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The article reflects on the symbolism of a photo taken during the pandemic in Kochi prefecture, Japan, evolving from a representation of perseverance to a celebration of community and the connections that bring light to challenging times

Anuurad, Tsetsen

MAGIS 
Volume 17 Issue 1 Article 12 
2023 
Community_Rays of Sunshine 
Tsetsen Anuurad 
Seattle University 
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Recommended Citation 
Anuurad, Tsetsen (2023) "Community_Rays of Sunshine," MAGIS: Vol. 17: Iss. 1, Article 12. 
Available at: https://scholarworks.seattleu.edu/magis/vol17/iss1/12 
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MAGIS: A STUDENT DEVELOPMENT ADMINISTRATION, VOLUME 17  45 
 
Community_Rays of Sunshine 
Tsetsen Anuurad 
 
 
This photo [image description below] was 
taken during the height of the pandemic, in 
April 2020, in Kochi prefecture, Japan. At 
that time, I had already committed to the 
SDA program and was preparing to go back 
to the U.S. in the summer.  
 
During my two years in the SDA program, I 
developed a fondness for this photo and 
started using it in various places, particularly 
as my phone background. Because of the 
continued pandemic, the light seeping 
through the tunnel in the photo came to 
represent, at first, the perseverance I 
developed throughout the program during 
the pandemic. Initially, the light seeping 
through the tunnel in the photo represented 
the perseverance I developed while 
attending the program because of the 
continued pandemic. Eventually, as I started 
to develop relationships and connections in 
the program and at Seattle University, the 
light came to represent the power of 
community or the little rays of sunshine, that 
1
Anuurad: Community_Rays of Sunshine
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MAGIS: A STUDENT DEVELOPMENT ADMINISTRATION, VOLUME 17  46 
 
I saw: The way the students I supervised 
came together to put out welcome events for 
transfer students after two years of virtual 
learning, the way my colleagues showed up 
every morning for our office in the corner, 
the way the 21-22 SUSDA Executive Board 
hopped on Zoom every other Monday night 
to think of ways we could engage full-time 
and part-time students in our program, and 
much, much more.  
 
As I now adjust to a full-time position, I 
have realized that tunnels will continue to 
appear time and time again in my personal 
and professional life, and that the rays of 
sunshine will not always be visible (at least 
not immediately). This, I'm learning, is 
especially true when I get stuck in a me-
against-the-world, or individualistic, 
mindset. When I reflect back on why this 
photo took on meaning during my time in 
SDA, I remember that it is because I started 
to associate it with the power of community 
and connections, which, funnily enough, is a 
flip from when I took this photo, by myself, 
wondering what the next chapters of my life 
would bring. Now, almost three years later, I 
have my answer: Community, and the rays 
of sunshine it brings.  
 
Imagine description: The photo shows a 
gray short tunnel located in rural Japan. A 
metal handrail passes through the tunnel and 
its shadow is reflected on the road. On the 
left-hand corner, the sunlight is seeping 
through and makes the end of the tunnel 
bright. The greenery of the trees and the 
grass on the road contrast with the gray 
color of the concrete tunnel. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
2
MAGIS, Vol. 17 [2023], Iss. 1, Art. 12
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English

Community_Rays of Sunshine

A digital illustration that portrays Seattle University in spring, adorned with blossoms in the air. Accompanying it is a note from the artist:  With the first blossoms of spring and the tiny needle prick from my final vaccine, I am filled with hope. As we move one step closer to \u27normalcy,\u27 we also have a unique opportunity to shape what that new normal will look like. I’m looking forward to it

Barron, Sayuri King

MAGIS: Student Development Journal 
Volume 15 Issue 1 Article 18 
2021 
Campus Blossoms 
Sayuri King Barron 
Seattle University 
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Recommended Citation 
Barron, Sayuri King (2021) "Campus Blossoms," MAGIS: Student Development Journal: Vol. 15: Iss. 1, 
Article 18. 
Available at: https://scholarworks.seattleu.edu/magis/vol15/iss1/18 
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1
Barron: Campus Blossoms
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Campus Blossoms

Lake, Erick

Fragments 
Volume 63 Pivot Article 7 
2021 
Since Vancouver Station 
Erick Lake 
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Recommended Citation 
Lake, Erick (2021) "Since Vancouver Station," Fragments: Vol. 63, Article 7. 
Available at: https://scholarworks.seattleu.edu/fragments/vol63/iss1/7 
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Since Vancouver Station 
Erick Lake 
 
 
 
 
“We’re about to leave The Station, we need the lounge opened. Over.” 
 
