Ultrasound for Critical Care Physicians: An Unexpected Target Lesion

Jantsen Smith, MD

Department of Internal Medicine

University of New Mexico Hospital

Albuquerque, NM USA

A 39-year-old woman was admitted to the hospital for shortness of breath. Her medical history was significant for human immunodeficiency virus infection (not on anti-retroviral therapy), superior vena cava (SVC) syndrome with history of SVC stenting, cerebrovascular accident complicated by seizure disorder and swallowing difficulties, moderate pulmonary hypertension, end-stage renal disease on hemodialysis with past episodes of acute hypoxic respiratory failure related to fluid overload. Shortly after admission, the patient experienced a cardiac arrest due to hypoxia and necessitated emergent intubation. This was presumed to be due to fluid overload. Nephrology was consulted for emergent dialysis (the patient had a right upper extremity fistula for dialysis access). Dialysis was initiated through a right arm fistula. On day three of admission, the patient was noted to have worsening right upper extremity and breast swelling and pain. Physical exam revealed indurated edema of the skin of the breast. Point of care ultrasound was performed of the patient’s right neck, and the following ultrasound was obtained approximately 4cm above the clavicle in the right lateral neck.

Video 1. Ultrasound image of the right neck in the transverse plane.

What is the most likely cause of this patient’s right upper extremity and breast swelling? (Click on the correct answer for an explanation).

1. Right breast cellulitis
2. Ascending SVC thrombus
3. Lymphatic blockage of right axillary nodes
4. Fluid overload complicated by third spacing in the R upper extremity

Cite as: Smith J. Ultrasound for critical care physicians: An unexpected target lesion. Southwest J Pulm Crit Care. 2019;18(3):63-4. doi: https://doi.org/10.13175/swjpcc011-19 PDF