Pulmonary embolism on endobronchial ultrasound

A 33-year-old ex-smoker, morbidly obese man presented with symptoms of orthopnoea, oedema and blood-tinged sputum. On physical examination, he exhibited signs consistent with acute pulmonary oedema, necessitating oxygen supplementation. He has a history of percutaneous coronary intervention to the left anterior descending coronary artery, performed a few years ago. A clinical diagnosis of congestive heart failure was confirmed after echocardiography showed a left ventricular (LV) ejection fraction of 15%. CT of the thorax performed for blood-tinged sputum showed cardiomegaly and mediastinal lymphadenopathy without suspicious lung lesions. Diuresis was initiated, resulting in symptom improvement, and the patient was discharged without complications. An endobronchial ultrasound (EBUS) performed a month later for investigation of isolated mediastinal lymphadenopathy showed significant regression in lymph node size, with a benign appearance likely related to underlying congestive heart failure. However, on examination at the right hilar region, an intravascular hyperechoic mass was noted within the lumen of the right pulmonary artery ( arrow, figure 1A). The Doppler signal was positive surrounding the mass, raising suspicion of an intravascular thrombus (figure 1B and online supplemental video 1). An urgent CT of the pulmonary artery (CTPA) was arranged, confirming pulmonary embolism (PE) of the right main …