selected reports Lung Sequestration* Diagnosis with Ultrasound and Triplex Doppler Technique in an Adult Ang Yuan, /II.D.; lbn-Chyr Yang, /II.D., F.C.C.P.; Dun-Bing Chang, M.D.; Chang-]en Yu, /II.D.; Sow-Hsong Kuo, M.D., F.C.C.P.; and Kwen-Tay Luh, /II.D., F.C.C.P.
The application of chest US with triplex Doppler technique to detect the systemic feeding artery of lung sequestration in an adult patient is described. To our best knowledge, this is the 6rst description of the use of this technique to diagnose pulmonary sequestration in adult patients. This 35-year-old man had necrotizing pneumonia with abscess formation at the left lower lobe. Chest US demonstrated a large tortuous vessel in the central part of the lesion. Spectral wave Doppler analysis showed that this vessel was a systemic feeding artery and had pulsatile arterial waveform. The color Doppler mapping delineated the blood Row originating from the descending aorta and toward the lesion, thus confirming the diagnosis of pulmonary sequestration. We conclude that chest US with triplex Doppler technique is a valuable method in evaluating a patient with a pulmonary lesion who was thought to have lung sequestration before performing invasive aortography. (Chest 1992; 102:1880-81) CT =computed tomography; PW =pulse wave; US= ultrasound
Tung sequestration is an uncommon congenital abnormality, that may mimic other diseases such as pneumonia, lung abscess or tumor. Noninvasive image to demonstrate the systemic feeding artery may be helpful in patients with suspected lung sequestration before performing aortography. With the aid of US and spectral wave Doppler analysis, the feeding artery and the direction of the blood Row can be demonstrated in the lung sequestration. •·• Ultrasonography with simultaneous color Doppler mapping (triplex Doppler technique) has also been described recently as a useful adjunct method in the diagnosis oflung sequestration in neonates and infants. l-6 To our best knowledge, the use of the chest US with triplex Doppler technique has never been reported in the diagnosis of lung sequestration in adult patients. In this report, we describe the application of US equipped with triplex Doppler in evaluating an adult patient with intralobar sequestration which manifests as a necrotizing pneumonia.
.I..J
*From the Departments of Internal Medicine (Drs. Yuan, Yang, Chang and Yu) and Clinical Pathology (Drs. Kuo and Luh), National Taiwan University Hospital, Taipei, Taiwan, Republic of China. Reprint requests: Dr. Yang, National Taiwan University Hospital, No. I Chang-Te Street, Taipei, Taiwan, Republic of China
1880
FIGURE I. Posteroanterior chest radiograph of the patient showing a pneumonic patch in the left lower lobe. CASE REPORT
A 35-year-old man was admitted to our hospital because of rm obtained from the carotid artery or other peripheral systemic I
B
:s :
FIGURE 3. Digital subtraction aortogram revealing a feeding artery arising from the abdominal aorta to the sequestration (arrowhead:;).
arteries (Fig 2). They all had a spiking systolic wave Mth short acceleration time and persistent diastolic How wave.'·" In the duplex Doppler analysis, the upward Doppler signal above the baseline indicated that the blood How moves toward the US probe. We can conclude that this large tortuous vessel was a systemic feeding artery of this pulmonary lesion. With the aid of color Doppler mapping (triplex Doppler technique), we can demonstrate the red to yellow color How, which indicates moderate to high velocity of blood How,"·' 0 moving from the abdominal aorta upward to the center of the lesion (Fig 2). A draining vein Mth blue-color How was also noted in the nearby feeding artery, but it cannot be clearly traced to its proximal portion (Fig 2). The patient underwent aortography which confirmed this feeding artery arising from the abdominal aorta (Fig 3). Venous drainage of this lesion was from the pulmonary vein. Intralobar sequestration of the lung was confirmed in this patient. This patient received clindamycin and netilmicin for three weeks and underwent lobectomy for resection of the sequestration. At surgery, this sequestrated lung was hyperemic, hard in consistency and associated Mth multiple areas of cystic degenerations. A pulsating artery, Mth 1.0 em diameter, went through the diaphragm to the sequestration. After entering the sequestration, the diameter of this vessel decreased to about 0.7 em and then this vessel divided into several branches. DISCUSSION
