COTW 6/11: 5 year old boy presents in respiratory distress

5 year old boy, without any past medical history, presents in respiratory distress.

He is tachypneic, with mild decrease in mental status, and requiring NRBR for respiratory support.

He is currently being treated for a pneumonia

As always, you grab the ultrasound…

You start with your parasternal long view…

You notice that you have to move your probe pretty lateral on the child’s chest in order to get your PLAX view..

You also notice that there is an echogenic structure medial to the cardiac border. Do you guys see the heterogeneous structure? You are certain that its not the liver… and finally figure out that its likely a mass.

On this view, you can still see the mediastinal mass anterior to the cardiac border

The mediastinal mass obstructs your ability to get great PLAX views-> so you aim for the apical 4 chamber which allows you to evaluate cardiac LV function. This is key in a child with respiratory distress and hypoxemia. Particularly if you are worried about CHF or myocarditis.

Such a smart move! Grab the linear probe and take a close look at the mediastinal mass.

Here, the crew is assessing for any blood flow within the structure.

This kiddo was pretty ill. Over time, his mental status declined, he started retaining and he was intubated for respiratory failure. His labs were notable for WBC 142 K… In the setting of hypoxemia, large mediastinal mass and markedly elevated leukocytosis -> highly concerning for leukemia or lymphoma. He was transferred to Rady Children’s for further workup and management- where the leading diagnosis appears to be ALL. On his CT imaging he had a huge mediastinal mass with main bronchus compression and right middle lobe consolidation.