“Yeah alright, I’m on my way.” 
 
“Out, girl, use the damn jargon. Over.” 
 
“Out.” 
 
She returned the radio to her belt and took a drag from her cigarette. She rolled the 
burnt end between her gloved fingers and stuffed it in her pocket. He told her that 
she had to quit, so now it was half a cigarette before she left and the other at The 
Station. 
 
She slipped her way out of The Station to reach the employee car. She made her way 
through the business cars, dodging a passenger’s complaints about his seat that were 
rapidly increasing in volume, as if that were her job or she gave a shit. 
 
She entered the lounge car, where there were already several passengers gathered. 
That one in the corner had been in there since Vancouver Station. The way he looked 
at her creeped her out. Didn’t that guy have a seat? When the hell was that guy’s stop? 
He hadn’t even ordered anything. They told her to stop whining, that if that one in 
the corner had a stamped ticket there wasn’t fuck all she could do about it. 
 
Greetings passengers. This is your trusty pilot speaking; I’ll be guiding 
this adventure safely to your destinations. To those who have just 
joined us from The Station, welcome aboard the Pacific Coast 
Moonlight Passenger Train Number Nineteen. We’ll be reaching our 
final destination at … oh … roundabout  
Midnight Twenty-Three.  
 
She heard him chuckle to himself over the intercom and she started to zone off as he 
gave the same spiel he gave at every Station. She could hear his mustache scratch against 
the intercom mic. 
 
1
Lake: Since Vancouver Station
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… Lastly, be sure to stop by the lounge car for drinks, snacks, and 
the best view in the house, at your leisure. Over and Out. 
 
She told her friends that she was in the “restaurant business.” What she did was pour 
watered down coffee and distribute granola bars to people who paid 120 bucks a 
ticket and still had to pay for dinner. The view was nice though. Like leaving every 
Station, she sat and watched the coast go by for hours. 
 
She, startled out of her trance, saw that one in the corner check his watch and then 
get up to approach the bar counter, the first time he’d moved since Vancouver 
Station. The sunlit lounge car full of passengers had turned dark and empty from the 
night without her noticing. Staring at her the entire way, that one in the corner leaned 
over towards her and reached for her. 
 
“You got a cigarette? For later.” 
 
She reached into her pocket and pulled out the cigarette from Vancouver Station, full 
and unburnt. That one in the corner beamed a crooked smile and showed her his 
watch; leaning over the counter, he whispered. 
 
“Midnight Twenty-Three” 
 
Evening passengers, please prepare your luggage for departure.  
Welcome to Vancouver Station. 
2
Fragments, Vol. 63 [2021], Art. 7
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Since Vancouver Station

Ford, Max

Fragments 
Volume 63 Pivot Article 11 
2021 
Three Unsent Letters 
Max Ford 
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Recommended Citation 
Ford, Max (2021) "Three Unsent Letters," Fragments: Vol. 63, Article 11. 
Available at: https://scholarworks.seattleu.edu/fragments/vol63/iss1/11 
This Prose is brought to you for free and open access by ScholarWorks @ SeattleU. It has been accepted for 
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three unsent letters 
Max Ford 
 
 
Ballad, 
I don’t know why you’re still here. I’ve given you every opportunity to just stop in one of these towns, fit yourself in 
the community, make a life for yourself. You’d do great in any of them. But for some reason… you've stayed with me. 
 I can’t... take care of you. Not really. I hope you’ve realized that. It may be my job, but I’m not that good at hunting. It 
was hard enough fending for myself, and I don’t know how long I can keep this up. For your sake and mine, I hope 
you find somewhere you can be, and be happy. Just let me live my life in the grass between the trees. 
I don’t know why I’m writing this. It’s not like I want you to read it. Maybe if I do, I can convince myself to tell you. 
Saul 
 