Lung sequestration is a congenital maldevelopment resulting in nonfunctioning lung tissue. The sequestrated lung receives its blood supply from an anomalous systemic artery. There are two forms of lung sequestration: intralobar and extralobar. The feeding artery is always from the descending thoracic aorta, abdominal aorta or one of its branches in both types of sequestration. The venous drainage is pulmonary vein in intralobar sequestration, and bronchial or other systemic veins, including inferior vena cava, azygos vein and porta veinous system, in extralobar sequestration.• The demonstration of systemic feeding artery by aortogram is essential for the diagnosis of lung sequestration. However, lung sequestration can mimic other pulmonary diseases and the aortogram will not be performed if lung sequestration is not suspected clinically. Therefore, some noninvasive diagnostic modality is necessary to screen these unresolved pulmonary lesions before performing this invasive aortogram. Chest US with triplex Doppler technique can meet this requirement. In this case, we demonstrated that there were several characteristic US findings in lung sequestration: (1) a large tortuous vessel with prominent pulsation in the real-time monitoring; (2) spectral wave Doppler analysis revealing arterial pulsating waveform, with spiking systolic wave of short accelerating time and persistent low diastolic flow wave, similar to that of peripheral systemic artery, such as carotid artery, renal artery or superior mensentary artery; 7 ·" (3) duplex Doppler image and color mapping suggesting the blood flow arising from the aorta or below the diaphragm toward the lesion. Therefore, if US and triplex Doppler technique could demonstrate a large systemic feeding artery in a unresolved pulmonary lesion, lung sequestration should be highly suspected. Aortogram can be performed to confirm the diagnosis. In addition, the chest US also can demonstrate the associated changes in lung sequestration, such as cystic degeneration and infective consolidation. This makes the microbiologic studies of the lesion possible via US-guided CHEST I 102 I 6 I DECEMBER, 1992
1881
aspiration in patients with clinically suspected secondary infection. Preoperative antibiotics can be directed effectively. We conclude that chest US with triplex Doppler technique may be a very valuable noninvasive method in assisting in the diagnosis of lung sequestration, even in adult patients. ACKNOWLEDGMENT: This work has been supported in part by the Kwang Ten Trading Co, Ltd, Taipei. REFERENCES
2 3
4 5 6
7
8
9 10
West MS , Donaldson JS, Shkolnik A. Pulmonary sequestration: diagnosis by ultrasound. J Ultrasound Med 1989; 8:125-29 Gudinchet F, Anderegg A. Echography of pulmonary sequestration. Eur J Radio! 1989; 9:93-95 Kaude JV, Laurin S: Ultrasonographic demonstration of systemic artery feeding extrapulmonary sequestration. Pediatr Radio! 1984; 14:226-27 Sauerbrei E. Lung sequestration: duplex Doppler diagnosis at 19 weeks gestation. J Ultrasound Med 1991; 10:101-05 Newman B. Real-time ultrasound and colol"Doppler imaging in pulmonary sequestration. Pediatrics 1990; 86:620-23 Schulman MH, Stein SM , Neblett WW Pulmonary sequestration: diagnosis with color Doppler sonography and a new theory of associated hydrothorax. Radiology 1991; 180:817-21 Kassan M, Johnston KW, Cobbold RSC . Quantitative estimation of spectral broadening for the diagnosis of carotid arterial disease: method and in vitro result. Ultrasound Med Bioi 1985; 11 :425 Nicholls SC, Kohler TR, Martin RL. Use of hemodynamic parameters in the diagnosis of mesenteric insufficiency. J Vascular Surg 1986; 3:507 Fraser RG. Diagnosis of diseases of the chest. 3rd ed. Philadelphia: WB Saunders Company, 1989:701-12 Cosgrove DO, Bamber JC, Davey JB, McKinnaJA, Sinnett HD. Color Doppler signals from breast tumors. Radiology 1990; 176:175-80
Evolving Aortic Mass in a Patient
with Sepsis and Systemic Embolization*
Detection by Transesophageal Echocardiography jonathan D. Dubin, M.D.; Clair Miller; M.D. ; Andrew Mayrer, M.D.; and Enrico Veltri, M.D ., F.C.C.P.
An elderly patient with sepsis and systemic embolization is described. An intraluminal aortic mass was discovered by transesophageal echocardiography that appeared to be the source of infection in this patient. Transesophageal echocardiography can be a useful diagnostic test in patients with sepsis and systemic embolization of unknown etiology. (Chest 1992; 102:1882-83)
I TEE= transesophageal echocardiography I
ransesophageal echocardiography (TEE) has been T shown to provide high quality images of the thoracic
aorta.' In recent studies, TEE has revealed abnormalities of •From the Departments of Cardiology, Infectious Disease, and Anesthesia, Sinai Hospital of Baltimore, Baltimore. Reprint requests: Dr. Dubin, Division of Cardiology, Sinai Hospital, Baltimore 21215-5271 1882
FIGURE 1. TEE image of the distal aortic arch-proximal descending thoracic aorta junction taken on the lOth hospital day. A pedunculated, echogenic mass is seen attached to the luminal surface.
