A46-11 Lung Ultrasound Unveiling Pyopneumothorax in aPatient With Acute Dyspnea

Abstract Introduction Pyopneumothorax secondary to esophageal rupture is a life-threatening emergency that requires rapid diagnosis and intervention. Point-of-care ultrasound (POCUS) can be invaluable in the emergency setting to promptly identify the etiology of acute dyspnea and guide management. Case Presentation A 40-year-old female presented with acute-onset breathlessness and non-productive cough for two days. She was a recently diagnosed case of carcinoma of the esophagus confirmed by upper gastrointestinal endoscopic biopsy and was awaiting surgical management.On examination, the patient was dyspneic at rest with a respiratory rate of 34/min, febrile (102 °F), tachycardic (heart rate 112/min), and hypotensive (blood pressure 90/60 mmHg), consistent with septic shock. Chest examination revealed absent breath sounds over the left hemithorax.POCUS demonstrated normal lung sliding with A-lines on the right lung fields. On the left side, the anterior upper zone (L1) showed absent lung sliding and lung pulse with A-lines, suggestive of pneumothorax. The mid-zone (L2) revealed pleural fluid containing hyperechoic floating particles—the “plankton sign”—indicative of pyothorax or hemorrhagic effusion. The lateral upper zone (L4) demonstrated the coexistence of pleural fluid with planktons on one half and a rapidly moving pleural line with A-lines on the other, consistent with the hydro-point , representing the air-fluid interface diagnostic of hydropneumothorax. In M-mode, a swirl sign( figure 1)was also noted at the same level.An intercostal chest tube was inserted, draining approximately 2.5 liter of pus mixed with food particles. The patient subsequently underwent partial esophagectomy with gastric pull-through surgery. Discussion POCUS is an indispensable bedside tool for differentiating causes of acute dyspnea. The presence of a hydro-point together with the plankton sign confirms pyopneumothorax with high specificity, analogous to the lung point in pneumothorax. The hydro-point corresponds to the air-fluid interface where pleural effusion appears anechoic and the pneumothorax component appears as a moving “curtain” with preserved A-lines and no lung sliding or pulse. This finding was first described by Volpicelli et al., and Lichtenstein demonstrated the swirl sign on M-mode representing alternating air and fluid phases. Conclusion This case highlights the critical role of POCUS in the rapid diagnosis of pyopneumothorax secondary to esophageal rupture. Early recognition of key sonographic signs—hydro-point, plankton sign, and swirl sign—can expedite diagnosis and life-saving management in the emergency department. This abstract is funded by: None