SAEM Clinical Images Series: Red Rash on My Legs

milaria

A 23-year-old female with no known past medical history presented with a rash concentrated on her legs, with a few areas on her arms and chest. The rash began the day before presentation when she became overheated while wearing sweatpants in 104°F weather. The rash was mildly pruritic but not painful. She denied any prior reaction to her sweatpants that she has had for several months. She denied any new soap or cosmetic use, prior rash, allergy, or medication use. Her review of systems and past medical history were negative.

Vitals: Normal

Skin: An erythematous papular rash is concentrated and symmetric on her lower extremities. There are a few sparse lesions on her arms, thorax, and abdomen with sparing of the palms, soles, and face. No pustules or vesicles are noted. There is no scale or crust. No other skin lesions are present. The rest of the examination is normal.

Non-contributory

Miliaria, or prickly heat (heat rash).

Miliaria, also known as prickly heat or heat rash, is caused by blocked eccrine sweat glands and ducts. Exposure to heat with sweating causes eccrine sweat to pass into the dermis or epidermis causing a rash. It is common in warm and humid climates during the summer months. It can affect up to 30% of adults living in hot and humid conditions. It may present as vesicles, papules, or pustules depending on the depth of the eccrine gland obstruction. In adults the rash is most likely seen where clothes rub on the skin. Infants and children typically have lesions on the upper trunk, neck, and head. Miliaria is a clinical diagnosis. Treatment involves measures to reduce sweating and exposure to hot and humid conditions. Air conditioning and the reduced humidity of indoor environments are helpful. If significant inflammation is present with pruritis, some improvement can be seen with 0.1% triamcinolone topically, though ointment should be avoided and only cream or lotion applied.

Take-Home Points

  • Miliaria, or prickly heat, is caused by sweating and blocked eccrine sweat glands.
  • Treatment involves retreating to cool, indoor environments.
  • Triamcinolone 0.1% cream or lotion may reduce pruritis.
  • Guerra KC, Toncar A, Krishnamurthy K. Miliaria. 2023 Aug 8. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan–. PMID: 30725861.

By |2024-03-26T10:26:51-07:00Apr 1, 2024|Dermatology, SAEM Clinical Images|

SAEM Clinical Images Series: Seeing Double

ophthalmoplegia

A 53-year-old woman with no significant past medical history presented to the emergency department with a 3-day history of double vision on leftward gaze. She initially presented to urgent care with a chief complaint of chest heaviness and concern that her blood pressure was too high, but was sent to the emergency department for further cardiac and neurological evaluation after her urgent care provider noticed abnormal eye movement. She endorsed mild, intermittent headaches associated with diplopia when looking to the left. However, she denied any blurry vision when looking forward. She denied any trauma or falls.

Vitals: Temp 36.7°C; Heart rate 86 beats/min; Respirations 18 breaths/min; BP 150/82 mmHg; O2 Saturation: 100%

General: No acute distress and appears comfortable. She is alert and oriented.

Eyes: Equal, round and reactive pupils and severely limited adduction of the right eye, all other extraocular movements are normal.

Neuro: All other cranial nerves are intact, normal tone in bilateral upper and lower extremities, normal sensation bilaterally to light touch and pinprick except for mildly decreased sensation to pinprick over right ulnar distribution.

CBC, CMP, EKG, and Troponins were normal.

Lipid panel: Cholesterol 241 (H)

CSF: No oligoclonal bands, Protein 197 (H), Albumin 57 (H), IgG 16.3 (H)

Internuclear ophthalmoplegia (INO) is defined as the inability to adduct the eye due to a lesion in the medial longitudinal fasciculus (MLF) and can be accompanied by nystagmus in the same eye. The two main causes of internuclear ophthalmoplegia are demyelination of the medial longitudinal fasciculus (MLF) from multiple sclerosis (MS) and ischemic cranial nerve damage from stroke. However, a comprehensive list of causes of INO includes: infarction (ischemic stroke), demyelination (MS), tumor, encephalitis, hemorrhage, hydrocephalus, Chiari malformation, infection (Lyme Disease), and trauma. Usually, MS is seen in younger patients where both eyes are affected whereas strokes occur more often in older patients and only one eye is affected.

The therapeutic approach focuses on treating the underlying cause and hence determining the etiology is of immense importance. A brain MRI should be ordered to evaluate for ischemia and demyelination. Proton density imaging is beneficial in identifying MLF lesions in multiple sclerosis. A lumbar puncture can also help rule out infections. A kappa-free light chain antibody test is a faster and less expensive way to test for multiple sclerosis than looking for oligoclonal bands in the CSF.

