Goubaa Mohamed MD Djerba Tunisia

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This 16-year-old male presented with fever (temperature >39) ,chills, and left thoracic pain. Thoracic ultrasound (and radiography) demonstrate : banal lung pneumonia (scan 1, 2, 3). Although treated with oral antibiotics, the patient continues to be feverish and on the follow-up examination 4 days later (scan .4, 5, 6), the patient's thoracic lesions more extensive and the ultrasound examination demonstrates a septated fluid collection around the Lung. C'est un patient jeune, âgé de 16 ans, se présentant avec une fièvre (39°) , frisson, et une douleur thoracique gauche. Une échographie thoracique a été pratiqué (cliché 1, 2, 3) montrant une pneumonie banale. Malgré un traitement antibiotique par voie orale, le patient reste fébrile et l'examen de contrôle 4 jours plus tard (cliché 4, 5, 3) montre une extension de la lésion pulmonaire et l'échographie montre l'apparition de liquide autour de tout le poumon gauche.





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The follow-up study, 4 days later (scan 4, 5, 6), shows small lung which is coarsened in echotexture and surrounded by pleural effusion. The appearance of this lung " hepatization " is most consistent with a atelectasis and gas, only, within the tubular bronchus appears as linear echogenic foci. Ultrasonographic examination reveal an accumulation of anechogenic fluid in the pleural space associated with echogenic bands of fibrin between the thoracic wall and pulmonary surface.This appearance is most consistent with postobstructive left lung pneumonia and an associated pleural effusion. The patient is then treated, at hospital, with appropriate antibiotics. The patient left the hospital 20 days after admission, and the lesion resolved on a follow-up ultrasound and radiology study. Le suivie 4 jours plus tard (cliché 4, 5, 6) montre un petit poumon collabé , perméable au ultrasons, entouré par du liquide pleural. Cet aspect "d'hépatisation" du poumon est évoque un atélectasie et le gaz, visible seulement dans la bronche apparaît sous forme de foyers échogènes linéaires. L'echographie révèle aussi la présence de liquide anéchogène dans la plèvre avec des cloisons et des ponts de fibrine. Cet aspect est fort évocateur de pneumonie gauche post-obstructive avec un épanchement pleural associé. Le patient est alors traité, à l'hôpital, avec une antibiothérapie appropriée. Il quitte l'hôpital 20 jours après admission, et, sur les contrôles échographiques et radiologiques, la lésion a complètement disparu.

pneumonia of all the left lung with pleural effusion(pleurisy). Pneumonie de tout le poumon gauche avec participation pleurale (pleurésie). _____


Lobar Pneumonia

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The value of ultrasound examination of the pleura and lungs remains highly underestimated to this day. While the ventilated lungs and the osseous skeleton of the thorax represent potent obstacles for ultrasound, a multitude of pathological processes of the chest wall, pleura, and lungs results in altered tissue composition, providing markedly increased access and visibility for sonographic examination. These conditions support the sonographic diagnosis of pleural and pulmonary disorders. However, the main value of pleura and lung ultrasonography is not the primary diagnosis of chest lesions but the follow up, differential diagnosis, detection of complications, such as abscesses and post embolic lung infarction, and guidance of diagnostic and therapeutic interventions in patients with pathological pleural and pulmonary findings (2). Major advantages include bedside availability, absence of radiation, and guided aspiration of fluid-filled areas and solid tumors. Pulmonary vessels and vascular supply of consolidations may be visualized without contrast (3).

