A 64 year old male with a PMH of asthma, hypertension and Type 2 Diabetes presented with gradual onset central chest tightness worse on exertion, associated shortness of breath and feeling hot for 8 days. He had no other symptoms of note.
Examination revealed scattered bibasal crackles on auscultation but no other abnormalities.
SpO2 93% RA, 80% on exertion. HR96, T37.5, RR20, BP 136/78.
He had a lung ultrasound and bedside echo:
The echo is essentially normal, with no signs of right heart strain nor LV dysfunction. The focus here is on the lung ultrasound.
There are diffuse B-lines that in many places are coalescing, pleural irregularity and areas of sub-pleural consolidation. Remember, B-lines represent ‘alveolar-interstitial syndromes’ (pulmonary oedema, inflammation). We see these most commonly in pulmonary oedema. However, given a normal bedside Echo and especially the pleural thickening and sub-pleural consolidation, this is highly suggestive of a diffuse inflammatory process which in this case is most likely COVID-19 pneumonia.
This patient was admitted under the medical team. As he had a normal lymphocyte count, low CRP, was tachycardic and had pleuritic chest pain he had a CTPA which was reported as:
“No pulmonary embolism identified. Bilateral new peripheral ground-glass opacification is highly suspicious of COVID-19 pneumonia. Correlation with RT-PCR is recommended”
Lung Ultrasound in COVID-19:
Lung ultrasound has been put to great use in the COVID-19 pandemic in many countries, from streaming patients to tracking progression of disease in ICU and titrating therapy according to findings, and more evidence continues to be published on it’s utility. The sensitivity of Lung Ultrasound for signs of viral pneumonia is considerably higher than chest XR and approaches that of CT.
The classic findings in viral pneumonia are:
- B-lines, focal and confluent
- Irregular or thickened pleural line
- Sub-pleural consolidation
- Small or no pleural effusions (large effusions are uncommon in COVID-19)
- Dense consolidation with air bronchograms in more severe disease
Lung ultrasound can identify features strongly supporting a diagnosis, map progression of disease and most importantly assess for alternative diagnoses (e.g. pneumothorax, pleural effusions).
- Moore S, Gardiner E. Point of care and intensive care lung ultrasound: A reference guide for practitioners during COVID-19. Radiography (Lond). 2020 Nov;26(4):e297-e302. doi: 10.1016/j.radi.2020.04.005. Epub 2020 Apr 17. PMID: 32327383; PMCID: PMC7164867.
- Shumilov E, Hosseini ASA, Petzold G, Treiber H, Lotz J, Ellenrieder V, Kunsch S, Neesse Comparison of Chest Ultrasound and Standard X-Ray Imaging in COVID-19 Patients. Ultrasound Int Open. 2020 Sep;6(2):E36-E40. doi: 10.1055/a-1217-1603. Epub 2020 Sep 2. PMID: 32905446; PMCID: PMC7467801.
- Peng QY, Wang XT, Zhang LN; Chinese Critical Care Ultrasound Study Group (CCUSG). Findings of lung ultrasonography of novel corona virus pneumonia during the 2019-2020 epidemic. Intensive Care Med. 2020