Given this patient’s relatively young age and vascular risk factors, stroke is highest on the differential. Her brain MRI showed areas of restricted diffusion in the right dorsal medial pons correlating with her exam. It also showed periventricular and subcortical white matter changes which is a non-specific finding in chronic small vessel ischemic changes vs underlying demyelinating disease. This was followed up with an MRI of her spine that demonstrated C5-6 stenosis with associated cord edema and an additional enhancing C3-4 lesion concerning for demyelinating disease. Her lumbar puncture revealed 3 nucleated cells and a protein of 197 but was deemed a traumatic tap. There were no oligoclonal bands. The initial brain MRI findings favored stroke for which she underwent a stroke work-up and was ultimately discharged on aspirin and atorvastatin for secondary prevention. However, due to concern for demyelinating disease, she was also treated with a 3-day course of IV methylprednisolone. Ultimately, she was discharged and asked to come back for a follow-up for repeat brain imaging and evaluation. A recent study showed that patients with unilateral or bilateral INO who experienced symptomatic diplopia were commonly managed by uniocular occlusion. Another case report showed that a young man who presented with acute INO responded rapidly to treatment with IV alteplase when administered within 2 hours of the onset of symptoms and resolution within 15 minutes. A case series revealed that 1 in 5 patients failed to recover from an INO. Hence, it is critical that a definitive workup is carried out to determine the etiology of the INO.

Take-Home Points

  • Brain MRI including DWI is a useful diagnostic tool for INO.
  • Unilateral INO is more frequently related to ischemic/vascular causes whereas bilateral INO is associated with MS.
  • Kim SS, Lee MH, Ji C. Unilateral Internuclear Ophthalmoplegia Following Minor Head Injury. Korean J Neurotrauma. 2022 Oct 24;18(2):329-334. doi: 10.13004/kjnt.2022.18.e64. PMID: 36381451; PMCID: PMC9634317.
  • Mahawish KM, Aravind A. Acute onset internuclear ophthalmoplegia responsive to treatment with intravenous alteplase. N Z Med J. 2020 May 22;133(1515):119-121. PMID: 32438384.
  • Simmons J, Rhodes M. Conservative and Surgical Management of Unilateral and Bilateral Internuclear Ophthalmoplegia (INO)-A Retrospective Analysis. Br Ir Orthopt J. 2022 Nov 7;18(1):152-158. doi: 10.22599/bioj.280. PMID: 36420121; PMCID: PMC9650975.

By |2024-03-16T21:53:50-07:00Mar 22, 2024|Neurology, Ophthalmology, SAEM Clinical Images|

SAEM Clinical Images Series: Purple Finger

bruising

A 30-year-old female with a past medical history of Crohn’s Disease presented to the ED for evaluation of an acutely bruised right 4th finger. She stated she was typing on a computer keyboard approximately 10 minutes prior to presentation and she noticed a sudden popping sensation at the base of her right ring finger. After the popping sensation, she noticed a cool sensation of the finger and numbness to the entire finger. Shortly after that, the finger turned purple, so she came to the Emergency Department for evaluation. She denied pain in the hand and has had no problems moving the finger. She denied trauma to the hand or finger. No other complaints or issues. She noted that she has had this once in the past, which self-resolved on its own in 10 days a few months ago in the same situation.

General: No acute distress

Right hand: Right 4th finger with diffuse ecchymosis across the palmar surface of the finger with swelling, no tenderness, ecchymosis does not extend to the palmar surface of the hand. FROM of all 5 digits at both the DIP and PIP joints. Sensation to the right 4th finger is decreased to light touch.

Left hand: Normal

Extremities: Normal other than the right ring finger

Pulses: Radial pulses 2+ bilaterally

Remainder of the physical exam is normal.

Non-contributory

Achenbach Syndrome, also known as paroxysmal finger hematomas, is a self-limited condition. It typically afflicts middle-aged women and presents as spontaneous subcutaneous bleeding of the palmar surface of the middle and index fingers of the hand. Patients usually present with pain, swelling, tingling, numbness, and ecchymosis. Many report a burning sensation to the finger. Diagnosis is based on presentation and exam. Laboratory testing and imaging do not show pathologic findings in this disorder. There is no known treatment and symptoms usually resolve on their own in a few days, but can last up to months. It has been shown to be recurrent, but without a known cause. Given the dramatic presentation of Achenbach Syndrome, it is important to be aware of this benign process to prevent unnecessary testing and workup, as it is a self-limited process.

Take-Home Points

  • Achenbach Syndrome is a benign, self-limited condition that does not require treatment
  • Relapses may occur.
  • No testing is indicated, but if sent will be normal including laboratory studies and arterial dopplers of the extremity.
  • Ahmed Z, Elmallah A, Elnagar M, Dowdall J, Barry M, Sheehan SJ. Painful Blue Finger-Achenbach’s Syndrome: Two Case Reports. EJVES Short Rep. 2018 Jun 27;40:1-2. doi: 10.1016/j.ejvssr.2018.05.008. PMID: 30094355; PMCID: PMC6070693.
  • van Twist DJL, Hermans W, Mostard GJM. Paroxysmal finger hematoma. Cleve Clin J Med. 2020 Apr;87(4):194. doi: 10.3949/ccjm.87a.19122. PMID: 32238371.

