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Letter to the Editor

Med Ultrason 2018, Vol. 20, no. 3, 399-404

Hypereosinophilic syndrome with cardiac involvement in a patient with multiple malignancies

Mihaela Ioana Dregoesc


, Adrian Corneliu Iancu


, Alexandra Alina Lazãr


, Şerban Bãlãnescu


1Cardiology Department, “Iuliu Haţieganu” University of Medicine and Pharmacy, Cluj-Napoca, 2“Niculae Stãncioiu”

Heart Institute, Cluj-Napoca, 3 “Elias” University Hospital, “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania

Received 05.05.2018 Accepted 11.06.2018 Med Ultrason

2018, Vol. 20, No 3, 399-400, DOI: 10.11152/mu-1574 Corresponding author: Prof. Adrian C. Iancu

19-21 Calea Moţilor, Cluj-Napoca, Romania, 400001

Phone: +40744751027, Fax: +40264595090 E-mail: [email protected]

To the Editor,

A 72-year-old woman with a history of multiple ma- lignancies was referred to the Cardiology Department in April 2017 for dyspnea on exertion. She had a history of bilateral mastectomy in 1986 for breast cancer and total thyroidectomy in 1993 for papillary carcinoma. In 2015 she underwent a corporeal-caudal pancreatectomy for an intra-ductal papillary mucinous neoplasm. Bone and liver metastases were documented three months prior to the current admission.

On transthoracic echocardiography, an echogenic mass covered the apex and the lateral wall of the left ven- tricle and markedly reduced its cavity. Left ventricular systolic function could not be accurately quantified due to the presence of the intraventricular mass. Moderate mitral regurgitation, a dilated left atrium and a mild peri- cardial effusion were also identified (fig 1 A,B).

Given past medical history, left ventricular metasta- ses were suspected. However, marked peripheral blood eosinophilia (3740/μl), accounting for 53.6% of the cir- culating leukocytes, raised awareness of Loeffler endo- carditis. Cardiac magnetic resonance imaging revealed a non-dilated left ventricle, with an ejection fraction of 50%. Areas of subendocardial hypoperfusion adjoined regions covered by a massive cardiac thrombus, with a

heterogeneous structure, more recent in the periphery and older in its central regions (fig 1 C,D). Subendocar- dial hypoperfusion and thrombus formation represent classic findings in the second stage of eosinophilic en- docarditis [1].

Retrospectively, an increased eosinophil count had been constantly noticed in her blood tests since 2015.

Parasitic infections and allergies were ruled out. The patient was started on anticoagulants and heart failure Fig 1. A – Echocardiography apical five chamber view: an echogenic mass covers the apex and the lateral wall of the left ventricle; B – Echocardiography apical two chamber view: the left ventricular cavity is markedly reduced by an echogenic mass that covers the apex; C – Cardiac magnetic resonance imaging transverse view: massive left ventricular thrombus; D – Cardiac magnetic resonance imaging frontal view: the car- diac thrombus has a heterogeneous structure, more recent in the periphery and older in its central regions.


medication but she declined cytoreductive therapy. The course of the disease was unfavorable. The patient died two months later from sudden cardiac sudden cardiac death.

Paraneoplastic eosinophilia is usually mild, but abso- lute counts may occasionally exceed 1500/μl. These pa- tients may remain asymptomatic or develop signs of end- organ dysfunction many years after the eosinophilia is first noted [2]. The most common mechanisms account- able for hypereosinophilia in patients with malignancies regard the production of cytokines by the primary tumor [3], the eosinophilotactic response due to tumor necrosis or the increased production of eosinophils as a conse- quence of bone marrow invasion [4].


1. Debl K, Djavidani B, Buchner S, et al. Time course of eo- sinophilic myocarditis visualized by CMR. J Cardiovasc Magn Reson 2008;2013:21.

2. Chen YY, Khoury P, Ware JM, et al. Marked and persistent eosinophilia in the absence of clinical manifestations. J Al- lergy Clin Immunol 2014;133:1195.

3. Anagnostopoulos GK, Sakorafas GH, Kostopoulos P, et al.

Disseminated colon cancer with severe peripheral blood eosinophilia and elevated serum levels of interleukine-2, interleukine-3, interleukine-5, and GM-CSF. J Surg Oncol 2005;89:273–275.

