very short

hi all, i hope u r doing well, y r u lazy these days?

this case was mentioned by dr. Qassim mohammed sultan during my course..and to be onset no one of our group knew the dignosis!!! (do u remeber that day dear mohammed taib?)

A 35 years old male, presented to u with sudden onset of shortness of breath and pin point petechiae all over his body, he has a preceding history of leg trauma that resulted in frature of femur 1 week ago......

what is the probable dignosis? and what test would u perform to support ur dignosis?

Hi Ahmed...How r u ??? i miss u in this 3 day holiday...
I remeber the case very well .... SO :
The Dx is .....
The test is ....
Let's other students answer it .

hi dear, i miss u too...i appreciate ur honesty by not telling the correct diagnosis cuz after all these cases are for our friends benefit....
thanx again...

see u tomorrow...

it seems to be a case of FAT EMBOLISM... I don't know the name of the test ...AM I RIGHT?

well the first thing came to my mind is fat embolism too and i think it is correct but why we dont consider it as ARDS following trauma ?

hello ahmed &mohammed i hope ur doing well i miss u alot .
the most propable dx is fat embolism syndrome and i depend on the following data :
1. there is hx of trauma {we consider the following as +ve for FES :
History
• Trauma to long bone or pelvis, including orthopedic procedures
• Parenteral lipid infusion
• Recent corticosteroid administration
2. also the patient develope sudden sob and pin point petechiae and these are of major criteria for dx of FES which are :Respiratory symptoms, signs or radiologic disease; cerebral signs without other etiologies; and petechial rash .
minor :A pulse that is over 110 beats/min, fever over 38.5ºC, retinal changes of fat globules or petechiae, renal dysfunction, jaundice, acute drop in hemoglobin and/or platelets, and elevated sedimentation rate.
investigation :

Lab Studies
• Arterial blood gas: An otherwise unexplained increase in pulmonary shunt fraction alveolar-to-arterial oxygen tension difference, especially if it occurs within 24-48 hours of a sentinel event associated with fat embolism syndrome, is strongly suggestive of the syndrome.
• Hematocrit, platelet count, fibrinogen: Thrombocytopenia, anemia, and hypofibrinogenemia are indicative of fat embolism syndrome; however, they are nonspecific.
• Urine studies: Urinary fat stains are not felt to be sensitive or specific enough for diagnosing fat embolism or for detecting a risk of it.
•
o Fat globules in the urine are common after trauma.
o Preliminary investigations of the cytology of pulmonary capillary blood obtained from a wedged pulmonary artery catheter revealed fat globules in patients with FES and showed that this method may be beneficial in early detection of patients at risk.
o In the future, genotyping for polymorphisms associated with increased susceptibility to inflammatory stimuli may help identify those at risk of fat embolism syndrome.
• Specific antibody therapy targeting inflammatory molecules has not been useful.
Imaging Studies
• Chest radiography: Serial radiographs reveal increasing diffuse bilateral pulmonary infiltrates within 24-48 hours of onset of clinical findings.
• Noncontrast head CT: Findings from head CT performed because of alterations in mental status may be normal or may reveal diffuse white-matter petechial hemorrhages consistent with microvascular injury.
• Nuclear medicine ventilation/perfusion imaging of the lungs: Performed for suspicion of pulmonary embolus, the findings from this scan may be normal or may demonstrate subsegmental perfusion defects.
• Helical chest CT for pulmonary embolism: As the embolic particles are lodged in the capillary beds, helical CT findings may be normal. Parenchymal changes consistent with lung contusion, acute lung injury, or adult respiratory distress syndrome may be evident. Nodular or ground glass opacities in the setting of trauma suggest fat embolism.
• MRI: Scant data exist regarding MRI findings in patients with this syndrome; however, in one small patient group, multiple, nonconfluent, hyperintense lesions were seen on proton-density– and T2-weighted images.
• Transcranial Doppler sonography: In a small case study, 5 patients with trauma were monitored with intracranial Doppler sonography, 2 during intraoperative nailing of long bone fractures.1 Cerebral microembolic signals were detected as long as 4 days after injury.
• Transesophageal echocardiography (TEE): TEE may be of use in evaluating intraoperative release of marrow contents into the bloodstream during intramedullary reaming and nailing. The density of the echogenic material passing through the right side of the heart correlates with the degree of reduction in arterial oxygen saturation. Repeated showers of emboli have been noted to increase right heart and pulmonary artery pressures. Embolization of marrow contents through patent foramen ovale also has been noted. However, evidence of embolization by means of TEE is not correlated with the actual development of FES.
Procedures
• Bronchoalveolar lavage (BAL) with staining of alveolar macrophages for fat
•
o BAL specimens have been evaluated in trauma patients and sickle cell patients with acute chest syndrome, and the results have been mixed.
o Lipid inclusions commonly appear in patients with traumatic and nontraumatic respiratory failure; the standard cut-off of 5% fat-containing macrophages in the BAL studies results in a low specificity for the test. Some authors suggest increasing the cut-off to 30% to improve specificity.
o Presently, using BAL to aid in the diagnosis or to predict the likelihood of fat embolism syndrome is controversial