By |2024-04-01T09:11:49-07:00Mar 18, 2024|Orthopedic, SAEM Clinical Images|

SAEM Clinical Images Series: Workout Gone Wrong

hyphema

A 28-year-old male presented to the ED for evaluation of an injury to his right eye. While working out with an exercise band, it snapped back, hitting the patient in the right eye. He experienced blurry vision and excess eye tearing immediately after the incident occurred. The patient also developed gross blood over the front of the eye.

Vitals: Temp 98°F, HR 73, BP (135/77), RR 16, SpO2 99%

HEENT: Gross blood in the anterior portion of the right eye (grade I). The right pupil is dilated with minimal responsiveness to light. Visual Acuity: OD 20/70, OS 20/10, Both 20/10. Pressure: OD (21), OS (16). Decreased visual field on the right when compared to the left. Staining with tetracaine and fluorescein did not reveal any evidence of corneal abrasion or ulceration. Left eye is atraumatic in appearance.

Neurologic: Alert and oriented x3

Non-contributory

A Hyphema is a collection of blood in the anterior chamber of the eye due to the tearing of the iris root vessels.

The most common cause is blunt trauma to the eye. Spontaneous hyphemas can also occur and are often associated with sickle cell disease. It can be caused by ocular surgery and neoplastic disease, as well.

Take-Home Points

  • Hyphemas are an ocular emergency and should prompt immediate consultation with an ophthalmologist.
  • Patients should elevate the head of the bed to 45 degrees since layering of the blood is gravity-dependent.
  • Treatment usually involves the administration of steroidal and cycloplegic ophthalmic drops.
  • Cline, D., Ma, O. J., Meckler, G. D., Stapczynski, J. S., Thomas, S. H., Tintinalli, J. E., & Yealy, D. M. (2020). 241. In Tintinalli’s emergency medicine: A comprehensive study guide. essay, McGraw-Hill Education.
  • Traumatic Hyphema. Wikem. (2020, March 18). Retrieved January 11, 2023, from https://www.wikem.org/wiki/Main_Page

SAEM Clinical Images Series: Not Your Usual Irritated Eye

eye irritation

In July 2022, a 32-year-old male with a past medical history of HIV (on antiretroviral therapy, CD4 390, viral load undetectable) presented to the emergency department with constitutional symptoms and a rash for 4-5 days. His symptoms included malaise, body aches, subjective fevers, a sore throat, tender, swollen neck glands, body rash, and irritation of his left eye. He also noticed fluid-filled vesicles on his face, neck, trunk, and extremities. He denied travel outside the U.S. but reported a recent trip to New Orleans. He denied any new sexual partners or known exposure to individuals with similar symptoms.

Vitals: BP 135/83; Pulse 104; Temp 100.2 °F (37.9 °C); Resp 22; SpO2 99%

Constitutional: Alert, no acute distress

HEENT: 1×1 mm raised lesion to the left medial canthus/caruncle. No appreciated LAD. Oropharynx is clear and moist, and mucous membranes are normal.

Cardiovascular: Tachycardia, regular rhythm, and normal heart sounds.

Pulmonary: Breath sounds normal, unlabored respirations.

Abdominal: Soft. Non-tender.

Skin: Numerous 5-6 mm erythematous macules, bland fluid-filled vesicles, and umbilicated lesions throughout the face, neck, trunk, and extremities.

Complete Blood Count (CBC): WBC: 19.5 10^3/mcL, Hemoglobin: 15.2 gm/dL, Hematocrit: 43.6%, Platelet count: 325 10^3/mcL

Comprehensive Metabolic Panel (CMP): Within normal limits

RPR titer: Reactive, 1:4

Syphilis antibody IgG and IgM: Positive

Orthopoxvirus DNA: Pending

HIV RNA: Pending

The patient has Monkeypox with involvement of the caruncle of the left eye. The patient tested positive for non-variola orthopoxvirus DNA. Ophthalmology was consulted and did not find any other signs of compromise to the eye and recommended treatment with artificial tears. The patient received 14 days of Tpoxx. The patient’s eye lesion and symptoms resolved and he was discharged on hospital day eight.

Ocular lesions are a rare presentation of the monkeypox virus. There is limited literature documenting eye involvement and pictographic examples of its presentation. During the current outbreak, ocular involvement has been used as a criteria for hospital admission. The most commonly seen ophthalmologic lesions include a vesicular rash of the orbital and periorbital skin (25%), focal conjunctiva lesions, blepharitis, and conjunctivitis. Rarely, lesions can process to corneal ulcerations, keratitis, and vision loss. Given the late risk of vision loss in cases of ocular manifestations, clinicians should be aware of the varied presentation of ocular lesions associated with the monkeypox virus.