4. Rothenberg ME. Eosinophilia. N Engl J Med 1998;338:1592-1600.

A rare sonographic finding for suprascapular nerve entrapment: 

engorged suprascapular artery not vein

Wei-Ting Wu


, Ke-Vin Chang


, Levent Özçakar


, Carlo Martinoli


1Department of Physical Medicine and Rehabilitation and Community and Geriatric Research Center, National Taiwan University Hospital, Bei-Hu Branch and National Taiwan University College of Medicine, Taipei, Taiwan,

2Department of Physical and Rehabilitation Medicine, Hacettepe University Medical School, Ankara, Turkey, 3De- partment of Health Sciences (DISSAL), University of Genoa, Genoa, Italy

Received 09.05.2018 Accepted 10.06.2018 Med Ultrason

2018, Vol. 20, No 3, 400-401, DOI: 10.11152/mu-1579 Corresponding author: Ke-Vin Chang, MD, PhD

Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, Bei-Hu Branch, No. 87 Neijiang St, Wanhua District, Taipei City 108, Taiwan E-mail: [email protected];

[email protected]

To the Editor

A 56-year-old woman has been complaining of chron- ic left shoulder pain for the last one year, after having been forcefully pushed on her left shoulder. She described the pain as intermittent and shooting, and also aggravat- ing during active shoulder movements. On the first visit, Hawkin’s, painful arc and lift off tests were positive, but the shoulder radiography revealed no aspect suggesting fracture or dislocation. The initial ultrasound (US) exami-

nation showed subscapularis and supraspinatus calcific tendinopathies and supraspinatus tendon partial tear. Due to poor response to physical therapy and intermittent tin- gling sensation, she was later on referred for an US fol- low-up. In addition to the previous findings, a well-demar- cated anechoic lesion was noted in the spinoglenoid notch adjacent to the suprascapular nerve, thus giving a positive sono-Tinel sign. The spectral Doppler imaging showed a triphasic waveform, compatible with an artery (fig 1A).

We did not identify a similar pathology on contra-later- al side examination (fig 1B). It appeared as a pulsatile, tube-like structure under power Doppler imaging (fig 1C).

Magnetic resonance imaging (MRI) confirmed the supras- capular nerve entrapment caused by an engorged supras- capular artery (fig 1D) without muscle atrophy.

Suprascapular nerve entrapment is an uncommon cause of chronic shoulder pain that presents with symptoms like numbness, pain and muscle atrophy in longstanding cases.

The causes of entrapment include paralabral cysts (being



Med Ultrason 2018; 20(3): 400-404

the most common), vascular abnormalities (usually dilat- ed veins), transverse scapular or spinoglenoid ligament, bony abnormalities and scars of rotator cuff tears [1].

In our case, the underlying etiology causing the com- pression turned out to be a dilated artery - possibly due to the prior shoulder trauma. While the examiner can evalu- ate the change of pulsatility and collapse of the supras- capular vein under dynamic US imaging (with internal/

external shoulder rotation) [2], we also want to emphasize the importance of contrast-enhanced MRI because US cannot explore the lesion when the artery travels through the osseous tunnel of the scapular spine. The spectral Doppler imaging is also crucial in differentiating whether the lesion has arterial or venous origin. Concerning treat- ment, the imaging findings combined with the patient’s episodic shoulder pain may need suprascapular nerve re- lease through open or arthroscopic techniques [3].

In short, we emphasize the usefulness of US imag- ing while investigating the etiology of suprascapular nerve entrapment whereby the precise diagnosis will

help and/or guide the physician in choosing the best op- tion for treatment.

Acknowledgments: the present study is support- ed by National Taiwan University Hospital, Bei-Hu Branch Ministry of Science and Technology (MOST 106-2314-B-002-180-MY3) and Taiwan Society of Ul- trasound in Medicine.


1. Carroll KW, Helms CA, Otte MT, Moellken S, Fritz R.

Enlarged spinoglenoid notch veins causing suprascapular nerve compression. Skeletal Radiol 2003;32:72-77.

2. Park J, Chai JW, Kim DH, Cha SW. Dynamic ultrasonogra- phy of the shoulder. Ultrasonography 2017; doi: 10.14366/


3. Lafosse L, Tomasi A, Corbett S, Baier G, Willems K, Gob- ezie R. Arthroscopic release of suprascapular nerve entrap- ment at the suprascapular notch: technique and preliminary results. Arthroscopy 2007;23:34-42.

