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Emergency Ultrasound

Case Report: Seemingly Healthy College Student with Foot Pain

Amy Flores, MD, Meghan Kelly Herbst, MD, FACEP, and Samuel Lam, MD, FACEP

Chief Complaint: Bilateral Foot Pain and Numbness

  FootPain1  

FootPain2   FootPain3  
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Questions:

  1. Why did this otherwise young healthy male without chest pain have an abnormal electrocardiogram (EKG) and bilateral foot pain?
  2. Describe the abnormality on this patient’s parasternal short axis view.
  3. Describe the abnormality on this patient’s parasternal long axis view.


Case Presentation:

A 24-year-old male college student presented with bilateral foot pain and numbness that began progressively after playing basketball that evening. He stated he could not bear weight or move his feet. When asked about any trauma during the game, he stated the basketball had hit his chest, but “not hard,” and denied any chest pain. He denied any shortness of breath, fever, abdominal pain, lightheadedness, palpitations, change in vision, or headache.

On exam, he was well appearing and in no distress. Both feet and ankles were pale and cold to the touch, but warmer and pink proximal to the ankle. Bilateral dorsalis pedis and posterior tibial pulses were absent with palpation and with Doppler, but femoral pulses were palpable. He had full range of motion at all joints with the exception of the ankles and toes bilaterally. He additionally had no sensation distal to the ankles bilaterally.

Vascular surgery was promptly consulted secondary to the absence of pulses. EKG revealed ST elevations in the anterior leads. Emergency cardiac ultrasound demonstrated poor left ventricular squeeze and a mass in the left atrium. Cardiothoracic surgery was emergently consulted and heparin was initiated. Computed tomography (CT) chest imaging confirmed a 4cm by 3cm mass in the left atrium connected to the left interatrial wall consistent with a left atrial myxoma. He was taken emergently to the operating room for bilateral lower extremity embolectomies and bilateral fasciotomies and open heart surgery for left atrial myxoma removal.

Role of Emergency Cardiac Ultrasound in Patients with Abnormal EKGs:

Emergency cardiac ultrasound has been shown to have significant impact on medical decision-making and is a useful adjunct to the clinical exam when other radiologic and laboratory studies are often unreliable and nonspecific.1,2 In the setting of an abnormal EKG, emergency ultrasound of the heart including evaluation of left ventricular contractility, pericardial effusion, aortic outflow tract dilatation, IVC status, and the right-to-left ventricle ratio may help to differentiate primary cardiac from non-cardiac pathologies.3,4

Cardiac myxomas occur in up to 0.28% of the population. Approximately 75% are located in the left atrial cavity.5 Myxomas can be difficult to diagnose because they often present with symptoms that mimic other disease processes.6 Patients most commonly present in acutely decompensated heart failure, but cerebrovascular accidents (CVAs), pulmonary emboli, and cutaneous infarctions are also frequent presentations secondary to brain, peripheral and pulmonary artery embolization.6-8 Echocardiography has been established as the most useful diagnostic modality due to its availability, portability, and safety, but CT and magnetic resonance imaging can also be used. 6,8 In this case, a cardiac mass was incidentally found in the left atrium by emergency ultrasound meant to evaluate left ventricular function in the setting of an abnormal EKG, which resulted in expedited diagnosis and management of the case.

Answers to Questions:

  1. In this case the abnormal EKG reflects acute myocardial ischemia secondary to showering emboli to the coronary arteries. The patient’s foot pain is secondary to peripheral ischemia secondary to systemic embolization.
  2. The parasternal short view of the heart shows poor squeeze, and echoes within the chamber (referred to as “smoke”) reflect a low flow state.9 This is likely secondary to ischemic heart failure.
  3. The parasternal long view of the heart shows a large mass in the left atrium moving independently from the cardiac wall and valves. Its presence is causing turbulence and non-laminar flow in the left atrium, which increases the risk of clot formation. The aortic outflow tract measures less than 4 cm.


Take Home Points:

  1. Emergency cardiac ultrasound is a useful adjunct for assessing patients with abnormal EKGs and confusing clinical pictures.
  2. Atrial myxomas can result in heart failure, stroke, pulmonary emboli, cutaneous infarctions, and other disease processes that may make diagnosis difficult.
  3. Emergency cardiac ultrasound provides a timely, safe, and effective way to diagnose a myxoma.


References:

  1. Reardon R, Joing S. Cardiac. In: Ma O, Mateer J, Blaivas M. Emergency Ultrasound. 2nd ed. New York: McGraw Hill; 2008. pp. 109–48.
  2. Levitt M, Jan B. The effect of real time 2-D echocardiography on medical decision-making in the emergency department. J Emerg Med. 2002;22:229–33.
  3. Arntfield RT, Millington SJ. Point of care cardiac ultrasound applications in the emergency department and the intensive care unit--a review. Curr Cardiol Rev. 2012;8:98-108.
  4. Labovitz AJ, Noble VE, Bierig M, et al. Focused Cardiac Ultrasound in the Clinical Setting: A consensus statement of the American Society for Echocardiography and the American College of Emergency Physicians. J Am Soc Echo. 2010;23(12):1225-30.
  5. Meng Q, Lai H, Lima J, et al. Echocardiographic and pathologic characteristics of primary cardiac tumors: a study of 149 cases. Int J Cardiol. 2002;84:69-75.
  6. Frizell AW, Higgins GL. Cardiac myxoma as a mimic: a diagnostic challenge. Am J Emerg Med. 2014;32:1399-1404
  7. Reynen K. Review Articles: Cardiac Myxoma. N Engl J Med. 1995;333:1610-1617
  8. Torregrossa J, Perera P, Mailhot T, et al. Ultrasound diagnosis of a left atrial myxoma in the emergency department. West J Emerg Med. 2013;14:130-131.
  9. Black IW. Spontaneous echo contrast: where there’s smoke there’s fire. Echocardiography 2000; 17(4): 373-382.

 

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