Take-Home Points

  • While rare, ocular involvement of Monkeypox is associated with vision loss, and should be promptly identified and addressed by a clinician.
  • If there is ocular involvement of primarily cutaneous pathology, a thorough eye exam is indicated in the initial assessment of the patient.
  • Abdelaal A, Serhan HA, Mahmoud MA, Rodriguez-Morales AJ, Sah R. Ophthalmic manifestations of monkeypox virus. Eye (Lond). 2023 Feb;37(3):383-385. doi: 10.1038/s41433-022-02195-z. Epub 2022 Jul 27. PMID: 35896700; PMCID: PMC9905463.
  • Kumar N, Acharya A, Gendelman HE, Byrareddy SN. The 2022 outbreak and the pathobiology of the monkeypox virus. J Autoimmun. 2022 Jul;131:102855. doi: 10.1016/j.jaut.2022.102855. Epub 2022 Jun 25. PMID: 35760647; PMCID: PMC9534147.
  • Thornhill, John P., et al. “Monkeypox virus infection in humans across 16 countries—April–June 2022.” N Engl J Med. 2022 Aug 25;387(8):679-691. doi: 10.1056/NEJMoa2207323. Epub 2022 Jul 21. PMID: 35866746.

PEM POCUS Series: Pediatric Renal and Bladder Ultrasound

PEM POCUS fascia iliaca block

Read this tutorial on the use of point of care ultrasonography (POCUS) for pediatric renal and bladder ultrasonography. Then test your skills on the ALiEMU course page to receive your PEM POCUS badge worth 2 hours of ALiEMU course credit.

Module Goals

  1. List the indications for performing a pediatric renal/bladder point-of-care ultrasound (POCUS)
  2. Describe the technique for performing renal/bladder POCUS
  3. Identify hydronephrosis and its appearance at different severities
  4. List the limitations of renal/bladder POCUS
  5. Advanced: Recognize direct and other indirect signs of nephrolithiasis as well as gross renal/bladder structural anomalies such as cysts and masses

Case Introduction: Child with abdominal pain

Serena is a 9-year-old girl who comes into the emergency department complaining of one day of left flank and left lower quadrant pain (LLQ). The pain is intermittent, sharp, severe, and associated with 2 episodes of nonbloody, nonbilious emesis. Her mother denies any fevers, upper respiratory symptoms, sore throat, or diarrhea. She adds that her daughter has complained of 2-3 episodes of dysuria and gross hematuria over the last few days.

On arrival, her vital signs are:

Vital SignFinding
Temperature99 F
Heart Rate115 bpm
Blood Pressure97/50
Respiratory Rate19
Oxygen Saturation (room air)100%

You find her lying on the gurney, uncomfortable appearing, and intermittently crying. She has a normal HEENT, neck, cardiac, respiratory, and back examination. She has no flank tenderness, but she does cry out with palpation of the LLQ and suprapubic areas.

Given her pain with a history of intermittent hematuria and dysuria, you perform a renal and bladder point of care ultrasound (POCUS) examination.

Pediatric Renal and Bladder POCUS

  • Hematuria
  • Flank pain
  • Abdominal distension or palpable mass
  • Anuria, oliguria, or urinary retention
  • Concern for nephrolithiasis
  • Bladder volume assessment prior to urinary catheterization

Probe choice [1]

  • Typically based on the size of the child (Figure 1)
  • If unsure, perform test scans and choose the probe that most effectively provides the desired views and level of detail
ultrasound probe transducers

Figure 1. Ultrasound probes from left to right: linear (nenoates), phased array (infants/younger children), and curvilinear (older children/adolescents)

Pro tips for performing renal/bladder POCUS on a child [1]

  • Addressing potential anxiety leads to a more efficient and comfortable examination.
  • Explain to the parent (and child if old enough), the areas you need to examine.
  • Set up distractions such as toys or videos on a tablet or smartphone
  • When appropriate, demonstrate the probe(s) to the child and apply some ultrasound gel to the back of their hand so they understand it will not be painful.
  • Pre-warmed ultrasound gel is helpful when available.
  • Examine the patient in a position that maximizes comfort and minimizes anxiety.
    • Lay the patient supine when possible. They can lay on the stretcher, or in the parent’s lap if it calms them (Figure 2, left). This is also an optimal position in which the parent can hold a tablet or smart device above the patient’s face as a distractor.
    • If supine positioning is unsuccessful, the patient can be placed upright in their parent’s lap facing away from the sonographer (Figure 2, right). In this position, the parent can hug and hold the patient if needed.
pediatric ultrasound positioning

Figure 2: Patient positioning options: Left (supine) – Patient playing with the distractors during bladder POCUS; Right (upright) – Toddler facing away from sonographer during renal POCUS. Note: Blue dot represents the probe indicator.

