The Journal of Emergency Medicine, Vol. 46, No. 3, pp. e75–e77, 2014 Copyright Ó 2014 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/$ - see front matter
http://dx.doi.org/10.1016/j.jemermed.2013.08.092
Visual Diagnosis in Emergency Medicine
VIRAL MYOCARDITIS LEADING TO ACUTE HEART FAILURE IN A YOUNG ADULT Sarah E. Frasure, MD, Sebastian D. Siadecki, MD, Turandot Saul, MD, RDMS, and Resa E. Lewiss, MD Department of Emergency Medicine, Emergency Ultrasound Division, St. Luke’s/Roosevelt Hospital Center, New York, New York Reprint Address: Sarah E. Frasure, MD, St. Luke’s/Roosevelt Hospital Center, Department of Emergency Medicine, Division of Emergency Ultrasound, 1000 Tenth Avenue, Room GE-01, New York, NY 10019
pitting edema of his bilateral lower extremities with no calf tenderness, bruising, or rash. The electrocardiogram was notable for poor R-wave progression and T-wave inversions in leads V3–V6. A chest radiograph demonstrated an enlarged cardiac silhouette, a small left-sided pleural effusion, and diffuse reticular opacities. The laboratory analysis was significant for a white blood cell count of 9.1 103/mL and a hemoglobin of 15.6 g/dL. The basic metabolic panel, troponin, creatine phosphate kinase, and coagulation studies were all within normal limits. The B-type natriuretic peptide (BNP) was 863 pg/mL. The emergency physician performed a bedside cardiac ultrasound examination. The parasternal long and short axis, as well as the apical four-chamber cardiac views, demonstrated a hypokinetic left ventricle with a markedly reduced ejection fraction by gross visual estimation (Figures 1–3, Videos 1–3). This was evidenced by poor motion of the left ventricular walls, which failed to move symmetrically and vigorously towards the center of the ventricle, as well as minimal thickening of the walls during contraction. The emergency physician then performed a dedicated thoracic ultrasound examination. Diffuse B-lines were visualized bilaterally in the anterior (Figure 4, Video 4) and posterior lung fields. The ultrasound examinations further supported a diagnosis of heart failure as the etiology of the patient’s symptoms.
CASE REPORT A 35-year-old man was referred to the Emergency Department (ED) by his primary care physician with a chief complaint of dyspnea on exertion and concern for new-onset heart failure. Approximately 3 weeks prior to presentation he had developed an upper respiratory tract infection. At that time he saw his primary care physician, who prescribed an albuterol inhaler and a 5-day course of azithromycin. Although his initial symptoms of sore throat, subjective fevers, headache, and cough had resolved, he had become increasingly short of breath with even minimal exertion. He was unable to walk up two flights of stairs to his apartment without multiple stops to rest. He denied chest, back, or abdominal pain, nausea, vomiting, or diarrhea. He also denied neck pain or stiffness, sore throat, ear pain, headache, or rash. He denied recent travel or sick contacts. There was no relevant past medical history, he took no daily medications, and had no allergies. He smoked less than half a pack of cigarettes daily and rarely drank alcohol. The vital signs were as follows: blood pressure 120/86 mm Hg, heart rate 113 beats/min, respiratory rate 22 breaths/min, and oral temperature 98.1 F. Marked jugular venous distention was noted. On pulmonary examination, the physician auscultated both rhonchi and crackles bilaterally, and an S3 was heard on cardiac examination. The patient’s abdomen was nontender. He had symmetric 1+
RECEIVED: 28 February 2013; FINAL SUBMISSION RECEIVED: 16 July 2013; ACCEPTED: 15 August 2013 e75
e76
S. E. Frasure et al.
Figure 1. Parasternal long axis view of the heart. The left atrium (LA) and left ventricle (LV) are visualized.
An intravenous dose of furosemide was administered and the patient was admitted to the hospital with a diagnosis of new-onset congestive heart failure. Viral testing was performed to determine a possible etiology. Serologic examination for parvovirus B19 (immunoglobulin [Ig]M and IgG) was subsequently positive. Myocarditis, dilated cardiomyopathy, and left ventricular dysfunction are all reported complications of parvovirus infection.
Figure 3. Apical four-chamber view of the heart. The right atrium (RA), right ventricle (RV), left atrium (LA), and left ventricle (LV) are visualized.