the aortic intimal surface that have been described as "protruding atherosclerotic plaque"• or "atherosclerotic debris."3 These abnormalities are thought to be part of a diffuse atherosclerotic process and may be causally related to systemic emboli. We report herein a patient with a localized intraluminal aortic mass diagnosed by TEE. This mass appears to have been a source for sepsis and embolization in this patient. CASE REPORT A 76-year-old white woman with a history of non-insulin-dependent diabetes mellitus was found unresponsive at home. On admission to the emergency room, the patient was found to be hypotensive with a systolic blood pressure of 60 mm Hg. Initial laboratory examination revealed hyperglycemia (glucose 1,800 mgldl) with ketoacidosis (pH 7.07), and leukocytosis (WBC 31,000/cu mm). The initial chest x-ray film findings were normal. The patient was transferred to the intensive care unit and treated for sepsis with broad spectrum antibiotics. Blood cultures from the day of admission were positive for Staphylococcus aureus. The patient remained hemodynamically labile with leukocytosis. On the 4th hospital day, the patient developed a cool right foot with cyanotic toes. A transthoracic echocardiogram was done at that time to rule out endocarditis or cardiac thrombi. The study showed normal left ventricular function, mitral annular calcification, normal valves, and normal cardiac chamber sizes. No evidence of vegetation or intracardiac thrombi were seen. Over the next few days, the patient underwent a head CT scan and abdominal sonogram that were unremarkable. Blood cultures became sterile on nafcillin therapy; however, several recurrent episodes of embolization to the right foot occurred. By the lOth hospital day, the patient remained unstable. The source of sepsis and embolization remained unclear. To better rule out a cardiac source, TEE was performed. Cardiac imaging confirmed the findings of the transthoracic echocardiogram and showed no evidence of valvular vegetations or intracardiac thrombi. The thoracic aorta was then imaged. At the junction of the distal aortic arch and the proximal descending aorta with the TEE probe placed approximately 25 em from the patient's incisors, an ovoid echogenic mass measuring approximately 1.5 X 1 em was seen attached to the aortic intimal surface (Fig 1). The mass was pedunculated and mobile. The aortic root, arch, and the remainder of the descending thoracic aorta were then carefully imaged. No other aortic intimal EI/Oiving Aortic Mass (Dubin et at)
The application of chest US with triplex Doppler technique to detect the systemic feeding artery of lung sequestration in an adult patient is described. To our best knowledge, this is the 6rst description of the use of this technique to diagnose pulmonary sequestration in adult patients. This 35-year-old man had necrotizing pneumonia with abscess formation at the left lower lobe. Chest US demonstrated a large tortuous vessel in the central part of the lesion. Spectral wave Doppler analysis showed that this vessel was a systemic feeding artery and had pulsatile arterial waveform. The color Doppler mapping delineated the blood Row originating from the descending aorta and toward the lesion, thus confirming the diagnosis of pulmonary sequestration. We conclude that chest US with triplex Doppler technique is a valuable method in evaluating a patient with a pulmonary lesion who was thought to have lung sequestration before performing invasive aortography. (Chest 1992; 102:1880-81) CT =computed tomography; PW =pulse wave; US= ultrasound
Tung sequestration is an uncommon congenital abnormality, that may mimic other diseases such as pneumonia, lung abscess or tumor. Noninvasive image to demonstrate the systemic feeding artery may be helpful in patients with suspected lung sequestration before performing aortography. With the aid of US and spectral wave Doppler analysis, the feeding artery and the direction of the blood Row can be demonstrated in the lung sequestration. •·• Ultrasonography with simultaneous color Doppler mapping (triplex Doppler technique) has also been described recently as a useful adjunct method in the diagnosis oflung sequestration in neonates and infants. l-6 To our best knowledge, the use of the chest US with triplex Doppler technique has never been reported in the diagnosis of lung sequestration in adult patients. In this report, we describe the application of US equipped with triplex Doppler in evaluating an adult patient with intralobar sequestration which manifests as a necrotizing pneumonia.
