A very scary abscess story
Dr. Andrea Unger is an emergency physician and avid POCUS educator. She has recorded some of the scariest images you will ever see when it comes to abscesses, reinforcing why ultrasound should be a crucial part of your exam of potential fluid collections. [Ed.]
I was asked to come and see a patient, by a concerned nurse, in our department one evening. She had just finished doing an ECG on a 19 year old who came in describing pleuritic chest pain and when she put the leads on his chest she saw an usual skin finding.
He acknowledged that there was a slowly growing red mass just below his sternum that he thought was related to being hit in the chest by a basketball sometime in the previous month. I went to examine him and sure enough he has a raised 3X3 purple mass just below his sternum. It was soft but not overly fluctuant, slightly warm and faded out onto the chest wall circumferentially without a clear border. In retrospect, I would have loved to take a picture.
I thought it was odd because it was so perfectly symmetrical and central. Touching it did not recreate the pain that had prompted him to come in but it certainly seemed to be related. A few minutes of history got a story that besides being hit by the basketball (which seemed like a very minor injury), he had a history of IV drug use. He denied ever using his torso for an injection site. The red raised area had many features of a collection under the skin, although it didn’t look like the classic forearm abscess we all see so frequently.
Because I thought POCUS might help in my assessment, I brought in the linear probe.
Sure enough there was a collection visible but I was also able to visualize a stalk, attached to the mass, that dove down deep under the sternum and appeared to have a pulsatile nature. Not being able to visualize deep enough with the linear probe, I changed to the typical abdominal probe and did a classic Subxiphoid EDE exam. I immediately saw a large mass, sitting up next to the right ventricle exactly where my stalk had left off.
My findings were enough to organize a chest CT and referral to Thoracic Surgery to investigate the sub sternal abscess that pressed up against the pericardium and was now eroding through sternum, eating the cartilage from the inside out. He went on to grow MRSA in his blood cultures and be treated successfully with IV antibiotics inpatient in a tertiary care centre. The abscess never needed to be drained percutaneously, saving the destroyed cartilage from a long drawn out healing process. Without the superficial soft tissue POCUS exam, leading me to find the massive thoracic extension, a casual Incision and Drainage in the ER could have had devastating effects.