Fig 1. A) Ultrasonographic imaging over the infraglenoid notch (while the probe is being kept parallel to the spine of the scapula) shows the cyst-like lesion (red arrow) next to the suprascapular nerve (yellow arrowhead) at the left shoulder. The spectral Doppler image at right upper corner showing triphasic waveform indicating the suprascapular artery; B) The image at contra-lateral side showing normal finding under short axis view. Red arrow indicat- ing the suprascapular artery; C) Longitudinal view over the lesion showing its curvilinear appearance with some power Doppler signals (red arrows) and the suprascapular nerve (yel- low arrowhead); D) Magnetic resonance imaging (sagittal view) showing the suprascapular artery engorgement (red arrow) along the scapular bone. The hyperintense lesion (curved ar- row) indicating the supraspinatus tendon tear. H: humeral head; IS: Infraspinatus tendon; SS:

supraspinatus tendon.


A new method for ocular ultrasound examination

Juan de Dios Berná-Serna, Pablo Chico-Sánchez, Juan de Dios Berná-Mestre, Guillermo  Carbonell-López del Castillo

Department of Radiology, Hospital Clínico Universitario Virgen de la Arrixaca, IMIB, Ctra. Madrid-Cartagena, 30120, El Palmar (Murcia), Spain.

Received 07.08.2018 Accepted 12.07.2018 Med Ultrason

2018, Vol. 20, No 3, 402-400, DOI: 10.11152/mu-1640 Corresponding author: Juan de Dios Berná-Serna, MD

Departamento de Radiología, Hospital Clínico Universitario Virgen de la Arrixaca, Ctra.

Madrid-Cartagena, 30120 El Palmar (Murcia), Spain

E-mail: [email protected]

To the Editor

Ocular B-mode ultrasonography (US) is a widely used technique for assessing a variety of eye conditions, especially when ophthalmoscopy is not possible due to opacification of the transparent [1-4]. US examination is an accessible, easy, rapid, non-invasive and dynamic tool for the evaluation of the eye [1,4].

Usually the first step in ocular B-mode US is to place a generous amount of ultrasound gel on the eyelid to eliminate the air interface. The problem with this pro- cedure, which is performed with the eyes closed and an abundant amount of gel, is the pain or the discomfort re- ported by patients due to gel seeping into their eyes and to the pressure applied on the eyeball by the examiner with the transducer. Only one study [5] reported the use

of transparent dressings that allows the gel to be applied on these and not directly on the eyelid, so that the pa- tient’s discomfort is potentially eliminated.

The purpose of the present letter to editor is to de- scribe a simple procedure of performing ocular B-mode US using saline solution plus gel moistened gauze.

The ocular US examination consisted in evaluat- ing the eye using the saline-moistened gauze method (GGM) with a 14-5 MHz linear transducer. To perform the eye examination, we previously prepared the saline solution moistened gauze and placed the adhesive plas- ter shaped in “L”. then the gauze was placed over the corresponding eye and secured to the frontal and tem- poral area with the plaster (fig 1a). Gel was applied on the gauze and the transducer was placed gently on the gel (fig 1b). Finally, cross-sectional and longitudinal images were obtained.

The application of saline-moistened gauze on the eye- lid prevents the gel from coming into direct contact with the eye and also prevents the sticky sensation that ha- bitually follows the standard method examination. Fur- thermore, the GGM obtains images of similar quality to those obtained with the standard method (fig 1c,d). The GGM prevents pain or discomfort during ocular B-mode Fig 1. Placement of the moistened gauze over the eye (a). Application of gel on the gauze and positioning the transducer to obtain an axial image of the eye (b). Comparison of images obtained with both methods of ocular B-mode US examination of the same subject.

Axial image obtained using standard method (c). Axial image obtained using moistened gauze plus gel method (white arrows in d).



Med Ultrason 2018; 20(3): 400-404 US examination. Moreover, the procedure is simple, safe

and well tolerated.


1. Bedi DG, Gombos DS, Ng CS, Singh S. Sonography of the eye. AJR Am J Roentgenol 2006;187:1061-1072.

2. Kilker BA, Holst JM, Hoffmann B. Bedside ocular ultra- sound in the emergency department. Eur J Emerg Med 2014;21:246-253.

3. De La Hoz Polo M, Torramilans Lluís A, Pozuelo Segura O, Anguera Bosque A, Esmerado Appiani C, Caminal Mitjana JM. Ocular ultrasonography focused on the posterior eye segment: what radiologists should know. Insights Imaging 2016;7:351-364.