Right Kidney (Longitudinal View)

  • Begin in the mid-axillary line around the 10th or 11th intercostal space with the probe marker pointed toward the patient’s head and identify the renal structures (Figure 3).
  • While maintaining probe contact on the skin, tilt it perpendicular to its long axis in each direction (also known as fanning) to assess the entire kidney (Video 1).
Longitudinal view ultrasound right kidney

Figure 3. Longitudinal view of the right kidney: Left – Probe placement in right mid-axillary line; Right – Unlabeled and labeled ultrasound view

Video 1. Longitudinal view of the right kidney

Right Kidney (Transverse View)

  • From the longitudinal view, rotate the probe 90 degrees and fan the probe to assess the entire kidney in the transverse plane (Video 2).
  • Identify the medullary pyramids, calyces, renal cortex, and renal pelvis (Figure 4).
Video 2. Transverse view of the right kidney
right kidney ultrasound transverse view

Figure 4. Transverse ultrasound view of the right kidney with anatomical labels

Left Kidney (Longitudinal View)

  • Place the probe in the left posterior axillary line (the left kidney is slightly more superior and posterior than the right) around the 8th to 10th intercostal space (Figure 5).
  • As performed on the right kidney, identify the relevant structures and fully assess the left kidney by fanning through (Video 3).
left kidney longitudinal ultrasound probe position

Figure 5. Longitudinal view of the left kidney with probe placement in posterior axillary line

Video 3. Longitudinal view of the left kidney

Left Kidney (Transverse View)

  • From the left longitudinal view, rotate the probe 90 degrees. Identify the relevant structures and fully assess the left kidney by fanning through (Video 4).
Video 4. Transverse view of the left kidney

Bladder (Transverse View)

  • With the indicator towards the patient’s right, place the probe on the patient’s midline just above the pubic symphysis and fan the probe downward into the pelvis (Figure 6). The pelvis, the bladder, uterus, prostate, and rectum can be seen in this view (Figure 7).
    • Pro Tip: The bladder is always directly behind the pubic symphysis, so if you cannot locate it, the probe may be too superior. 2
  • Fan through the entire bladder from superior to inferior borders (Video 5).

Figure 6. Probe positioning for transverse view of the bladder

Figure 7. Transvere ultrasound views of the bladder: Left – Uterus identified posteriorly in girl; Right – Prostate identified posteriorly in boy (Images courtesy of Dinh et al.)

Video 5. Transverse view of the bladder

Bladder (Longitudinal/Sagittal View)

  • From the transverse view, rotate the probe 90 degrees clockwise so the indicator is now pointing to the patient’s head.
  • Identify the bladder, bowel gas, uterus or prostate, and rectum (Figure 8). Then fan to scan from one lateral border of the bladder to the other (Video 6).
bladder longitudinal sagittal view

Figure 8. Sagittal view of bladder: Left – Uterus identified posteriorly in girl; Right – Prostate identified posteriorly in boy (Images courtesy of Dinh et al.)

Video 6. Sagittal view of bladder

Formula

Figure 9. Bladder volume calculation per dimension

The bladder’s shape may appear more rounded when it is full or distended. Bladder volume may be assessed prior to urinary catheterization to avoid an unsuccessful catheterization. Many ultrasound machines also have software which can calculate estimated bladder volume based on the above measurements.

Manual Measurement (Figure 10)

  • In the transverse view, measure the width and depth.
  • In the sagittal view, measure the height from the apex to the base.

Figure 10. Bladder measurement example: Left – Transverse view with width (4.35 cm) and depth (3.65 cm); Right – Sagittal view with height (3.53 cm). Estimated volume = 39.2 mL

Estimated Bladder Capacity by Age

  • [Age of the child (yr) x 30] + 30 = bladder capacity in mL
  • In a toilet-trained child, a post-void volume of ≤20 mL is normal [1].

The scope of POCUS focuses on the detection of hydronephrosis which would necessitate further workup. Hydronephrosis may be secondary to various obstructive etiologies such as nephrolithiasis, masses, or anatomical anomalies.

Severity Grading

Hydronephrosis severity grading begins with dilation at the renal pelvis (grade 1 or pelviectasis), which can be present in normal individuals who have not urinated in some time. The greater the degree of hydronephrosis, the more the dilation extends outwards into the calyces and the renal cortex (Figures 11-15 and Videos 7-9).

Figure 11. Hydronephrosis grading scale (courtesy of Dinh et al.)

Hydronephrosis: Hydroureter

Figure 12. Hydroureter on ultrasound of the right kidney

Hydronephrosis: Mild

Figure 13. Mild hydronephrosis on ultrasound with only pelviectasis, or dilation of the renal pelvis (Image courtesy of Dr. Jim Tsung)

Video 7. Renal ultrasound showing pelviectasis

Hydronephrosis: Moderate

Figure 14. Moderate hydronephrosis showing dilation extending into the major/minor calyces (Image courtesy of POCUS atlas)

Video 8. Moderate hydronephrosis (full video from Figure 14)

Hydronephrosis: Severe

Figure 15. Severe hydronephrosis with dilation causing cortical thinning (Image courtesy of POCUS Atlas)

Video 9. Severe hydronephrosis with “bear claw” sign (full video from Figure 15)

Direct Visualization

Stones may be located anywhere along the urogenital tract. If directly visible, stones will appear as hyperechoic structures and may have acoustic shadowing (Figure 16).

