Expand ("E")   Collapse

Age: 16

Sex: Male

Indication: Pneumonia

Save ("V")

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.



📣 Feedback?

⌨️  Keyboard Shortcuts ("K")

Call Preparation  

Curated case sets, sample reports, focused discussion, and our call simulator.

1,400+ cases    91.25 CME
 Call Simulator

   Neuro CT

250 cases

  Neuro MRI

146 cases

   Peds Radiographs

372 cases

   MSK Radiographs

281 cases

   Chest CT

84 cases

   Chest Radiographs

97 cases

   KUB

43 cases

   Body CT

127 cases

   Ultrasound

75 cases

Call Simulator

• Shuffle cases from our courses to simulate the mix of a call shift.
• Submit your own report before reviewing the case write-up.

Neuro Fellowship  

Develop expert knowledge with in depth reviews of neuro topics.
  118 cases 11.8 CME

   Brain Tumors

105 cases

   Neurodegenerative

13 cases

Call Prep

   Neuro CT

250 cases

   Neuro MRI

146 cases

   Peds Radiographs

372 cases

   MSK Radiographs

281 cases

   Ultrasound

75 cases

   Chest CT

84 cases

   Chest Radiographs

97 cases

   Body CT

127 cases

   KUB

43 cases

Neuro Fellowship

   Brain Tumors

105 cases

   Neurodegenerative

13 cases

Call Simulator

• Shuffle cases from our courses to simulate the mix of a call shift.
• Submit your own report before reviewing the case write-up.

CME

• Earn up to 91 CME by completing cases in our radiology courses.
• Claim your CME to receive a certificate.

On Call

Quick references created specifically to help while on call.

  Peds Normals by Age

Reference database of normal imaging from birth to age 16

   Incidental Findings

Summary of consensus guidelines for managing incidental CT findings

   Media Index

Index of select illustrations & videos from our courses

  Neuro CT Mimics

Visual reference for common mimics of pathology on CT

Anatomy

Labelled radiographs and CT/MRI series teaching anatomy with a level of detail appropriate for medical students and junior residents.

   Pelvis

Pelvic MRI anatomy

   Chest

Chest radiograph & CT anatomy

   Body

Abdominal CT anatomy

   Cardiac

Cardiac CT anatomy

   Brain

Brain & calvarial anatomy on CT/MRI

   Cranial Nerves

Cranial nerves on MRI

   Shoulder

Shoulder MRI anatomy

   Knee

Knee MRI anatomy

   Temporal Bone

Resident/fellow-level anatomy

   Neuro CT

250 cases

   Neuro MRI

146 cases

   Peds Radiographs

372 cases

   MSK Radiographs

281 cases

   Ultrasound

75 cases

   Chest CT

84 cases

   Chest Radiographs

97 cases

   Body CT

127 cases

   KUB

43 cases

Call Simulator

• Shuffle cases from our courses to simulate the mix of a call shift.
• Submit your own report before reviewing the case write-up.

CME

• Earn up to 91 CME by completing cases in our radiology courses.
• Claim your CME to receive a certificate.

⌨️ Keyboard Shortcuts

View shortcuts

Zoom/Pan

  Full screen

  Window/Level

  Expand/collapse

  Scroll

  Save the case

  Close case/tab

Previous Slice (Scroll)

Next Slice (Scroll)

 Toggle presets

 Previous series (if multiple)

 Next series (if multiple)

  Previous case (⌘ ◄ on a mac)

  Next case (⌘ ► on a mac)

Toggle dark mode