LAUSR

© Author(s) (or their employer(s)) 2022. No commercial reuse. See rights and permissions. Published by BMJ. A21year old woman presented with exertional breathlessness, fatigue and episodic mild haemoptysis for the past 7 months. Peripheral arterial oxygen saturation (SpO2) was 87% on room air. Clubbing and central cyanosis were present. There was no improvement in SpO2 and cyanosis with supplemental oxygen therapy. Chest radiograph revealed a heterogeneous opacity in right upper zone (figure 1A). CT pulmonary angiogram revealed diffuse pulmonary AV malformation (PAVM) involving apical and anterior segments of right upper lobe with multiple pulmonary arterial branches directly communicating with the pulmonary veins (figure 1B). A subcentrimetric area of diffusely enhancing soft tissue attenuation was seen alongside right lower end of trachea adjacent to PAVM, for which endobronchial ultrasound (EBUS) was advised by the radiologist for possible diagnostic sampling to rule out any associated chronic inflammatory lesion. Convex probe (CP)EBUS scanning extending from station 2R to 10R was performed that revealed a large lesion with multiple hypoechoic areas interspersed with hyperechoic areas (figure 1C). Doppler mode of EBUS revealed a ‘mosaicpattern’ indicative of mixing of arterial and venous blood consistent with PAVMs (figure 1D). No other abnormality was detected so no sampling was done. A bubble echocardiogram also confirmed the intrapulmonary shunt. The patient was taken for angioembolisation of PAVM. Multiple feeding arteries were embolised using multiple microcoils and vascular plug. There was a significant improvement in baseline SpO2 from 85% to 94% post angioembolisation. Thin section CT scanning is the imaging of choice to diagnose a PAVM. This also helps in planning the treatment. A good acoustic window to image PAVMs is possible during noninvasive transthoracic ultrasonography when the location of PAVM is close to pleura or only partially embedding the parenchyma. 3 In our patient, since the lesion was located centrally, close to mediastinum, colour Doppler mode during CPEBUS bronchoscopy was able to provide a vivid image of a ‘mosaicpattern’ indicative of PAVM. This is the first report to mention the use of CPEBUS bronchoscopy in being able to detect a PAVM.