  
1
Ford: Three Unsent Letters
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Ballad, 
Why am I still waiting for you to leave? You should have found some place to live by now. Over the past few weeks, 
we’ve stopped in maybe a dozen or so towns. You made friends with some farmer or craftsperson or innkeep in every 
last one. When we work in exchange for food or a night’s sleep, there are jobs you really seem to enjoy- caring for 
people’s crops, minor repairs, even just moving bags of grain or other supplies from one place to another. Are you 
even thinking about where you want to end up? You could so easily just start your life anywhere. Why don’t you just do 
it already? 
Why am I still waiting for you to leave? Am I so desperate to be alone again? It’s not like having you with me has been 
bad. Having another voice has been… nice. Comforting. But… I don’t know if I want to get used to that. Someday 
soon, you’ll probably find some town you fit great into, and finally we’ll part ways, leaving me behind like the other 
towns. And then the forest trails will be quiet again. No voice but my own. I don’t know if I’m ready for that. 
Saul 
 
  
2
Fragments, Vol. 63 [2021], Art. 11
https://scholarworks.seattleu.edu/fragments/vol63/iss1/11
 
Ballad, 
I don’t know if you’ve noticed, but I’ve been out of it the past week or so. I hope you noticed. I hope you didn’t. I 
don’t want you to feel you need to stay with me. I’ll… I’ll be fine. I was fine before, and I’ll be fine again. 
There isn’t anything special about me that should be making you stay. I just happened to be the first person to find you 
in the woods that day. Any traveller or wandering salesman could have been the one to save you, I was just the closest. 
And now I’m just the closest when you wake up in the morning, so you happen to follow me out. 
I don’t want to get my hopes up that you staying with me for this long means anything. You just haven’t found 
somewhere or… someone better, so you stay with me. Floating from one town to the next, not yet belonging 
anywhere. For you I hope there is a yet. I hope you find a place to call home, a house, a bed, a family. But I… I don’t 
want to hope that that could be me.  
I don’t know why I’m writing this. It’s not like I want you to read it. Maybe if I do, I can convince myself to tell you. 
Saul 
3
Ford: Three Unsent Letters
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Three Unsent Letters

Bhattacharya, Oishi

Fragments 
Volume 63 Pivot Article 30 
2021 
It's Anxiety 
Oishi Bhattacharya 
Follow this and additional works at: https://scholarworks.seattleu.edu/fragments 
Recommended Citation 
Bhattacharya, Oishi (2021) "It's Anxiety," Fragments: Vol. 63, Article 30. 
Available at: https://scholarworks.seattleu.edu/fragments/vol63/iss1/30 
This Poetry is brought to you for free and open access by ScholarWorks @ SeattleU. It has been accepted for 
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It’s Anxiety 
Oishi Bhattacharya 
 
 
 
Wrap around my spine, lock and snap me, 
take my breath in its captivating eyes 
to break me down to screaming cries. 
Soundless the being has met me 
to take the words locked in my throat 
and tear me down to wit’s end. 
From behind it traps me in a vacuum of sightless chaos 
wherein a breathless being falls prey to the chokehold of an invisible predator. 
I am held upon the thin line between impossible and possible, 
and this beast, this creature, this hand of claws rips me from the clutches of possibility to 
tear my heart and mind down to nothingness. 
1
Bhattacharya: It's Anxiety
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It\u27s Anxiety

Lindsey, Rose

introducing the centerpiece

Gil, Alejandra

Seattle University 
ScholarWorks @ SeattleU 
Bachelor of Science in Diagnostic Ultrasound 
Projects College of Nursing 
6-1-2025 
Mitral Valve Vegetation: A Case Study 
Alejandra Gil 
Seattle University 
Follow this and additional works at: https://scholarworks.seattleu.edu/dius-projects 
Recommended Citation 
Gil, Alejandra, "Mitral Valve Vegetation: A Case Study" (2025). Bachelor of Science in Diagnostic 
Ultrasound Projects. 10. 
https://scholarworks.seattleu.edu/dius-projects/10 
This Article is brought to you for free and open access by the College of Nursing at ScholarWorks @ SeattleU. It 
has been accepted for inclusion in Bachelor of Science in Diagnostic Ultrasound Projects by an authorized 
administrator of ScholarWorks @ SeattleU. 
Case Study    
 
