Ultrasound visualization of a pleural adhesion.

A group of multidisciplinary sonologists conduct weekly Intensive Care Unit (ICU) rounds consisting of ultrasound examinations on select patients recommended by the critical care staff. This image was acquired on a 51-year-old male in the ICU with known valve vegetations, and a pleural adhesion was incidentally discovered on ultrasound.

INTRODUCTION

The utility of ultrasonography is becoming more and more recognized in the field of emergency medicine. With an increasing patient population becoming more chronically ill, the emergent diagnosis of critical conditions is essential to the emergency physician's skill set. In order to train emergency medicine residents to become more facile with ultrasound, programs are trying to expose residents to ultrasound in every possible venue.

CASE REPORT

This patient was originally selected for imaging of endocarditis with known vegetations present on his bioprosthetic aortic valve. The patient was a 51-year-old gentleman with complex medical history, including intravenous poly-substance abuse, endocarditis requiring two bioprosthetic aortic valves in addition to multiple other comorbidities. He initially presented for bacteremia, NSTEMI, and altered mental status. Computed tomography (CT) imaging showed septic emboli involving the brain and spleen. Formal transesophageal echocardiogram showed endocarditis of a bioprosthetic valve.

The patient's bedside cardiac ultrasound exam did not visualize vegetations. Upon interrogating the thorax with the curvilinear probe, the patient was found to have a large right pleural effusion accompanied by a large, thick band of tissue traversing the effusion from the diaphragm to the visceral pleura [Figure 1]. Review of the prior CT images showed this finding to be a pleural adhesion, a rare finding via ultrasound technology.

Figure 1

Ultrasound still image of right sided pleural adhesion

Numerous etiologies can result in a pleural adhesion; however, they can be organized into three categories — trauma, infectious, and iatrogenic.[12] After a complete retrospective review of the patient's chart, thoracotomy was determined to be the most likely cause of a large pleural adhesion visualized on routine ultrasound.

Literature review makes it evident that thoracic surgeons visualize pleural adhesions preoperatively, but it has not been described in the other literature to this point.[34] Pleural slide test using transthoracic ultrasound had a sensitivity of 88.0%, a specificity of 82.6%, and an overall accuracy of 83.8% by one radiologist in one prospective blinded study.[5]