Endobronchial Ultrasound Diagnosis of Pulmonary EmbolismSachdeva, Ashutosh MBBS; Lee, Hans J. MD; Malhotra, Rajiv DO; Shepherd, Ray W. MDJournal of Bronchology & Interventional Pulmonology: January 2013 - Volume 20 - Issue 1 - p 33–34 doi: 10.1097/LBR.0b013e31827cc8e2 Bronchoscopic Images Abstract Author Information 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. 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: email@example.com). Received May 22, 2012 Accepted August 13, 2012 Article OutlineEndobronchial 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. Back to Top | Article Outline 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. Figure 1 Figure 2 Figure 3 Figure 4 Back to Top | Article Outline 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. Back to Top | Article Outline REFERENCES1. Aumiller J, Herth FJF, Krasnik M, et al. Endobronchial ultrasound for detecting central pulmonary emboli: a pilot study. Respiration. 2009;77:298–302 Cited Here... | View Full Text | PubMed | CrossRef 2. Fedullo PF, Tapson VF. The evaluation of suspected pulmonary emboli. N Engl J Med. 2007;349:1247–1256 Cited Here... Keywords: endobronchial ultrasound; pulmonary embolism; lung nodule © 2013 Lippincott Williams & Wilkins, Inc. Article Outline Abstract CASE REPORT DISCUSSION REFERENCES Source Endobronchial Ultrasound Diagnosis of Pulmonary Embolism Journal of Bronchology & Interventional Pulmonology. 20(1):33-34, January 2013. Full-Size Email + Favorites Export View in Gallery Email to a Colleague Colleague's E-mail is Invalid Your Name: (optional) Your Email: Colleague's Email: Separate multiple e-mails with a (;). Message: Thought you might appreciate this item(s) I saw at Journal of Bronchology & Interventional Pulmonology. Send a copy to your email Your message has been successfully sent to your colleague. Some error has occurred while processing your request. Please try after some time. 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