Dominga (pictured above) is a 68yo female with a history of COPD. She presented to our clinic in rural Guatemala a couple of days before Christmas with a two week history of worsening cough and shortness of breath. She was evaluated by Dr. Sina, a resident physician visiting from Ventura, CA.
He quickly noted that our patient had increased work of breathing and was hypoxic. Her oxygen saturation on room air was 81% a the time of her presentation.
Labs and imaging were obtained. Simultaneously, treatment was initiated. Our patient's labs were unremarkable. Conversely, her imaging was noteworthy for several abnormalities.
Dominga's echocardgiogram revealed an abnormal right ventricle to left ventricle ratio (with normal being ~2:3 and our patient's RV:LV ratio closer to 1:1).
The wall of her right ventricle was thickened (>5mm is typically considered abnormal).
The above two findings are not terribly surprising and are consistent with our patient's history of chronic lung disease leading to chronic right sided heart strain.
Lung ultrasound was notable for scattered B-lines, dynamic air bronchograms, an irregular pleural line, and evidence of consolidation at the base of her right lung. Specifically, her right lung had a "shred sign."
"An irregular border often exists between the consolidated and normal lung tissue and is sometimes appreciated by ultrasound resulting in what is
known as the 'shred sign'"(1).
Our working diagnosis was acute pneumonia and exacerbation of chronic obstructive pulmonary disease. Dominga received supplemental oxygen, nebulizer treatments, systemic steroids, and antibiotics. Her work of breathing improved as did her oxygenation. She was able to be discharged to home in improved and stable condition with her two young grandchildren (the only family members that had accompanied her to clinic as our patient was reportedly watching the children- despite her hypoxia and respiratory distress- while their mother had gone shopping for fireworks to complement their Christmas celebration).
Dominga has followed up a couple of times since that first visit pre-Christmas. She has returned to her baseline health and her oxygen saturation is now back above 90% without the use of supplemental oxygen.
Oxygen normalized. Navidad survived. Bring on 2025!
Thanks to your ongoing support, Dominga and others like her are able to continue to share precious time with their loved ones as we transition into 2025.
Beshara, M., Bittner, E.A., Goffi, A. et al. Nuts and bolts of lung ultrasound: utility, scanning techniques, protocols, and findings in common pathologies. Crit Care 28, 328 (2024). https://doi.org/10.1186/s13054-024-05102-y