The patient’s history and physical examination findings were suggestive of heart failure. A bedside ultrasound performed by the emergency physician revealed cardiac and thoracic findings confirming the suspected diagnosis. Physicians, however, often rely solely on physical examination findings, chest radiographs, and BNP levels to diagnosis heart failure. Stevenson et al. prospectively
compared physical examination findings with hemodynamic measurements in 50 patients with known chronic heart failure. Remarkably, rales, edema, and an elevated mean jugular venous pressure were absent in 18 of 43 patients with pulmonary capillary wedge pressures $ 22 mm Hg (1). Bedside ultrasonography of the heart and lungs, however, can help the physician make a diagnosis of heart failure, particularly when overt physical examination findings are absent, and without having to wait for radiologic or laboratory testing. Bedside cardiac ultrasound is an invaluable tool in the ED, on the medical floor, and in the intensive care unit. In addition to examining the heart for evidence of pericardial effusion or asystole, the physician can assess the ejection fraction (2). Multiple studies have evaluated the capacity of noncardiologists to approximate left ventricular function. Moore et al. demonstrated that
Figure 2. Parasternal short axis view of the heart. The right ventricle (RV) and left ventricle (LV) are visualized.
Figure 4. Ultrasound of the third anterior intercostal space demonstrating a confluence of B-lines (arrow).
DISCUSSION
Acute Heart Failure in a Young Adult
emergency physicians who underwent goal-directed training were able to accurately utilize bedside cardiac ultrasound to assess left ventricular function in hypotensive patients (3). Similarly, Alexander et al. showed that medical house staff who participated in a 3-h point-of-care echocardiography training program could assess left ventricular function with moderate accuracy when compared to a cardiologist (4). Although the most common cause of heart failure in the developed world is ischemia from coronary artery disease, bedside cardiac ultrasound may also reveal a left ventricular aneurysm or even valvular disease (5). Recent literature suggests that bedside thoracic ultrasound represents a useful tool in the assessment of interstitial pulmonary fluid. Specifically, the sonographic appearance of interstitial fluid is characterized by a vertical artifact that is known as the B-line (6). Though an isolated B-line may be a normal finding, the presence of multiple B-lines is suggestive of pulmonary edema. Bedside thoracic ultrasonography can provide an immediate assessment of the presence of pulmonary edema in dyspneic patients (7). Thus, within minutes of meeting a patient and performing a rapid bedside thoracic ultrasound examination, the emergency physician can determine whether pulmonary volume overload is a component of a patient’s respiratory distress and immediately provide appropriate diuretic treatment (8). Patients who present with symptoms that are concerning for either new-onset or worsening congestive heart failure could benefit from an immediate focused ultrasound examination. In this case, bedside cardiac and
e77
thoracic ultrasonography by the emergency physician aided in the diagnosis and expedited treatment decisions for the patient. REFERENCES 1. Stevenson LW, Perloff JK. The limited reliability of physical signs for estimating hemodynamics in chronic heart failure. JAMA 1989; 261:884–8. 2. Noble VE, Nelson B, Sutingco AN. Echocardiography. In: Manual of emergency and critical care ultrasound. Cambridge, UK: Cambridge University Press; 2007:53–80. 3. Moore CL, Rose G, Taval V, et al. Determination of left ventricular function by emergency physician echocardiography of hypotensive patients. Acad Emerg Med 2002;9:186–93. 4. Alexander JH, Peterson ED, Chen AY, et al. Feasibility of point-ofcare echocardiography by internal medicine house staff. Am Heart J 2004;147:476–81. 5. Kaddoura S. Heart failure, myocardium and pericardium. In: ECHO Made Easy. London: Elsevier; 2002:69–102. 6. Lichtenstein D, Meziere G. Relevance of lung ultrasound in the diagnosis of acute respiratory failure: the BLUE protocol. Chest 2008; 134:117–25. 7. Agricola E, Bove T, Oppizzi M, et al. ‘‘Ultrasound comet-tail images:’’ a marker of pulmonary edema: a comparative study with wedge pressure and extravascular lung water. Chest 2005;127: 1690–5. 8. Volpicelli G, Caramello V, Cardinale L, et al. Bedside ultrasound of the lung for the monitoring of acute decompensated heart failure. Am J Emerg Med 2008;26:585–91.