   
 
Mitral Valve Vegetation: A Case Study 
 
Alejandra Gil 
 
Abstract 
Endocarditis is an infection that is caused by bacteria, fungus, or other germs entering the blood 
stream targeting the heart's endocardium or heart valves. Symptoms vary from person to person. 
It is a rare infection. This case study goes over a 49-year-old patient admitted into the hospital. 
A complete transthoracic echocardiogram was ordered to rule out any vegetations. The initial 
echo showed no obvious vegetation. A transesophageal echocardiogram was ordered for further 
testing. The patient was transferred two hours away to the nearest hospital that could perform 
the transesophageal echocardiogram. An .8cm vegetation was found in the anterior mitral valve 
that was not shown in the initial echo. This case study shows the importance of closing the gap 
between rural medicine and urban medicine.    
 
Keywords 
Infective endocarditis, Staph aureus, Vegetation, Transesophageal echocardiogram 
 
Infective endocarditis is a rare condition with a 
high mortality rate if left untreated. 3-10 people 
out of 100,000 develop endocarditis. It can be 
caused by bacteria entering the bloodstream. 
There is also non-infective endocarditis, which 
can also be called non-bacterial thrombotic 
endocarditis. Both affect the valves of the heart. 
Both have a set of symptoms that vary from 
patient to patient. The Duke criteria is used to 
diagnose infective endocarditis.   
 
 Patients in rural areas often experience gaps 
in treatment compared to patients receiving 
care in urban areas. Patients are often 
transferred to other hospitals in rural areas to 
get the medical care they need. There are 
other barriers that affect patient care in rural 
areas, including but not limited to; provider 
shortages, insurance, and transportation. 
 
In this case report, a 49-year-old patient was 
admitted into the hospital to be treated for 
sepsis. Blood culture showed the patient had 
staph aureus.  The patient also presented with a 
new murmur.  A complete transthoracic 
echocardiogram was ordered. Vegetation in the 
AV could not be excluded. A Transesophageal 
echocardiogram was ordered. Due to limited 
resources, the patient was transferred two hours 
away to the nearest hospital for the exam to be 
performed. 
 
 
 
 
 
Case Study    
 
   
 
 
Case Report   
A 49-year-old male was admitted as an in-
patient for sepsis. Blood culture was done to 
know what kind of bacteria the patient had. The 
blood culture showed the patient had a staph 
aureus bacterium. A new, unrecorded murmur 
was heard.  A 2D complete transthoracic 
echocardiogram was ordered for endocarditis 
and to find the source of the new murmur. 
Patient had no previous study for comparison 
 
 
An .8cm vegetation in the anterior mitral valve 
leaflet was found during the transesophageal 
echocardiogram 
 The left ventricular systolic function was 
normal with an EF of 55-60%. The right 
ventricle cavity was mildly dilated. The mitral 
valve was mildly thickened. The aortic valve 
transvalvular velocity measured higher than 
expected at 2.5 m/s, possibly due to coexisting 
AI or underlying illness. AV vegetation cannot 
be excluded. It was recommended to perform a 
transesophageal echocardiogram to rule out 
possible vegetation. The patient was 
transferred to Confluence Health Hospital and 
a transesophageal echocardiogram was 
performed. An .8cm vegetation was found in 
the anterior mitral valve leaflet that was not 
seen in the initial echo. There was moderate to 
severe AR. There was restrictive closing of the 
right coronary cusp in the aortic valve. There 
was no vegetation. There was no obvious 
vegetation in the tricuspid valve. After the 
vegetation was confirmed, no other testing was 
carried out. The patient was treated for the 
vegetation, and a follow-up echo was 
performed a few months later. The followed-up 
echo showed no significant change from the 
prior exam. 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Case Study    
 
   
 
 
 
Discussion   
Infective endocarditis causes vegetation in the 
inflow side of the valve that is affected. In a 
normal echo, the leaflets are thin, and they open 
and close normally. Patient has no symptoms. 
When a patient presents clinical symptoms, 
which may include fever, murmur, and 
shortness of breath, it may be an indication that 
they may have endocarditis. A blood culture can 
be used to confirm the type of bacterial infection 
if there are any. Staph aureus is the most 
common bacteria. If the blood culture is 
positive, then a full transthoracic 
echocardiogram should be done. If no 
vegetation is seen or cannot be excluded, a 
transesophageal echocardiogram should be 
done to further evaluate the valves.    
 
