CHEST Guidelines-An-87-Year-Old-Man-With-Unique-Bedside-Ultrasound-

An-87-Year-Old-Man-With-Unique-Bedside-Ultrasound-

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The case report discusses an 87-year-old man with a complex medical history who presented with progressive swelling and discoloration of the right lower extremity. Initial evaluations, including exploratory surgery, did not provide a clear diagnosis but revealed an intramuscular hematoma. Subsequent imaging noted a cirrhotic-appearing liver and other investigations ruled out thrombosis. A notable event occurred on the third postoperative day when a bedside point-of-care ultrasound (POCUS) identified echogenic particulate matter (PM) in the inferior vena cava and right atrium, a finding different from the more common spontaneous echo contrast (SEC).<br /><br />The sudden appearance of PM was found just before the patient experienced acute clinical decompensation characterized by a significant increase in white blood cell count and the presence of blasts on the differential count, indicating a potential leukemic transformation. A peripheral smear confirmed neutrophilia and circulating blasts, suggesting myelodysplastic or myeloproliferative disorder, despite negative blood cultures throughout the hospital stay.<br /><br />PM detected during the ultrasound is associated with embolic processes, often due to air bubbles, amniotic fluid, or fat emboli, contrasting SEC's smoke-like appearance, which is related to red blood cell aggregation in certain circulatory conditions. In this case, the PM might have resulted from acute myeloid leukemia transformation and leukostasis, a condition previously unreported in medical literature as PM on POCUS. The findings highlight the potential for POCUS to detect significant hematological changes, such as leukemic transformations, before they manifest in standard lab results. The case underscores the diagnostic utility and significance of distinguishing PM from SEC in patients with complex medical histories.

Keywords

intramuscular hematoma

point-of-care ultrasound

echogenic particulate matter

inferior vena cava

leukemic transformation

myelodysplastic disorder

myeloproliferative disorder

diagnostic utility

embolic processes

acute myeloid leukemia