Not all that twinkles is gold.

Abstract

A 53-year-old male presented to the emergency department for decreased urinary stream. He denied any blood, dysuria, or leakage of urine and decreased volume output for 3 days. The patient had a recent computed tomography (CT) scan that only demonstrated a nonspecific enlarged right iliac lymph node. Review of systems oxygen was negative. Laboratory reports showed a creatinine of 1.33 and a negative urinalysis for infection. Point-of-care ultrasound was performed and demonstrated no hydronephrosis bilaterally and a bladder with approximately 110 mL urine. It also demonstrated a small hypere-choic object noted with connection to the bladder with a positive twinkle sign (Video 1, Figure 1, Figure 2). This man with difficulty voiding was found to have a large hyperechoic object that was “twinkling” when color flow Doppler was applied. This twinkle artifact, which focuses on alternating colors behind a rough reflective object appearing as turbulent flow, allowed the providers to conclude that this object was a large stone obstructing urinary outflow. As a result, this patient initially was able to avoid more radiation of a CT scan and decrease time to disposition. The twinkle sign has been studied in other pathology; however, it is most noteworthy in use for nephrolithiasis, indicating a calcified object that may not have acoustic shadowing or may not otherwise be clear due to surrounding grayscale. There are other applications of using the twinkle sign for diagnosis, and recognizing and correlating it clinically can help save a patient's time, radiation, and further discomfort in the emergency department. No special funding was provided for this submission. All edits per editor were acknowledged and implemented. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.