case_images: PMC10865048_01
case_images: Pre EM Titration. Marked cardiac enlargement with increased pulmonary vascularity. Prominent diffuse bilateral pulmonary infiltrates. Remainder unremarkable.
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case_images: fig1
case_images: Chest x-ray obtained after intubation revealed vascular congestion with cardiomegaly versus hypoaeration of the lungs with an enlarged heart and retrocardiac opacity, left lower lobe atelectasis or possibly pneumonia (Figure 1 Pre EM Titration).
case_images: Post EM Titration. Endotracheal tube tip is about 3.9 cm above the carina. NG tube overlies the mediastinum, the tip not seen, and can be confirmed by abdominal radiograph. Diffuse bilateral patchy airspace disease, similar to prior. No large effusions or pneumothorax. Unchanged cardiac size.
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case_images: fig2
case_images: ICU course as his respiratory failure continued to improve on empiric antibiotics and steroids (Figure 2 Post EM Titration). Infectious disease workup was positive for streptococcus pyogenes bacteremia with suspicion for streptococcus pharyngitis. Repeat imaging demonstrated improved aeration (Figure 4 Post EM Titration (admit 2), which correlated with the patient's decreased oxygenation requirements, facilitating rapid discontinuation of inhaled epoprostenol and improvement in his PaO2/FiO2 ratio which precluded the need for prone positioning.
case_images: Pre EM Titration (admit 2). Portable view of the chest is performed. Endotracheal tube is in the right mainstem bronchus and should be repositioned approximately 2-3 cm in the more proximal airway. Pulmonary vascular congestion is present possibly due to hypoaeration of the lungs. Heart appears enlarged. Retrocardiac opacity likely due to left lower lobe atelectasis or possibly pneumonia.
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case_images: fig3
case_images: Chest x-ray revealed marked cardiac enlargement (Figure 3.
case_images: Post EM Titration (admit 2).Marked left lower lobe atelectasis and/or infiltrate. Right lung grossly clear. Tubes and lines grossly unchanged.
case_images: gr4.jpg
case_images: PMC10865048_01_gr4.jpg
case_images: fig4
case_images: Repeat imaging demonstrated improved aeration (Figure 4 Post EM Titration (admit 2), which correlated with the patient's decreased oxygenation requirements, facilitating rapid discontinuation of inhaled epoprostenol and improvement in his PaO2/FiO2 ratio which precluded the need for prone positioning.