Figure 16. Left – Hyperechoic renal stone with acoustic shadowing and associated moderate hydronephrosis; Right – Bladder stone with acoustic shadowing (images courtesy of Dr. James Tsung)

Video 11. Renal stone with acoustic shadowing and moderate hydronephrosis

Indirect Visualization

Direct visualization will not always be possible since stones are most commonly located in the ureters and may be obscured by bowel gas. Indirect signs of stones include hydronephrosis, twinkling artifact, and absence of ureteral jet [1, 4].

Twinkling artifact is a color Doppler finding that can help identify a stone that may not be directly visible in B-mode. It is generated from turbulent flow around a rough-edged structure (i.e, a stone). Color Doppler interrogation will produce a multi-colored high high-intensity structure behind the stone (Figure 17). The turbulent flow depicted can be seen even if the causative hyperechoic stone is not visible [1, 3].

Figure 17. Twinkling artifact in a patient with a right ureterovesciular junction stone (Image courtesy of Dr. James Tsung)

Video 12. Twinkling artifact from a renal stone
Renal cysts are thin-walled, smooth, localized, and anechoic areas that are round or oval in shape. They can occur as solitary lesions or multiple lesions often in the periphery of the kidney (Figures 18-19). They should not be confused with dilated medullary pyramids from hydronephrosis, which appear as branching and “interlinked” hypoechoic areas resembling a cauliflower. Cysts will have a more spherical shape and will not “communicate” with one another [5].

Figure 19. Single renal cyst without (left) and with (right) color Doppler flow to differentiate from vasculature (Images courtesy of Dr. Jeffrey Tutman)

Figure 20. Multiple renal cysts without (left) and with (right) color Doppler flow differentiating from vasculature  (Images courtesy of Dr. Jeffrey Tutman)

Hyperechoic and heterogeneous lesions that distort or do not conform to typical renal architecture are concerning for renal masses. Wilms tumor is the most common renal malignancy in children with peak incidence between ages 1 and 5 years old. On ultrasound, it appears as an echogenic intrarenal mass that may have cystic areas from hemorrhage and necrosis (Figure 21) [4].

Figure 21. Wilms tumor in the right kidney without (left) and with (right) color Doppler flow (Images courtesy of Dr. Jeffrey Tutman)

Other potential neoplasms within or adjacent to the genitourinary system include but are not limited to neuroblastoma, rhabdoid tumor, rhabdomyosarcoma, renal cell carcinoma, and clear cell carcinoma [4, 6]. The most common malignant bladder mass is rhabdomyosarcoma, and the genitourinary tract is the second most common tumor site. It is usually large, nodular, well-defined, homogeneous, and slightly hypoechoic (Figure 13) [6].

Figure 22. Bladder rhabdomyosarcoma tumor without (left) and with (right) color Doppler flow (Images courtesy of Dr. Jeffrey Tutman)

  • Always scan both kidneys for comparison
  • Scan the bladder when evaluating the kidneys
  • Rib shadowing – attempt to maneuver around rib shadows by reangling the probe or moving up or down a rib space.
  • Bladder dimension calculations may be inaccurate if the calipers are not placed in the right orientations.
  • Large ovarian cysts may be mistaken for the bladder.
  • Because renal stones can be difficult to visualize directly, look for secondary signs such as hydronephrosis.
  • Because renal vasculature may be mistaken for hydronephrosis, use color Doppler to differentiate.
  • Renal cysts can be confused for hydronephrosis, and both warrant further imaging by Radiology.

Bladder volume estimation

Measuring bladder volume via POCUS in pediatric patients has been studied, demonstrating a benefit on Emergency Department workflow and length of stay (Table 1). For example, POCUS can confirm urine in the bladder, prior to catheterization in infants [7-8].

Author, Title, Journal, Publication YearStudy Type, Location, Time FrameN, AgesSummary
Milling et al., Use of ultrasonography to identify infants for whom urinary catheterization will be unsuccessful because of insufficient urine volume: validation of the urinary bladder index. Ann Emer Med, 2005 [7]Prospective, blinded, observational study performed in the pediatric ED, 3 month periodN=44, < 2 years of age
  • Created a bladder urinary index by multiplying the AP and transverse bladder diameters.
  • Determined the smallest bladder index that would result in successful urinary catheterization, which was defined as yielding at least 2 mL of urine.
  • The index achieved 100% sensitivity and 97% specificity.
Chen et al., Utility of bedside bladder ultrasound before urethral catheterization in young children. Pediatrics, 2005 [8]Prospective 2 -hase study, performed in the pediatric ED, 6 month periodN=136 for observation phase