 
In this case study, the patient had a blood 
culture done to see if there were any bacterial 
infections. The sepsis was caused by the 
bacteria staphylococcus. With the 
transesophageal echocardiogram confirming 
vegetation in the mitral valve, two criteria in 
the Duke criteria were met. 
Echocardiography is useful to diagnose 
endocarditis, along with clinical symptoms and 
blood cultures. A transesophageal 
echocardiogram can also be used to further 
diagnose and visualize the vegetation more 
closely. The Duke criteria is used to diagnose 
endocarditis. To be able to diagnose 
endocarditis, the patient must meet either 2 
major criteria, 1 major and 3 minor, or 5 minor 
criteria. There is an updated Duke criteria 
called “modified Duke criteria” which can also 
be used to diagnose. 
 
 
 
 
 
 
There is also non-bacterial or noninfective 
endocarditis. The symptoms also vary with 
each patient. It is also rare. In noninfective 
endocarditis, bacteria do not cause vegetation. 
A sterile palate and fibrin thrombus are 
formed. It is caused by trauma, vasculitis, or a 
hypercoagulable state. An echocardiogram can 
confirm the presence of one. Anticoagulation 
medicine can treat it.  
To treat endocarditis, antibiotics can be used to 
treat it. In severe cases, surgery is needed. It 
can lead to death if left untreated. The valve 
may have to be replaced if the vegetation is 
severe.  
 
 
 
 
 
 
 
 
 
 
 
Case Study    
 
   
 
 
Conclusion   
There is a gap between the care that patients in 
rural and urban areas receive. Patients are often 
transferred to other hospitals in rural areas to 
get more medical care. Barriers include but are 
not limited to provider shortages, insurance, 
and transportation. These barriers can cause 
patients to travel long distances to get the care 
that they need. It also limits what providers can 
provide to their patients. It may delay the care 
they need. It is important to remember that this 
vulnerable population includes children and 
the elderly, whose care is the responsibility of 
their guardian. If their guardian can’t take them 
to their appointments due to transportation, 
then they can’t get the care they need. 
 
 
Some suggestions for improvements could 
be the use of telehealth and the help of 
artificial intelligence. This would help the 
patient with the cost and time spent on 
transportation. Instead of them traveling 
long distances, they can meet with a 
provider at home. The use of AI can 
reduce the burnout of the staff. It can help 
healthcare providers to be able to get the 
information they need to help the patient. 
The use of mobile clinics can also help 
with reducing the disparities of being to 
access care. 
 
 
Ethics Approval                                            Funding 
Ethical approval was not used for this case 
study because it is for educational purposes. 
The author received no financial support for the 
research, authorship, or publication of this article. 
 
Informed consent 
Informed consent was not needed because the 
data was de-identified. 
Declaration of Conflicting Interests 
The author declares that there are no conflicts of 
interest with respect to the research, authorship, and 
publication of this article. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Case Study    
 
   
 
 
 
 
References 
1. Butzner, M., & Cuffee, Y. 
(2021). Telehealth 
interventions and outcomes 
across rural communities in 
the United States: Narrative 
Review. Journal of medical 
Internet research, 23(8), 
e29575. 
https://doi.org/10.2196/29575 
2. Cahill, T. J., Baddour, L. M., 
Habib, G., Hoen, B., Salaun, 
E., Pettersson, G. B., Schäfers, 
H. J., & Prendergast, B. D. 
(2017). Challenges in 
infective endocarditis. Journal 
of the American College of 
Cardiology, 69(3), 325–344. 
https://doi.org/10.1016/j.jacc.
2016.10.066  
3. Cahill, T. J., & Prendergast, B. 
D. (2016). Infective 
endocarditis. Lancet (London, 
England), 387(10021), 882–
893.   
https://doi.org/10.1016/S0140
-6736(15)00067-7 
4. Holland, T. L., Baddour, L. 
M., Bayer, A. S., Hoen, B., 
Miro, J. M., & Fowler, V. G., 
Jr (2016). Infective 
endocarditis. Nature Reviews. 
Disease primers, 2, 16059. 
https://doi.org/10.1038/nrdp.2
016.59 
5. Hurrell, H., Roberts-
Thomson, R., & Prendergast, 
B. D. (2020). Non-infective 
endocarditis. Heart (British 
Cardiac Society), 106(13), 
1023–1029. 
https://doi.org/10.1136/heartj
nl-2019-315204 
 
