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Journal of Bronchology & Interventional Pulmonology:
doi: 10.1097/LBR.0b013e31827cc8e2
Bronchoscopic Images

Endobronchial Ultrasound Diagnosis of Pulmonary Embolism

Sachdeva, Ashutosh MBBS; Lee, Hans J. MD; Malhotra, Rajiv DO; Shepherd, Ray W. MD

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Author Information

Virginia Commonwealth University Medical Center, Richmond, VA

Disclosure: There is no conflict of interest or other disclosures.

Reprints: Ashutosh Sachdeva, MBBS, Division of Pulmonary & Critical Care, 110 S. Paca Street, 2nd Floor, Baltimore, MD 21201 (e-mail: asachdeva@medicine.umaryland.edu).

Received May 22, 2012

Accepted August 13, 2012

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Abstract

A 68-year-old woman presented for mediastinal lymph node sampling while undergoing work up for a solitary pulmonary nodule. During endobronchial ultrasound examination of the airways, an echogenic abnormality was noted within the right pulmonary artery. The patient underwent computed tomography angiography of the chest, and diagnosis of pulmonary embolism was confirmed. We describe endobronchial ultrasound evaluation of a pulmonary embolus.

Endobronchial ultrasound-guided sampling is the preferred modality in the work up of pulmonary nodule with hilar and/or mediastinal lymphadenopathy. The pulmonary vessels parallel the central airways and can be evaluated with endobronchial ultrasound. We report a case of pulmonary embolism suspected on endobronchial ultrasound evaluation, which was subsequently confirmed on a computed tomography (CT) angiogram.

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CASE REPORT

A 68-year-old nonsmoking woman, with a family history of cancer was referred for mediastinal lymph node sampling. She had a right middle lobe nodule (Fig. 1) that revealed hypermetabolic activity on a positron emission tomography scan. In addition, right hilar and subcarinal lymph nodes revealed 18F-fluro-2-deoxy-D-glucose avidity with a standardized uptake value of 5.2 and 3.7, respectively. On examination, she was noted to have a left ankle-immobilizing cast, which had been placed 4 weeks prior for an ankle injury. She underwent endobronchial ultrasound (EBUS)-guided transbronchial needle aspiration sampling of the abnormal mediastinal and hilar lymph nodes. While performing EBUS surveillance of airways, a partially mobile echogenic abnormality was noted in the right pulmonary artery (Fig. 2). These characteristics were highly suspicious for a clot. On the basis of these findings, the patient underwent CT angiography of the chest (Figs. 3, 4), and the diagnosis of pulmonary embolism was confirmed. The patient subsequently underwent video-assisted thoracoscopic wedge resection of the right middle lobe nodule, which revealed granulomatous inflammation with necrosis and oval yeast with narrow-based budding consistent with histoplasmosis.

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DISCUSSION

The pulmonary vessels parallel the central airways at a distance of <5 mm. Paucity of ventilated tissue between the vessels and bronchi makes EBUS a feasible technology to detect central pulmonary emboli. In a nonblinded study, Aumiller et al1 reported a 96% accuracy of EBUS in detection of known central pulmonary emboli. CT angiography is currently the preferred diagnostic modality in patients able to undergo a contrast study for evaluation of acute pulmonary emboli.2 There have been no studies evaluating the utility of EBUS in diagnosing pulmonary emboli in patients with contraindication to iodinated contrast, indeterminate ventilation-perfusion scans, or inability to undergo CT angiogram (eg, hemodynamically unstable patients in the intensive care unit) and as such, the authors do not recommend its use in general. There may be a potential complication in these specific clinical situations. Also, one must be aware of limitations of the extent of visualization that the EBUS is capable of and that it is an invasive modality. Physicians should be familiar with EBUS imaging characteristics of pulmonary emboli especially in the context of its increasing utility in evaluation of patients with lung nodules and hilar or mediastinal lymphadenopathy. These patients may have underlying malignancy and thus may be predisposed to thromboembolic disorders. In addition, as in our patient, even large emboli may be relatively asymptomatic. Also, emboli diagnosed with EBUS are likely to be central and associated with the greatest case fatality. Therefore, familiarity with imaging characteristics may lead to earlier diagnosis and prompt institution of therapy in a potentially lethal disease.

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REFERENCES

1. Aumiller J, Herth FJF, Krasnik M, et al. Endobronchial ultrasound for detecting central pulmonary emboli: a pilot study. Respiration. 2009;77:298–302

2. Fedullo PF, Tapson VF. The evaluation of suspected pulmonary emboli. N Engl J Med. 2007;349:1247–1256

Keywords:

endobronchial ultrasound; pulmonary embolism; lung nodule

© 2013 Lippincott Williams & Wilkins, Inc.

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