.I..J
*From the Departments of Internal Medicine (Drs. Yuan, Yang, Chang and Yu) and Clinical Pathology (Drs. Kuo and Luh), National Taiwan University Hospital, Taipei, Taiwan, Republic of China. Reprint requests: Dr. Yang, National Taiwan University Hospital, No. I Chang-Te Street, Taipei, Taiwan, Republic of China
1880
FIGURE I. Posteroanterior chest radiograph of the patient showing a pneumonic patch in the left lower lobe. CASE REPORT
A 35-year-old man was admitted to our hospital because of rm obtained from the carotid artery or other peripheral systemic I
B
:s :
FIGURE 3. Digital subtraction aortogram revealing a feeding artery arising from the abdominal aorta to the sequestration (arrowhead:;).
arteries (Fig 2). They all had a spiking systolic wave Mth short acceleration time and persistent diastolic How wave.'·" In the duplex Doppler analysis, the upward Doppler signal above the baseline indicated that the blood How moves toward the US probe. We can conclude that this large tortuous vessel was a systemic feeding artery of this pulmonary lesion. With the aid of color Doppler mapping (triplex Doppler technique), we can demonstrate the red to yellow color How, which indicates moderate to high velocity of blood How,"·' 0 moving from the abdominal aorta upward to the center of the lesion (Fig 2). A draining vein Mth blue-color How was also noted in the nearby feeding artery, but it cannot be clearly traced to its proximal portion (Fig 2). The patient underwent aortography which confirmed this feeding artery arising from the abdominal aorta (Fig 3). Venous drainage of this lesion was from the pulmonary vein. Intralobar sequestration of the lung was confirmed in this patient. This patient received clindamycin and netilmicin for three weeks and underwent lobectomy for resection of the sequestration. At surgery, this sequestrated lung was hyperemic, hard in consistency and associated Mth multiple areas of cystic degenerations. A pulsating artery, Mth 1.0 em diameter, went through the diaphragm to the sequestration. After entering the sequestration, the diameter of this vessel decreased to about 0.7 em and then this vessel divided into several branches. DISCUSSION
Lung sequestration is a congenital maldevelopment resulting in nonfunctioning lung tissue. The sequestrated lung receives its blood supply from an anomalous systemic artery. There are two forms of lung sequestration: intralobar and extralobar. The feeding artery is always from the descending thoracic aorta, abdominal aorta or one of its branches in both types of sequestration. The venous drainage is pulmonary vein in intralobar sequestration, and bronchial or other systemic veins, including inferior vena cava, azygos vein and porta veinous system, in extralobar sequestration.• The demonstration of systemic feeding artery by aortogram is essential for the diagnosis of lung sequestration. However, lung sequestration can mimic other pulmonary diseases and the aortogram will not be performed if lung sequestration is not suspected clinically. Therefore, some noninvasive diagnostic modality is necessary to screen these unresolved pulmonary lesions before performing this invasive aortogram. Chest US with triplex Doppler technique can meet this requirement. In this case, we demonstrated that there were several characteristic US findings in lung sequestration: (1) a large tortuous vessel with prominent pulsation in the real-time monitoring; (2) spectral wave Doppler analysis revealing arterial pulsating waveform, with spiking systolic wave of short accelerating time and persistent low diastolic flow wave, similar to that of peripheral systemic artery, such as carotid artery, renal artery or superior mensentary artery; 7 ·" (3) duplex Doppler image and color mapping suggesting the blood flow arising from the aorta or below the diaphragm toward the lesion. Therefore, if US and triplex Doppler technique could demonstrate a large systemic feeding artery in a unresolved pulmonary lesion, lung sequestration should be highly suspected. Aortogram can be performed to confirm the diagnosis. In addition, the chest US also can demonstrate the associated changes in lung sequestration, such as cystic degeneration and infective consolidation. This makes the microbiologic studies of the lesion possible via US-guided CHEST I 102 I 6 I DECEMBER, 1992
1881
aspiration in patients with clinically suspected secondary infection. Preoperative antibiotics can be directed effectively. We conclude that chest US with triplex Doppler technique may be a very valuable noninvasive method in assisting in the diagnosis of lung sequestration, even in adult patients. ACKNOWLEDGMENT: This work has been supported in part by the Kwang Ten Trading Co, Ltd, Taipei. REFERENCES
2 3
4 5 6
7
8
9 10
West MS , Donaldson JS, Shkolnik A. Pulmonary sequestration: diagnosis by ultrasound. J Ultrasound Med 1989; 8:125-29 Gudinchet F, Anderegg A. Echography of pulmonary sequestration. Eur J Radio! 1989; 9:93-95 Kaude JV, Laurin S: Ultrasonographic demonstration of systemic artery feeding extrapulmonary sequestration. Pediatr Radio! 1984; 14:226-27 Sauerbrei E. Lung sequestration: duplex Doppler diagnosis at 19 weeks gestation. J Ultrasound Med 1991; 10:101-05 Newman B. Real-time ultrasound and colol"Doppler imaging in pulmonary sequestration. Pediatrics 1990; 86:620-23 Schulman MH, Stein SM , Neblett WW Pulmonary sequestration: diagnosis with color Doppler sonography and a new theory of associated hydrothorax. Radiology 1991; 180:817-21 Kassan M, Johnston KW, Cobbold RSC . Quantitative estimation of spectral broadening for the diagnosis of carotid arterial disease: method and in vitro result. Ultrasound Med Bioi 1985; 11 :425 Nicholls SC, Kohler TR, Martin RL. Use of hemodynamic parameters in the diagnosis of mesenteric insufficiency. J Vascular Surg 1986; 3:507 Fraser RG. Diagnosis of diseases of the chest. 3rd ed. Philadelphia: WB Saunders Company, 1989:701-12 Cosgrove DO, Bamber JC, Davey JB, McKinnaJA, Sinnett HD. Color Doppler signals from breast tumors. Radiology 1990; 176:175-80
Evolving Aortic Mass in a Patient
with Sepsis and Systemic Embolization*
Detection by Transesophageal Echocardiography jonathan D. Dubin, M.D.; Clair Miller; M.D. ; Andrew Mayrer, M.D.; and Enrico Veltri, M.D ., F.C.C.P.