6. Maganty, A., Byrnes, M. E., 
Hamm, M., Wasilko, R., Sabik, 
L. M., Davies, B. J., & Jacobs, 
B. L. (2023). Barriers to rural 
health care from the provider 
perspective. Rural and remote 
health, 23(2), 7769. 
https://doi.org/10.22605/RRH77
69  
7. Mayo Clinic. (2020). 
Endocarditis - Symptoms and 
causes. Mayo Clinic. 
https://www.mayoclinic.org/dise
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conditions/endocarditis/symptom
s-causes/syc-20352576 
8. Nuotio, J., Vähämurto, L., 
Pahkala, K., Magnussen, C. G., 
Hutri-Kähönen, N., Kähönen, 
M., Laitinen, T., Taittonen, L., 
Tossavainen, P., Lehtimäki, T., 
Jokinen, E., Viikari, J. S. A., 
Raitakari, O., & Juonala, M. 
(2020). CVD risk factors and 
surrogate markers - Urban-rural 
differences. Scandinavian 
Journal of Public Health., 48(7), 
752–761. 
https://doi.org/10.1177/1403494
81986981 
9. Le Bot, A., Jégo, P., Donal, E., 
Flécher, E., Revest, M., & 
Tattevin, P. (2018). Les 
endocardites non infectieuses 
[Non-infective endocarditis]. La 
Revue de medecine interne, 
39(10), 782–791. 
https://doi.org/10.1016/j.revmed.
2018.03.020 
10. Wang, A., Gaca, J. G., & Chu, 
V. H. (2018). Management 
Considerations in Infective 
Endocarditis: A review. JAMA : 
The Journal of the American 
Medical Association., 320(1), 
Case Study    
 
   
 
72–83. 
https://doi.org/10.1001/jama.201
8.7596 
 


Mitral Valve Vegetation: A Case Study

Ortiz, Alyssa

Seattle University 
ScholarWorks @ SeattleU 
Bachelor of Science in Diagnostic Ultrasound 
Projects College of Nursing 
6-1-2025 
Leiomyoma: A Case Report 
Alyssa Ortiz 
Seattle University 
Follow this and additional works at: https://scholarworks.seattleu.edu/dius-projects 
Recommended Citation 
Ortiz, Alyssa, "Leiomyoma: A Case Report" (2025). Bachelor of Science in Diagnostic Ultrasound Projects. 
11. 
https://scholarworks.seattleu.edu/dius-projects/11 
This Article is brought to you for free and open access by the College of Nursing at ScholarWorks @ SeattleU. It 
has been accepted for inclusion in Bachelor of Science in Diagnostic Ultrasound Projects by an authorized 
administrator of ScholarWorks @ SeattleU. 
Case Report 
Leiomyoma: A Case 
Report 
Alyssa Ortiz 
 
Abstract 
Leiomyomas are the most common benign 
gynecologic tumor within the uterus seen in 
premenopausal women. This case report 
describes the diagnostic procedure of 
evaluating leiomyomas with 
ultrasonography on a 35-year-old female 
patient. This patient had a transabdominal 
and transvaginal ultrasound to evaluate the 
uterus, adnexal region, and ovaries. 
Ultrasound showed multiple fibroids with an 
incidental right adnexal simple cyst. This case 
report highlights the importance of treating 
gynecologic symptoms seriously and 
increasing patient education and awareness 
of women’s health-related pathology. 
 