SUPPLEMENTARY DATA Supplementary data related to this article can be found online at http://dx.doi.org/10.1016/j.jemermed.2013. 08.092.
http://dx.doi.org/10.1016/j.jemermed.2013.08.092
Visual Diagnosis in Emergency Medicine
VIRAL MYOCARDITIS LEADING TO ACUTE HEART FAILURE IN A YOUNG ADULT Sarah E. Frasure, MD, Sebastian D. Siadecki, MD, Turandot Saul, MD, RDMS, and Resa E. Lewiss, MD Department of Emergency Medicine, Emergency Ultrasound Division, St. Luke’s/Roosevelt Hospital Center, New York, New York Reprint Address: Sarah E. Frasure, MD, St. Luke’s/Roosevelt Hospital Center, Department of Emergency Medicine, Division of Emergency Ultrasound, 1000 Tenth Avenue, Room GE-01, New York, NY 10019
pitting edema of his bilateral lower extremities with no calf tenderness, bruising, or rash. The electrocardiogram was notable for poor R-wave progression and T-wave inversions in leads V3–V6. A chest radiograph demonstrated an enlarged cardiac silhouette, a small left-sided pleural effusion, and diffuse reticular opacities. The laboratory analysis was significant for a white blood cell count of 9.1 103/mL and a hemoglobin of 15.6 g/dL. The basic metabolic panel, troponin, creatine phosphate kinase, and coagulation studies were all within normal limits. The B-type natriuretic peptide (BNP) was 863 pg/mL. The emergency physician performed a bedside cardiac ultrasound examination. The parasternal long and short axis, as well as the apical four-chamber cardiac views, demonstrated a hypokinetic left ventricle with a markedly reduced ejection fraction by gross visual estimation (Figures 1–3, Videos 1–3). This was evidenced by poor motion of the left ventricular walls, which failed to move symmetrically and vigorously towards the center of the ventricle, as well as minimal thickening of the walls during contraction. The emergency physician then performed a dedicated thoracic ultrasound examination. Diffuse B-lines were visualized bilaterally in the anterior (Figure 4, Video 4) and posterior lung fields. The ultrasound examinations further supported a diagnosis of heart failure as the etiology of the patient’s symptoms.
CASE REPORT A 35-year-old man was referred to the Emergency Department (ED) by his primary care physician with a chief complaint of dyspnea on exertion and concern for new-onset heart failure. Approximately 3 weeks prior to presentation he had developed an upper respiratory tract infection. At that time he saw his primary care physician, who prescribed an albuterol inhaler and a 5-day course of azithromycin. Although his initial symptoms of sore throat, subjective fevers, headache, and cough had resolved, he had become increasingly short of breath with even minimal exertion. He was unable to walk up two flights of stairs to his apartment without multiple stops to rest. He denied chest, back, or abdominal pain, nausea, vomiting, or diarrhea. He also denied neck pain or stiffness, sore throat, ear pain, headache, or rash. He denied recent travel or sick contacts. There was no relevant past medical history, he took no daily medications, and had no allergies. He smoked less than half a pack of cigarettes daily and rarely drank alcohol. The vital signs were as follows: blood pressure 120/86 mm Hg, heart rate 113 beats/min, respiratory rate 22 breaths/min, and oral temperature 98.1 F. Marked jugular venous distention was noted. On pulmonary examination, the physician auscultated both rhonchi and crackles bilaterally, and an S3 was heard on cardiac examination. The patient’s abdomen was nontender. He had symmetric 1+
RECEIVED: 28 February 2013; FINAL SUBMISSION RECEIVED: 16 July 2013; ACCEPTED: 15 August 2013 e75
e76
S. E. Frasure et al.
Figure 1. Parasternal long axis view of the heart. The left atrium (LA) and left ventricle (LV) are visualized.
An intravenous dose of furosemide was administered and the patient was admitted to the hospital with a diagnosis of new-onset congestive heart failure. Viral testing was performed to determine a possible etiology. Serologic examination for parvovirus B19 (immunoglobulin [Ig]M and IgG) was subsequently positive. Myocarditis, dilated cardiomyopathy, and left ventricular dysfunction are all reported complications of parvovirus infection.
Figure 3. Apical four-chamber view of the heart. The right atrium (RA), right ventricle (RV), left atrium (LA), and left ventricle (LV) are visualized.