Sonography :
with clinically and radiologically confirmed pneumonia : 88% could be visualised in the sonogram of patients. 6% had a pleural effusion. The remaining 6% had no pathological findings (7).
The consolidated area of the lung is usually hypoechoic, poorly defined, and wedge-shaped. The air-filled bronchi produce linear, high-amplitude branching echoes that converge toward the lung root. Posterior acoustic shadowing and reverberation artifacts are seen accompanying the proximal large bronchi (10).
Ultrasonographic examination can reveal an accumulation of anechogenic to hypoechogenic fluid in the pleural space associated with echogenic bands of fibrin between the thoracic wall and pulmonary surface.
ultrasonically guided lung aspiration is a technique with a high diagnostic yield and a low complication rate for various types of pneumonia. It is especially useful for patients without satisfactory clinical responses or without accurate microbiologic diagnosis (6).
Targhetta and Bourgeois (8) reported a series of thirty-nine consecutive patients with consolidated lung confirmed radiologically underwent sonography, and their sonograms were compared with results for healthy subjects, The hyperechoic line of normal aerated lung and its air artifacts showed respiratory motions (''gliding sign''). Patients with pneumonia demonstrated distinct sonographic patterns. Strong linear echoes with characteristic air artifacts (air bronchogram) and anechoic tubular structures (fluid bronchogram) were visualized in 92 % of patients. The superficial lung showed a homogeneous hypoechoic band termed 'superficial fluid alveolograms'' with respiratory motions in 90-100 %. they conclude that sonography can evaluate pulmonary consolidation and may provide additional roentgenographic information, especially when fluid bronchograms are visualized.

Differential :
1° Focal alveolar syndrome :
Bronchiole-alveolar cancer.
Thoracic contusion
2° Diffused alveolar syndrome :
Pulmonary edemas, vascular inflammation.
Disease of the hyalin membranes.
Bronchioli-alveolar cancer.
Sarcoidosis (alveolar form).
Pulmonary lymphomas.
Pulmonary hemorrhages.
Alveolar Protéinose, alveolar Microlithiasis.

Chest x-ray :
Chest radiograph findings indicate a segmental or lobar opacity with air bronchogram with or without pleural effusion.

Conclusion :
ultrasonography is useful for the evaluation of pulmonary consolidation. (9). Major advantages include bedside availability, absence of radiation, and guided aspiration of fluid-filled areas and solid tumors. Pulmonary vessels and vascular supply of consolidations may be visualized without contrast. US may help to diagnose conditions such as associate pleural or pericardial effusion.

Reference :
* 1: Mathis G. [Thoraxsonography--part 2--Subpleural lung lesions] Schweiz Rundsch Med Prax. 2004 Apr 21;93(17):719-24. Review. German.
* 2: Dietrich CF, Hirche TO, Schreiber D, Wagner TO. [Sonographie von pleura und lunge] Ultraschall Med. 2003 Oct;24(5):303-11. Review. German.
* 3: Beckh S, Bolcskei PL, Lessnau KD. Real-time chest ultrasonography: a comprehensive review for the pulmonologist. Chest. 2002 Nov;122(5):1759-73. Review.
* 4: Krejci CS, Trent EJ, Dubinsky T. Thoracic sonography. Respir Care. 2001 Sep;46(9):932-9. Review. * 28: Mathis G, Gehmacher O. [Lung and pleural ultrasound] Schweiz Rundsch Med Prax. 2001 Apr 19;90(16):681-6. German.
* 5: Braun U, Pusterla N, Fluckiger M. Ultrasonographic findings in cattle with pleuropneumonia. Vet Rec. 1997 Jul 5;141(1):12-7.
* 6: Chen CH, Lai CL, Chiu MH, Liu RD, Shih JF, Lee YC, Perng RP. [Diagnostic value of ultrasonically guided lung aspiration in pneumonia] J Formos Med Assoc. 1995 Dec;94 Suppl 2:S137-43. Chinese.
* 7: Gehmacher O, Mathis G, Kopf A, Scheier M. Ultrasound imaging of pneumonia. Ultrasound Med Biol. 1995;21(9):1119-22.
* 8: Targhetta R, Chavagneux R, Bourgeois JM, Dauzat M, Balmes P, Pourcelot L. Sonographic approach to diagnosing pulmonary consolidation. J Ultrasound Med. 1992 Dec;11(12):667-72.
* 9: Yang PC, Luh KT, Chang DB, Yu CJ, Kuo SH, Wu HD. Ultrasonographic evaluation of pulmonary consolidation. Am Rev Respir Dis. 1992 Sep;146(3):757-62.
* 10: Weinberg B, Diakoumakis EE, Kass EG, Seife B, Zvi ZB. The air bronchogram: sonographic demonstration. AJR Am J Roentgenol. 1986 Sep;147(3):593-5.