Keywords 
Ultrasonography; Women’s Health; 
Gynecology; Uterus; Leiomyoma 
 
Introduction 
Leiomyomas, or Uterine Fibroids, are benign 
tumors that affect the myometrium of the 
uterus. Leiomyomas affect about 70% of 
women in reproductive age.1  Fibroids can be 
asymptomatic and incidentally found, or can 
cause a variety of symptoms depending on 
their size, location, and quantity. There is 
also a disproportionately higher incidence of 
fibroids in black women compared to white 
women, as well as a greater severity of 
symptoms.2,3  The patient in this case study is 
a 35-year-old black female presenting with 
menorrhagia, or heavy/ prolonged 
menstrual bleeding, with a regular cycle. 
They have a clinical gravida para of G2P0020 
with two SAB (spontaneous abortions).  
 
Case Report 
The 35-year-old female patient was seen at 
an outpatient imaging center for a follow-up 
ultrasound after a visit to the ER department. 
They were seen in the ER with six out of 10 
pain and increased vaginal bleeding. Up until 
the ER visit, the patient denies any history of 
heavy bleeding. The patient’s relevant labs 
appeared to be within normal limits. They 
had no prior ultrasounds or other cross-
sectional imaging available at the time of 
intervention. A transabdominal and 
transvaginal ultrasound was performed. 
Sonographic findings showed 3 leiomyomas. 
Leiomyomas are classified into a category 
known as FIGO (International Federation of 
Gynecology and Obstetrics 2, 4, 5. This system 
assigns a number 0-8 based on a fibroid’s 
location in the uterus in relation to the 3 
different layers; external serosal layer, 
muscular myometrium, and inner 
endometrium. For this patient, fibroid #1 
measuring 25 x 26 x 24 mm is classified as 
FIGO 5 (subserosal/ intramural) located at 
the right lateral wall of the uterus (see 
Figures 1 and 5). Fibroid #2 measuring 15 x 9 
 
Figure 1. Transvaginal imaging of the 
uterus in a sagittal view with caliper 
measurements on a FIGO 5 leiomyoma. 
Ortiz 2 
x 12 mm is classified as FIGO 1 (submucosal) 
located anterior-mid uterus (see Figures 2 
and 5). Lastly, fibroid #3 measuring 28 x 26 x  
28 mm is classified as FIGO 4 (intramural) 
located left lateral wall of the uterus (see 
Figures 3 and 5). There was also an incidental 
finding of a simple para-ovarian cyst 
measuring 13 x 9 x 5 mm located lateral to 
the ovary in the right adnexal region (see 
Figure 4). The patient followed up with a 
gynecologist approximately 1-2 months after 
the initial ultrasound. Since then, the 
patient’s symptoms have resolved thus the 
follow-up recommendation was ultrasound 
surveillance in 8-12 months, unless 
new/worsening symptoms arise.  
 
 
Figure 4. Transvaginal imaging of the 
sagittal right adnexa showing a 
paraovarian simple cyst lateral to the right 
ovary. 
 
 
Figure 5. Transvaginal imaging of the 
uterus in a coronal view showing all three 
leiomyomas in one still image. 1.) FIGO 5, 
2.) FIGO 2, 3.) FIGO 4 
 
Discussion 
Leiomyomas are one of the most common 
benign gynecologic tumors 2. They 
disproportionately affect black women, and 
often get a delay of work-up due to the 
silence around menstruation for female 
adolescents, which carries over into 
adulthood. They appear on ultrasound as 
focal hypoechoic-heterogenous areas in the 
myometrium, which over time can develop 
 
Figure 2. Transvaginal imaging of the 
uterus in a sagittal view with caliper 
measurements on a FIGO 1 leiomyoma. 
 
Figure 3. Transvaginal imaging of the 
uterus in a coronal view with caliper 
measurement on a FIGO 4 leiomyoma. 
 
