SonoCase: 15 yr old diagnosed with pyelonephritis, persistent fevers…back in the ED

This is a guest post from my good friend and colleague, Dr. Zoe Howard, an ultrasound lover and user, part of ACEP’s medical student initiative, and helping us incorporate bedside ultrasound into the medical school curriculum. She had an amazing case where bedside ultrasound helped make the correct diagnosis for a patient who was getting worse, bounced back to the ED, and stayed in an observation unit to be seen by her (and the ultrasound machine) in the morning:

A sweet 15yo girl presented with a week of suprapubic pain and dysuria…that felt like a UTI (which she had a few of before). She was seen in our ED initially with a UA consistent with cystitis (full field whites and many bacteria) and started on ciprofloxacin. Slam dunk right? An enviable length of stay by all standards! But, with worsening abdominal pain she came back 3 days later and was admitted to our observation unit with a presumed diagnosis of pyelonephritis. Something just didn’t sit right with me when I saw her the next morning. She was on appropriate IV antibiotics (we had the culture and sensitivities at this point) and she still continued to be tachycardic and febrile. So who did I turn to? My trusted and most favorite bedside diagnostic partner — the ultrasound machine! As soon as I placed the curvilinear probe on her abdomen right above the pubic symphosis and started scanning the pelvis, I was immediately clued in to this interesting case…and why she wasn’t improving.

Sagittal Pelvis:

Transverse pelvis:

What you can see in the clip is an anechoic, tubular, large fluid-filled mass in the right adnexa with small regions of echogenicity within it, adjacent to the bladder (another anechoic fluid filled structure) which is consistent with hydrosalpinx.

Ultrasound is, of course, the test of choice in this clinical situation and while transabdominal (TA) sonography will give you a broad view of the pelvis and identify pathology that way, transvaginal (TV) sonography allows for an even more detailed and precise visualization of the adnexa. Don’t forget about your bladder requirements though – it will greatly optimize your images! (You want the bladder full for TA and empty for TV)

While my primary concern was looking for tubo-ovarian abscess (TOA), the simple anechoic nature of this patient’s fallopian tube was more consistent with hydrosalpinx – TOA, on the other hand would appear as a more complex structure, likely more hypoechoic with thicker walls and possibly multi-loculated or septated with associated free fluid. Given the setting of fever, pain, and my ultrasound finding, I consulted gynecology who admitted her for IV antibiotics for possible salpingitis/PID.  They did drain the fluid collection (in case it actually was a pyosalpinx) and she ended up doing great. Cheers for bedside ultrasound….once again, making a big difference in the diagnosis and management of our patients!

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