Multiple Bilateral Lobar Pulmonary Emboli Diagnosed With Endobronchial Ultrasound in an Asymptomatic Patient

Abstract

SESSION TITLE: Fellow Case Report Poster - Procedures SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM INTRODUCTION: Endobronchial ultrasound (EBUS) allows real-time visualization of structures adjacent to the airways during bronchoscopy. EBUS is the recommended initial modality for mediastinal staging in lung cancer1 and plays an important role in patients with sarcoidosis, tuberculosis and lymphoma2. So far, there is insufficient data to evaluate the role of EBUS in diagnosis of pulmonary embolus. There are 6 case reports describing diagnosis of central PE, and a pilot study comparing EBUS to CT-angiography which demonstrated 96% accuracy but the bronchoscopists knew the diagnosis and location of the PE prior to EBUS3. We describe a case report of multiple acute bilateral lobar PE diagnosed with EBUS in an asymptomatic patient. CASE PRESENTATION: A 66 y/o man with COPD and h/o smoke exposure was admitted with T6-8 epidural abscess and underwent laminectomy with abscess drainage. Initial CT-Angiogram (CTA) revealed right upper lobe mass suspicious for malignancy without evidence of pulmonary embolus. He was discharged to home and returned for EBUS as an outpatient a week later without respiratory complaints. During EBUS, multiple filling defects were noticed in the bilateral pulmonary arteries and were confirmed with Doppler. As the patient was hemodynamically stable, mediastinal staging was completed which revealed N1 squamous cell cancer of right lung. Post-procedure CTA confirmed multiple PEs at the sites determined by EBUS. No lesion was noticed in central artery by EBUS or CT. Patient was admitted for anticoagulation and further work up. DISCUSSION: EBUS is highly validated in diagnosing malignant and benign lesions adjacent to airways but so far there are no guidelines to define its role in evaluating pulmonary vascular structures. With our case report, we support that EBUS can be a valuable tool in diagnosing PE and evaluating central and lobar vascular structures of the lung. Once validated, EBUS could be highly beneficial as it does not require contrast and can be performed at bedside. CONCLUSIONS: Randomized and prospective studies are required to define the role of EBUS as a primary or alternative tool for diagnosing pulmonary emboli. Reference #1: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2013 May;143(5 Suppl) Reference #2: Technical Aspects of EBUS guided TBNA: CHEST Guideline and Expert Panel Report. Chest. 2016 Mar;149(3):816-35. Reference #3: Endobronchial ultrasound for detecting central pulmonary emboli: a pilot study. Respiration. 2009;77(3):298-302 DISCLOSURE: The following authors have nothing to disclose: Deepankar Sharma, Alexis Smith, Christina Bellinger No Product/Research Disclosure Information