated left pleural fluid collection with adjacent airspace consolidation, concerning for pneumonia and empyema. No discernible right pleural effusion.


Discussion

Empyema

  • Ultrasound can be very useful in evaluating pleural fluid collections as it is more sensitive for detecting pleural fluid than radiography and can be used for procedural planning and guidance
  • Simple/transudative pleural effusions should be anechoic on ultrasound
  • Worry about a complicated effusion (which may represent empyema, hemothorax, or malignant effusion depending on the clinical scenario) if the fluid collection has hyperechoic areas or if it contains internal septations

 

Pneumonia

  • Ultrasound is very useful in evaluating pneumonia, particularly in children
  • Here is a basic overview of the ultrasound evaluation of pneumonia:
    • Normal, air-filled lung looks like television static on ultrasound. What you CAN see is the pleural lining, which will appear as a hyperechoic line with multiple parallel reverberations of that line extending deep into the lung like ripples – these are called “A-lines” (see annotated image #2)
    • Pneumonia results in alveoli filling with fluid, displacing the air that should normally be there. Early on, this leads to many air-fluid interfaces which produce comet-tail artifacts (hyperechoic bands running perpendicular to the pleural margin), which are also called “B-lines”. This case does not have a great example of a B-line, though an example is shown in the listed reference by Stadler et al.
    • As the lung fills with fluid, the only remaining air is in the bronchi, which produces air bronchograms – these appear as punctate and linear echogenic foci within the lung (see annotated image #3)
    • Also, when densely consolidated, the lung becomes more discretely visible and takes a liver-like appearance, referred to as “hepatization”
  • Atelectasis can also result in a hepatized appearance of the lung. Some features that favor pneumonia over atelectasis include:
    • Pneumonia is an airspace filling process, so the size of the hepatized lung relative to the adjacent pleural fluid collection is often larger in pneumonia than in atelectasis
    • Dynamic (i.e. shifting, moving) air bronchograms have been described as more typical for pneumonia than atelectasis
  • Take away: if you look in the chest with ultrasound, television static = good and liver = bad


Images

Complex left pleural fluid collection with echogenic internal septations (red arrows), concerning for an empyema. Ultrasound evaluation of the normal right lung in this patient shows the pleural line (blue arrow) with multiple ripple-like echogenic lines extending deep (yellow lines), which are referred to as A-lines. Multiple punctate and linear echogenic foci in the left lung (red arrows), consistent with air bronchograms.

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