Sonography for Beriberi. #POCUS for severe vitamin deficiency coming soon.

Ramping up for our fall trip to southeast Asia.  This year we are excited to start work on a project in Laos where we will be evaluating pediatric patients with severe vitamin B1 deficiency.  Also, commonly called Beriberi.  Did you know you can diagnose and manage Beriberi with ultrasound?  It likely has not crossed your mind unless you have worked in regions with severe vitamin deficiencies, but the literature is out there.  Some anyway.  Surprisingly the spectrum of vitamin B1 deficiency is not well characterized.  We worked over the past year to develop an exam protocol looking at infant brains and hearts for signs of beriberi as part of a Gates Foundation Grant.  Our experience from Laos showed us that due to the mother’s restrictive diets post-partum and cultural food preparation practices (rice washing) infants can present in florid heart failure due to beriberi.  As part of their manage in these endemic regions Vitamin B1 is given intramuscularly and rapid clinical improvement typical ensues.

Echo demonstrates global reduced systolic function.  Cranial has symmetric hyperechoic changes near the putamen, caudate nucleus.

The current plan is to train local Lao sonography technicians to do these exams and patients will be identified and tracked over time.  There will be a two-week training, remote quality assurance, and local oversight by a Lao pediatric cardiologist.  Likely re-visit in 6 months.

After the Lao training, we plan to move onto Hanoi, Vietnam where we will be training the PICU and ED physicians at one of the country’s largest pediatric hospitals in POCUS.  Since we were told they have not had previous training, we will start with the basics and move on to cover resuscitation, echo, lung, FAST, and procedural guidance.  There is an annual EM and critical care conference in Vietnam (VSEM) that runs a POCUS workshop that I know many attend (since I helped teach the course in 2015).

It is looking like fall is all pediatrics all the time!  Pictures to come.

Laos 2017

Practicing in urban southeast Asia a seven-year-old girl presents after several weeks of progressive left leg pain and inability to walk.  Over a month ago the girl had a fever.  Her father was concerned and went to the local pharmacy.  The pharmacy provided the father with an intramuscular injectable anti-pyretic.  The father injected the medicine into her upper left leg.

The patient presented with a fever and was ill appearing.  She was unable to range her left hip or walk due to pain.  There was no apparent cellulitis or subcutaneous abscess.  She was admitted for intravenous antibiotics and fluids.  The admitting physicians were most concerned about a septic joint, but the diagnosis could also be pyomyositis (a common diagnosis in this region).  A radiograph of the left hip and knee were done and interpreted as unremarkable.  All other imaging was unavailable.  A surgical consultation was ordered, but without imaging the surgeon was not willing to attempt any intervention.

Upon our arrival to the hospital we performed a musculoskeletal POCUS of the bilateral hips.  POCUS of the hip joint is best accomplished with the high frequency or linear probe in the pediatric patient, but low frequency probes may be used if the linear probe is unavailable.  To evaluate the hip for an effusion with POCUS begin just medial to the ASIS, in a slightly oblique-sagittal plane.  This will give you a longitudinal view of the hip joint.  Identify the femoral head and acetabulum, followed by the femoral neck inferiorly.  Hip effusions typically appear as an anechoic collection at the femoral head that extends to the femoral neck.  You may also visualize effusions from the lateral position of the patient.

hip case anatomy with fluid collection copy

A collection that is not acute may not appear purely anechoic.  However, there ought to be asymmetry when compared to the contralateral hip.

hip case dual screen copy

A large mass like collection was identified in this patient.  It was initially assumed to be a large joint effusion, but on further evaluation it was less clear if the collection was within the joint capsule or just outside the capsule.  I believed the collection was just outside the joint and likely pyomyositis.  A radiologist at the bedside believed it was most likely within the hip joint.

hip case long fluid collection copyhip case collection in short axis copy

Surgery was re-consulted post imaging and they recommended ultrasound guided diagnostic fluid aspiration.

For this procedure, it is important to identify your landmarks and then take note of nearby blood vessels and nerves.  I mark the location of the vessels so I am sure to avoid them during the procedure.  We used an anterior approach, because the fluid collection was most accessible from this view.  Using the high frequency probe, sterile technique, follow a large gauge (18) spinal needle in-plane (longitudinally) and aspirate fluid.  In this case, we used procedural sedation.

hip case measure depth for procedure copyhip case needle aspiration copy

The procedure was completed without issue, but we were unable to aspirate any fluid.  The reason is unknown, but likely due to the chronic nature of the infection and the now near solid consistency of the collection.

Without aspiration of fluid the surgeon was not willing to intervene.  Another week went by without significant clinical improvement before the surgeon took her to the operating theater.  The surgeon identified a large collection of purulent fluid just anterior to the left hip joint, but not within the joint space.  It was incised, drained, and irrigated.  The patient’s clinical condition improved on antibiotics.  Her fevers resolved and she appears well now.  Her ambulation improved some and she is using crutches.  Unfortunetaly, at the time of this posting her ESR level remained above 100 and a repeat ultrasound showed re-accumulation of the fluid collection.  More to come….

Laos Friends Hospital for Children (LFHC) is a newly built (about 5 years old now) pediatric hospital in Laung Prabang, Laos.  LFHC was built as a co-venture between the NGO Friends without Borders and the Laos government.  It has a busy outpatient clinic, inpatient ward, small emergency department, small NICU, and a single operating theater.  The model that has been created is to utilize a constant team of foreign trained physicians to work with and train young Lao physicians.  The administrative team does a fantastic job recruiting and bringing in a constantly rotating team of fantastic people from all over the world.  They have fostered an educational environment where there is constant learning and teaching going on.  Formal teaching goes on once a week and Lao physicians also spend dedicated time learning English.  For rotating faculty and residents, the clinical and educational experience is superb.  Our focus during our first trip was to assess the site, teach ultrasound, and help out in the ED.  We now have goals and expectations for POCUS training moving forward and have an established site for trainees and faculty to work and gain valuable pediatric experience.  Our global health and ultrasound fellow will be traveling there once or twice this year and we have at least one senior resident that will do their global health rotation at this hospital.

If you are going as a resident, be prepared to function as a senior resident there as well.  Some big reasons to work and learn at this site is that the diversity of pathology is fantastic, the infectious disease profile is likely very different than what you have seen before, and it is a fun place to work!  The people are great, welcoming and the city of Laung Prabang is a wonderful, safe place to visit.