Situs Inversus Totalis in the Critical Care Unit: A Case Report and Literature Review

Abstract

Situs inversus is a rare congenital disorder where the reversal of some of the major thoracic or abdominal organs is present. In this disorder, alterations in the fetus's organ lateralization lead to a complete reversal in the arrangement of the internal organs. Most of the time, they are found incidentally when having a procedure or imaging modality. Little has been written regarding the challenges encountered while providing critical care to these patients. Here we present the case of a 68-year-old male patient admitted to the intensive care unit (ICU) with hypoxemic respiratory failure secondary to pneumonia who underwent diagnostic bronchoscopy for organism identification and was confirmed to have situs inversus totalis. Situs inversus totalis represents a challenge at different levels of care to these patients, including in the ICU. Limitations in critical care can be seen upon imaging identification, and during routine procedures performed at the ICU. Confusion might appear while performing bedside point of care ultrasound, obtaining vascular access, performing electrocardiogram, and sample identification, among others. The case brings the relevance of being able to recognize this rare disorder, which can be diagnosed even in advanced age since it might present the clinician with challenges at the time of providing care to patients.

Keywords: anatomic imaging; bronchoscopy; critical care and hospital medicine; pneumology; s: embryology; situs-inversus-totalis.

Figure 1. CI with opacities at right base & prominent cardiac silhouette with dextrocardia.

Figure 2. Initial electrocardiogram of patient. Noted positive aVR, and aVF, with negative I.

Figure 3. Head CT without contrast. Noted left and right chronic infarcts. (A) Demonstrate coronal view. (B) Demonstrate axial view.

Figure 4. Chest CT demonstrating inverted anatomy.

Figure 5. Abdominal imaging with noted right-sided spleen and left-sided liver.

Figure 6. Bronchoscopy results obtain in our patient with SIT.

L = Left; R = Right; LML = Left Middle Lobe; LLL = Left Lower Lobe; LUL = Left Upper Lobe; RLL = Right Lower Lobe; RUL = Right Upper Lobe.

Figure 7. Anatomical variations.

“A” demonstrates situs solitus which is the normal position of abdominal and thoracic organs. “B” demonstrates situs ambiguous describes any abnormal arrangement of abdominal and thoracic organs across the left-right axis. In this case, the heart is the only organ with a change in its axis. Lastly, “C” demonstrates situs inversus totalis, which is the complete transposition or mirror imaging of the normal anatomical position of abdominal and thoracic organs.

Figure 8. Adequate position of leads in a patient with SIT.

By color: Red demonstrate lead V1, yellow lead V2, light blue lead V3, orange lead V4, purple lead V5, and green lead V6.

Figure 9. Appreciation of bronchial tree angulation.

Ventral to dorsal CT images demonstrating by arrows the Trachea (A), Carina (B), and Right and Left primary bronchi (C). Left Primary Bronchi can be appreciated to have a more downward slope compared to the horizontal presentation seen on the Right Primary Bronchi in SIT.