N=112 for intervention phase

Ages 0-24 months

  • Observation Phase: The success rate of the first urethral catheterization attempt was calculated without preemptive bladder ultrasound
  • Intervention Phase: Bladder POCUS was performed, and catheterization was withheld until sufficient urine was present.
  • Successful catheterization rate during the observation phase was 72% overall, compared to 96% in the intervention phase.
Dessie et al., Point-of-Care Ultrasound Assessment of Bladder Fullness for Female Patients Awaiting Radiology-Performed Transabdominal Pelvic Ultrasound in a Pediatric Emergency Department: A Randomized Controlled Trial. Ann Emerg Med, 2018 [9]Randomized controlled trial, performed in a pediatric ED, 12 month periodN=120

8-18 years

  • To assess bladder fullness prior to transabdominal pelvic ultrasound, patients were randomized to subjective numerical scale versus bladder POCUS in addition to numerical scale.
  • Those in the bladder ultrasound arm completed their pelvic ultrasounds 51 minutes faster than the control group.
  • Success rate of pelvic ultrasound was 100% vs 84.7% in the control group.
Table 1. Pediatric bladder POCUS studies

Pediatric Hydronephrosis and Nephrolithiasis

Although adult studies (Table 2) have shown moderate diagnostic accuracy of POCUS in detecting hydronephrosis and nephrolithiasis, there is a dearth of POCUS-based renal studies in the pediatric literature . This has led to controversy whether to perform a renal ultrasound versus CT, even when the Radiology department performs the ultrasound.

  • Only 2 case series and 1 case report for POCUS-identified nephrolithiasis in children (Table 3)
  • No studies have aimed to determine sensitivity and specificity of POCUS for hydronephrosis in children in the context of renal colic.
Author, Title, Journal, Publication YearStudy Type, Location, Time FrameN, AgesSummary
Pathan et al., Emergency Physician Interpretation of Point-of-care Ultrasound for Identifying and Grading of Hydronephrosis in Renal Colic Compared With Consensus Interpretation by Emergency Radiologists, Acad Emerg Med, 2018 [10]Secondary analysis of images, obtained 2014-2015 from a large volume ED.N=651, Adults
  • Secondary analysis of ED physician POCUS images diagnosing hydronephrosis
  • Images were re-interpreted by radiologists to determine accuracy.
  • Sensitivity=85.7%, specificity=65.9%
  • CT was used as a reference standard when possible, yielding sensitivity=81.1% and specificity=59.4%.
Wong et al., The Accuracy and Prognostic Value of Point-of-care Ultrasound for Nephrolithiasis in the Emergency Department: A Systematic Review and Meta-analysis. Acad Emerg Med, 2018 [11]Systematic review & Meta-analysis, Multicenter, 2005 Through April 2016N=1,773, Adults
  • POCUS has modest diagnostic accuracy in adults for nephrolithiasis.
  • Moderate or greater hydronephrosis was highly specific for stones.
  • Detection of any hydronephrosis was suggestive of a stone >5 mm in size.
Kim et al., Usefulness of Protocolized Point-of-Care Ultrasonography for Patients with Acute Renal Colic Who Visited Emergency Department: A Randomized Controlled Study. Medicina, 2019 [12]Prospective randomized control trial in a tertiary care ED, March 2019-July 2019N=164, Adults
  • Evaluated POCUS protocol in managing patients with renal colic in the ED.
  • Patients were assigned to CT vs ultrasound group.
  • Length of stay was 62 min shorter and medical cost was lower in the ultrasound group with no difference in complications within 30 days.
Sibley et al., Point-of-care ultrasound for the detection of hydronephrosis in emergency department patients with suspected renal colic. Ultrasound J, 2020 [13]Prospective observational study in 2 Canadian academic EDs, April 2011 – July 2013N=413, Adults
  • Patients presenting with renal colic had an ED-performed POCUS.
  • The patients also had a CT or an ultrasound by Radiology as a reference standard.
  • For detecting hydronephrosis via POCUS, sensitivity=77.1% and specificity=71.8%.
Table 2. Adult POCUS studies on hydronephrosis and nephrolithiasis
Author, Title, Journal, Publication YearStudy Type, Location, Time FrameN, AgesSummary
Chandra et al., Point-of-care ultrasound in pediatric urolithiasis: an ED case series. Am J Emerg Med. 2015 [14]Case series in a pediatric ED, over a 2-year periodN=8

5-17 years

  • 8 cases of nephrolithiasis were identified with POCUS in patients presenting with renal colic.
  • All patients had confirmatory imaging in radiology.
  • Stones of 2 patients were visualized directly; others were identified by hydronephrosis, twinkling artifact, unilateral absence of ureteral jet, and/or a bladder bulge
Ng et al., Avoiding Computed Tomography Scans By Using Point-Of-Care Ultrasound When Evaluating Suspected Pediatric Renal Colic. Ultrasound in EM, 2015 [15]Retrospective case series in a pediatric ED, time frame not specifiedN=5

