An initial description of a sonographic sign that verifies intrathoracic chest tube placement.

PURPOSE: An initial description of a sonographic finding predictive of intrathoracic chest tube placement. METHODS: This was a prospective observational study using unembalmed cadaveric models. Chest tubes were randomly placed intra- and extrathoracically and evaluated using ultrasound. Chest tube location was confirmed using blunt dissection followed by tactile and visual confirmation. Sonographers were blinded to chest tube position. Sonographic images obtained in a transverse orientation revealed a subcutaneous hyperechoic arc, created by the chest tube, at the insertion site. The path of the hyperechoic arc was followed cephalad. Disappearance of the hyperechoic arc signified intrathoracic chest tube placement. In contrast, continuation of a subcutaneous hyperechoic arc for the full length of the chest tube signified extrathoracic chest tube placement (the Disappearance/Intrathoracic, Continuation/Extrathoracic sign). RESULTS: Ultrasound was used to evaluate 48 chest tube placements. All chest tube locations were identified correctly. In differentiating intra- vs extrathoracic chest tube placement, the Disappearance/Intrathoracic, Continuation/Extrathoracic sign revealed a sensitivity of 100% (95% confidence interval, 83%-100%) and a specificity of 100% (95% confidence interval, 83%-100%). CONCLUSIONS: In this small study, bedside ultrasound appears to be highly sensitive and specific in differentiating intra- versus extrathoracic chest tube placement.

Fatal community-associated methicillin-resistant Staphylococcus aureus pneumonia in an immunocompetent young adult.

Severe pneumonia caused by community-associated methicillin-resistant Staphylococcus aureus (MRSA) was reported in children soon after this pathogen emerged in the United States in the 1990s. Genes for Panton Valentine leukocidin, which are present in the majority of community-associated MRSA, are thought to enhance the ability of S aureus to cause necrotizing pneumonia. Despite the rapid spread throughout the United States of community-associated MRSA and related skin and soft-tissue infections, reports of severe pneumonia in adults have been rare. We describe a case of a healthy young adult who initially was treated as an outpatient with levofloxacin for what appeared to be typical community-acquired pneumonia. He soon returned to the emergency department (ED) with rapidly fatal necrotizing pneumonia, associated with hemoptysis, leukopenia, and sepsis syndrome, that was caused by community-associated MRSA carrying genes for Panton Valentine leukocidin. This case highlights the typical features of this form of pneumonia and the need to consider MRSA when evaluating and treating severe pneumonia in the ED. It also raises the question of whether the incidence of this form of pneumonia might be increasing in communities with a high prevalence of community-associated MRSA and whether current pneumonia treatment guidelines should be modified.