An elderly patient with sepsis and systemic embolization is described. An intraluminal aortic mass was discovered by transesophageal echocardiography that appeared to be the source of infection in this patient. Transesophageal echocardiography can be a useful diagnostic test in patients with sepsis and systemic embolization of unknown etiology. (Chest 1992; 102:1882-83)
I TEE= transesophageal echocardiography I
ransesophageal echocardiography (TEE) has been T shown to provide high quality images of the thoracic
aorta.' In recent studies, TEE has revealed abnormalities of •From the Departments of Cardiology, Infectious Disease, and Anesthesia, Sinai Hospital of Baltimore, Baltimore. Reprint requests: Dr. Dubin, Division of Cardiology, Sinai Hospital, Baltimore 21215-5271 1882
FIGURE 1. TEE image of the distal aortic arch-proximal descending thoracic aorta junction taken on the lOth hospital day. A pedunculated, echogenic mass is seen attached to the luminal surface.
the aortic intimal surface that have been described as "protruding atherosclerotic plaque"• or "atherosclerotic debris."3 These abnormalities are thought to be part of a diffuse atherosclerotic process and may be causally related to systemic emboli. We report herein a patient with a localized intraluminal aortic mass diagnosed by TEE. This mass appears to have been a source for sepsis and embolization in this patient. CASE REPORT A 76-year-old white woman with a history of non-insulin-dependent diabetes mellitus was found unresponsive at home. On admission to the emergency room, the patient was found to be hypotensive with a systolic blood pressure of 60 mm Hg. Initial laboratory examination revealed hyperglycemia (glucose 1,800 mgldl) with ketoacidosis (pH 7.07), and leukocytosis (WBC 31,000/cu mm). The initial chest x-ray film findings were normal. The patient was transferred to the intensive care unit and treated for sepsis with broad spectrum antibiotics. Blood cultures from the day of admission were positive for Staphylococcus aureus. The patient remained hemodynamically labile with leukocytosis. On the 4th hospital day, the patient developed a cool right foot with cyanotic toes. A transthoracic echocardiogram was done at that time to rule out endocarditis or cardiac thrombi. The study showed normal left ventricular function, mitral annular calcification, normal valves, and normal cardiac chamber sizes. No evidence of vegetation or intracardiac thrombi were seen. Over the next few days, the patient underwent a head CT scan and abdominal sonogram that were unremarkable. Blood cultures became sterile on nafcillin therapy; however, several recurrent episodes of embolization to the right foot occurred. By the lOth hospital day, the patient remained unstable. The source of sepsis and embolization remained unclear. To better rule out a cardiac source, TEE was performed. Cardiac imaging confirmed the findings of the transthoracic echocardiogram and showed no evidence of valvular vegetations or intracardiac thrombi. The thoracic aorta was then imaged. At the junction of the distal aortic arch and the proximal descending aorta with the TEE probe placed approximately 25 em from the patient's incisors, an ovoid echogenic mass measuring approximately 1.5 X 1 em was seen attached to the aortic intimal surface (Fig 1). The mass was pedunculated and mobile. The aortic root, arch, and the remainder of the descending thoracic aorta were then carefully imaged. No other aortic intimal EI/Oiving Aortic Mass (Dubin et at)