The patient’s history and physical examination findings were suggestive of heart failure. A bedside ultrasound performed by the emergency physician revealed cardiac and thoracic findings confirming the suspected diagnosis. Physicians, however, often rely solely on physical examination findings, chest radiographs, and BNP levels to diagnosis heart failure. Stevenson et al. prospectively
compared physical examination findings with hemodynamic measurements in 50 patients with known chronic heart failure. Remarkably, rales, edema, and an elevated mean jugular venous pressure were absent in 18 of 43 patients with pulmonary capillary wedge pressures $ 22 mm Hg (1). Bedside ultrasonography of the heart and lungs, however, can help the physician make a diagnosis of heart failure, particularly when overt physical examination findings are absent, and without having to wait for radiologic or laboratory testing. Bedside cardiac ultrasound is an invaluable tool in the ED, on the medical floor, and in the intensive care unit. In addition to examining the heart for evidence of pericardial effusion or asystole, the physician can assess the ejection fraction (2). Multiple studies have evaluated the capacity of noncardiologists to approximate left ventricular function. Moore et al. demonstrated that
Figure 2. Parasternal short axis view of the heart. The right ventricle (RV) and left ventricle (LV) are visualized.
Figure 4. Ultrasound of the third anterior intercostal space demonstrating a confluence of B-lines (arrow).
DISCUSSION
Acute Heart Failure in a Young Adult
emergency physicians who underwent goal-directed training were able to accurately utilize bedside cardiac ultrasound to assess left ventricular function in hypotensive patients (3). Similarly, Alexander et al. showed that medical house staff who participated in a 3-h point-of-care echocardiography training program could assess left ventricular function with moderate accuracy when compared to a cardiologist (4). Although the most common cause of heart failure in the developed world is ischemia from coronary artery disease, bedside cardiac ultrasound may also reveal a left ventricular aneurysm or even valvular disease (5). Recent literature suggests that bedside thoracic ultrasound represents a useful tool in the assessment of interstitial pulmonary fluid. Specifically, the sonographic appearance of interstitial fluid is characterized by a vertical artifact that is known as the B-line (6). Though an isolated B-line may be a normal finding, the presence of multiple B-lines is suggestive of pulmonary edema. Bedside thoracic ultrasonography can provide an immediate assessment of the presence of pulmonary edema in dyspneic patients (7). Thus, within minutes of meeting a patient and performing a rapid bedside thoracic ultrasound examination, the emergency physician can determine whether pulmonary volume overload is a component of a patient’s respiratory distress and immediately provide appropriate diuretic treatment (8). Patients who present with symptoms that are concerning for either new-onset or worsening congestive heart failure could benefit from an immediate focused ultrasound examination. In this case, bedside cardiac and
e77
thoracic ultrasonography by the emergency physician aided in the diagnosis and expedited treatment decisions for the patient. REFERENCES 1. Stevenson LW, Perloff JK. The limited reliability of physical signs for estimating hemodynamics in chronic heart failure. JAMA 1989; 261:884–8. 2. Noble VE, Nelson B, Sutingco AN. Echocardiography. In: Manual of emergency and critical care ultrasound. Cambridge, UK: Cambridge University Press; 2007:53–80. 3. Moore CL, Rose G, Taval V, et al. Determination of left ventricular function by emergency physician echocardiography of hypotensive patients. Acad Emerg Med 2002;9:186–93. 4. Alexander JH, Peterson ED, Chen AY, et al. Feasibility of point-ofcare echocardiography by internal medicine house staff. Am Heart J 2004;147:476–81. 5. Kaddoura S. Heart failure, myocardium and pericardium. In: ECHO Made Easy. London: Elsevier; 2002:69–102. 6. Lichtenstein D, Meziere G. Relevance of lung ultrasound in the diagnosis of acute respiratory failure: the BLUE protocol. Chest 2008; 134:117–25. 7. Agricola E, Bove T, Oppizzi M, et al. ‘‘Ultrasound comet-tail images:’’ a marker of pulmonary edema: a comparative study with wedge pressure and extravascular lung water. Chest 2005;127: 1690–5. 8. Volpicelli G, Caramello V, Cardinale L, et al. Bedside ultrasound of the lung for the monitoring of acute decompensated heart failure. Am J Emerg Med 2008;26:585–91.
SUPPLEMENTARY DATA Supplementary data related to this article can be found online at http://dx.doi.org/10.1016/j.jemermed.2013. 08.092.