4. Dudea SM. Ultrasonography of the eye and orbit. Med Ul- trason 2011;13:171-174.

5. Roth KR, Gafni-Pappas G. Unique method of ocular ultrasound using transparent dressings. J Emerg Med 2011;40:658-660.

Ultrasound imaging for lateral knee pain: popliteus tendon highlighted

Vincenzo Ricci


, Levent Özçakar


1IRCCS Rizzoli Orthopaedic Institute, Department of Biomedical and Neuromotor Science, Physical and Rehabilita- tion Medicine Unit, Bologna, Italy, 2Hacettepe University Medical School, Department of Physical and Rehabilitation Medicine, Ankara, Turkey

Received 12.06.2018 Accepted 10.07.2018 Med Ultrason

2018, Vol. 20, No 3, 403-400, DOI: 10.11152/mu-1616 Corresponding author: Vincenzo Ricci

IRCCS Rizzoli Orthopaedic Institute, Department of Biomedical and Neuromotor Science, Physical and Rehabilitation Medicine Unit, Bologna, Italy

E-mail: [email protected]

To the Editor,

A 45-year-old male patient was evaluated due to right knee pain for the past four weeks. The pain worsened during running activities especially in the postero-lateral side of the joint, referring to it as a “feeling of constric- tion” around the knee. He denied any trauma or episodes of joint locking and declared that nonsteroidal anti-in- flammatory drugs had been partially effective. Physical examination revealed pain in the popliteal cord and on the lateral side of the knee with negative McMurry and Ap- ley tests. Ultrasound (US) imaging was also performed in accordance with the EURO-MUSCULUS/USPRM knee scanning protocol [1].In addition to the slight amount of fluid in the suprapatellar recess and synovial hypertro- phy of the lateral para-meniscal recesses, a remarkable fluid distension surrounding the popliteus tendon (PT) in the groove of the lateral femoral condyle were observed (fig 1). An oral nonsteroidal anti-inflammatory drug and

low-level laser-therapy were prescribed for 1 week, fol- lowed by a personalized rehabilitation program with spe- cific stretching exercises for the popliteus muscle and the iliotibial band (ITB). After 3 weeks, the patient reported significant pain relief and considerable improvement in walking and running.

Lateral knee pain is really common, especially in runners, whereby the differential diagnosis includes ITB syndrome, lateral meniscal pathology, patella-femoral syndrome, biceps femoris and popliteus tendinopathies [2]. Biomechanically, PT is a major stabilizer of the pos- terolateral knee and overtraining can lead to extra friction between the popliteus tendon, lateral femoral condyle and the lateral meniscus, eventually causing inflammation of the superior lateral para-meniscal recess, which normally functions as an “incomplete sheath” for the PT. Anatomi- cal studies have shown that the popliteal recess is an ex- tra-articular extension of the synovial membrane of the knee joint and that this synovial recess extends from the popliteal hiatus along the proximal part of the PT [3].

Keeping in mind the fact that the capsule-synovial complex is a strongly innervated structure, the synovial popliteus recess is a critical potential pain generator that should be scanned diligently during the assessment of postero-lateral painful knee. Herein, we aimed to under- score that - although there is wide use of US for imaging and guided interventions of knee joint - some structures


are not routinely scanned in the daily US knee examina- tions and also that they might actually be the culprits of recalcitrant knee pain [4].


1. Özçakar L, Kara M, Chang KV, et al. EURO-MUSCULUS /USPRM Basic scanning protocols for knee. Eur J Phys Re- habil Med 2015;51:641-646.

Fig 1. Ultrasound imaging shows the iliotibial band (dotted yellow line), lateral meniscus (dot- ted white line), popliteus tendon (PT) and its groove on the lateral femoral condyle (white arrow). Superior (1) and inferior (2) para-meniscal recesses are marked with dotted red lines.

Inset shows the position of the probe during scanning of the lateral knee in coronal oblique view. LFC: lateral femoral condyle, GT: Gerdy’s tubercle, a: lateral inferior genicular artery

2. Smith J, Finnoff JT, Sante BS, et al. Sonographically guided popliteus tendon sheat injection. J Ultrasound Med 2010;29:775-782.

3. Jadhav SP, More SR, Riascos RF, et al. Comprehensive review of the anatomy, function, and imaging of the pop- liteus and associated pathologic conditions. Radiographics 2014;34:496-513.

4. Chang KV, Wu WT, Özçakar L. Ultrasound-guided diagno- sis and intervention for painful knee: sonoanatomy revis- ited. Pain Manag doi: 10.2217/pmt-2018-0014.



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