A 91-year-old woman with emphysema, heart failure, and remote coronary artery bypass grafting attended the emergency department (ED) with cough, fever, and dyspnea for 3 days. She lived with her son, who had recently tested positive for novel coronavirus disease 2019 (COVID-19). On examination, she had normal mentation, a temperature of 38.8°C (101.8°F), a pulse rate of 110 beats/min, a respiratory rate of 28 breaths/min, and oxygen levels of 91% on room air. On auscultation, she had bilateral coarse inspiratory crackles. The emergency physician performed bedside lung ultrasonography; the most prominent findings were in the right upper posterior lung zone (Figure 1 , Video 1) and left lower posterior zone (Figure 2 , Video 2). Then the physician obtained a confirmatory chest radiograph (Figure 3 ).
Figure 1.
Lung ultrasonography of the right upper posterior zone, demonstrating thickened irregular pleural line (short arrow) and B lines (long arrows). The emergency physician used a curvilinear probe (Sonosite C-60, 5 to 2 MHz; Sonosite, Bothell, WA) with a horizontal probe orientation with multibeam and tissue harmonic imaging presets off. The physician used the 12-zone technique.1 The most noteworthy findings were in the right upper posterior zone and the left lower posterior zone.
Figure 2.
Lung ultrasonography of the left lower posterior zone, demonstrating skip lesion of subpleural consolidation (vertical arrow) but minimal pleural discontinuity. Also note the B line (bracket) with A lines (short arrow) denoting surrounding normal lung tissue. Probe setting same as above.
Figure 3.
Chest radiography showing interstitial infiltrate.
Diagnosis
COVID-19 lung infection. The flocked nasopharyngeal swab demonstrated a positive test result (Cobas Roche 6800 reverse transcriptase–polymerase chain reaction; Roche Canada, Mississauga, Ontario, Canada) within 6 hours.
Ultrasonography is a rapid, repeatable test that minimizes patient transfer and infection concerns. Key features include a thickened, irregular pleural line, “skip” lesions caused by subpleural effusions, and B lines caused by thickened subpleural septa.2, 3, 4, 5, 6 There are no unique ultrasonographic findings in COVID-19, and comorbidities (eg, heart failure) may have similar appearance; as such, the optimal ED utility remains unclear.4 , 5 However, bilateral B lines appear to be one of the strongest clinical predictors of COVID-19 in undifferentiated ED patients,4 and ultrasonographic findings appear correlated with computed tomographic findings in ill patients.2
Footnotes
For the diagnosis and teaching points, see page e66.
To view the entire collection of Images in Emergency Medicine, visitwww.annemergmed.com.
Supplementary Data
Video of the right upper posterior zone. Note the multiple B lines throughout the video and pleura at the top right, progressively more irregular at 0:03.
Video of the left lower posterior zone. Skip lesion with B line particularly visible at 0:03. Note numerous A lines of normal surrounding lung tissue.
References
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Associated Data
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Supplementary Materials
Video of the right upper posterior zone. Note the multiple B lines throughout the video and pleura at the top right, progressively more irregular at 0:03.
Video of the left lower posterior zone. Skip lesion with B line particularly visible at 0:03. Note numerous A lines of normal surrounding lung tissue.