3-21 years

  • Hydronephrosis, ureteral jets, twinkling artifact, and the visualization of urinary tract stones were identified in patients with renal colic.
  • CT was avoided in all 5 patients.
Gillon et al., Diagnosis of Posterior Urethral Valves in an Infant Using Point-of-Care Ultrasound. Ped Emerg Care, 2021 [16]Case report in a tertiary pediatric ED, date not specified1, infant
  • Case report of 7-week old boy diagnosed with posterior urethral valves when the ED POCUS identified signs of bladder outlet obstruction. This included a thickened and distended bladder with bilateral hydroureter, severe bilateral hydronephrosis, and small perinephric fluid collections consistent with calyceal rupture.
Table 3. Pediatric POCUS studies on hydronephrosis and nephrolithiasis

Case POCUS

Using the curvilinear probe, you perform a POCUS on the bladder and both kidneys (Video 12).

Video 12. Bilateral renal ultrasound demonstrating twinkling artifact in the bladder and left-sided moderate hydronephrosis, indicative of a distal left ureteral stone (Video courtesy of Dr. Jim Tsung)

Case Resolution

Labs showed a slight leukocytosis with a serum WBC of 13 x109/L but no left shift and a normal creatinine. Urinalysis was positive for blood, RBC’s, and crystals but negative for glucose, ketones, leukocyte esterase, nitrites, WBC’s, squamous cells, and bacteria. The pain and vomiting were well-controlled with ketorolac and ondansetron, respectively. Urology was consulted and recommended medical management. The patient was discharged on tamsulosin and given urine-straining instructions.

Pediatrician Clinic Follow-Up

At her pediatrician clinic visit 2 weeks later, the patient had passed the stone and was asymptomatic.

Learn More…

References

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  2. Deschamps J, Dinh V, Ahn J, et al. Renal Ultrasound Made Easy: Step-By-Step Guide. POCUS101.com. [cited 2023 July 4].
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  9. Dessie A, Steele D, Liu AR, Amanullah S, Constantine E. Point-of-Care Ultrasound Assessment of Bladder Fullness for Female Patients Awaiting Radiology-Performed Transabdominal Pelvic Ultrasound in a Pediatric Emergency Department: A Randomized Controlled Trial. Ann Emerg Med. 2018 Nov;72(5):571-580. doi: 10.1016/j.annemergmed.2018.04.010. Epub 2018 Jul 3. PMID: 29980460.
  10. Pathan SA, Mitra B, Mirza S, Momin U, Ahmed Z, Andraous LG, Shukla D, Shariff MY, Makki MM, George TT, Khan SS, Thomas SH, Cameron PA. Emergency Physician Interpretation of Point-of-care Ultrasound for Identifying and Grading of Hydronephrosis in Renal Colic Compared With Consensus Interpretation by Emergency Radiologists. Acad Emerg Med. 2018 Oct;25(10):1129-1137. doi: 10.1111/acem.13432. Epub 2018 May 28. PMID: 29663580.
  11. Wong C, Teitge B, Ross M, Young P, Robertson HL, Lang E. The Accuracy and Prognostic Value of Point-of-care Ultrasound for Nephrolithiasis in the Emergency Department: A Systematic Review and Meta-analysis. Acad Emerg Med. 2018 Jun;25(6):684-698. doi: 10.1111/acem.13388. Epub 2018 Mar 25. PMID: 29427476.
  12. Kim SG, Jo IJ, Kim T, et al. Usefulness of Protocolized Point-of-Care Ultrasonography for Patients with Acute Renal Colic Who Visited Emergency Department: A Randomized Controlled Study. Medicina (Kaunas). 2019 Oct 28;55(11):717. doi: 10.3390/medicina55110717. PMID: 31661942; PMCID: PMC6915595.
  13. Sibley S, Roth N, Scott C, et al. Point-of-care ultrasound for the detection of hydronephrosis in emergency department patients with suspected renal colic. Ultrasound J. 2020 Jun 8;12(1):31. doi: 10.1186/s13089-020-00178-3. PMID: 32507905; PMCID: PMC7276462.
  14. Chandra A, Zerzan J, Arroyo A, Levine M, Dickman E, Tessaro M. Point-of-care ultrasound in pediatric urolithiasis: an ED case series. Am J Emerg Med. 2015 Oct;33(10):1531-4. doi: 10.1016/j.ajem.2015.05.048. Epub 2015 Jun 23. PMID: 26321169.
  15. Ng C, Tsung JW. Avoiding Computed Tomography Scans By Using Point-Of-Care Ultrasound When Evaluating Suspected Pediatric Renal Colic. J Emerg Med. 2015 Aug;49(2):165-71. doi: 10.1016/j.jemermed.2015.01.017. Epub 2015 Apr 29. PMID: 25934378.
  16. Gillon JT, Cohen SG. Diagnosis of Posterior Urethral Valves in an Infant Using Point-of-Care Ultrasound. Pediatr Emerg Care. 2021 Aug 1;37(8):435-436. doi: 10.1097/PEC.0000000000002393. PMID: 34397679
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