Ortiz 3 
calcifications. Fibroids will typically have 
posterior acoustic shadowing due to the 
dense nature of this tumor. With color 
doppler evaluation, it is common to see a 
vascular rim surrounding the circumferential 
fibroid 2. A normal uterus will have a smooth 
homogenous myometrium. 
The most common symptoms that women 
present with is abnormal uterine bleeding 
(AUB). Other signs and symptoms include 
heavy menstrual bleeding, irregular 
bleeding, pelvic pressure/ fullness, pelvic 
and or lower back pain, infertility, frequent 
urination, iron deficiency, and anemia 1-3, 6, 7. 
However, symptoms can vary depending on 
the fibroids' size, number, and location. 
Some cases of fibroids are incidentally found, 
with patients being asymptomatic.   
Fibroids have a hormonal dependency on 
estrogen to grow. The more estrogen a 
person has, the larger in size and amount 
fibroids can grow. Otherwise, these tumors 
have a good prognosis as they are benign, 
and are not believed to develop into a 
malignant tumor.  
There are a multitude of options for the 
treatment of fibroids, depending on several 
factors. Some key considerations are a 
patient’s symptoms, concern for fertility, 
conservative versus surgical approach, and 
age 1, 3, 4, 6. The most common treatment 
women pursue for treatment of 
symptomatic uterine fibroids is either a 
hysterectomy or myomectomy. 
Hysterectomy is the most definitive 
treatment plan for those who are not 
concerned about fertility 3. 
 
When considering differentials for 
leiomyomas, adenomyosis is a common 
pathology to rule out. Overlapping clinical 
signs/ symptoms of leiomyomas and 
adenomyosis include heavy and prolonged 
bleeding 2, 6. Ultrasound characteristics of 
adenomyosis involve diffuse enlargement of 
the uterus, typically a bulbous appearance. 
Another common characteristic is venetian 
blind shadowing, whereas fibroids can have 
stark posterior acoustic shadowing due to 
sound beam attenuation and calcifications. 
Dissimilarly, fibroids are more of a focal area 
of heterogeneity with well-defined borders.  
 
Ultrasound is the standard first-choice 
modality for evaluating and diagnosing 
fibroids 2-5. It is the most cost-effective route, 
and readily available to a vast population of 
patients. Transabdominally, it is more 
sensitive to larger fibroids, than are several 
centimeters large. Transvaginally, the 
ultrasound probe used has a higher 
frequency which allows the sonographer to 
evaluate the uterus with better resolution at 
the downside of poor depth penetration. 
Additionally, magnetic resonance imaging 
(MRI) can be utilized to evaluate and 
characterize fibroids. Since fibroids are very 
dense tumors they tend to attenuate much 
of the ultrasound beam, making it difficult to 
fully evaluate a uterus where there are large 
or numerous fibroids present 5.  It is also 
more sensitive at detecting small sub-
centimeter fibroids, and can be useful when 
evaluating submucosal fibroids as it can be 
difficult to appreciate the endometrium in 
some cases.  
 
Conclusion 
This case report reviewed leiomyomas in a 
patient with menorrhagia. Many women are 
hesitant to seek care for gynecological-
related issues, as they either dismiss their 
own symptoms as normal, or fear that their 
care team will be dismissive as well 2, 7. This 
perception can lead to a delay in diagnosis, 
and thus lead to worsening symptoms, 
pathologies, and treatment. It is important 
Ortiz 4 
to note that black women face a disparity 
when it comes to women’s health. They are 
more severely negatively impacted by fibroid 
symptoms and occurrence compared to 
white women. Fibroid and other gynecologic 
symptomology often get overlooked, thus it 
is vital to educate people about women’s 
health and open up about discussions 
regarding menstruation. By having these 
conversations regularly, we can destigmatize 
women’s health, and allow women to feel 
more comfortable sharing their experiences, 
as well as recognizing concerning symptoms. 
Furthermore, more research should be done 
regarding fibroids in black women, and other 
women of color. Racial disparities can play a 
huge role in women’s health, and getting the 
necessary care.  
 
Declaration of Conflicting Interests 
The author declares that there are no 
conflicts of interest with respect to the 
research, authorship, and/ or publication of 
this article. 
 
Ethics Approval 
Ethics approval was not sought for the 
present study because it did not interfere 
with patient care. 
 
Informed Consent 
Informed Consent was not sought for the 
present study because all case data was de-
identified and/or aggregated and followed 
ethics committee or IRB guidelines. 
 
Funding 
The author received no financial support for 
the research, authorship, and/ or publication 
of this article.  
 
References 
1. Vannuccini S, Petraglia F, Carmona F, 
Calaf J, Chapron C. The modern 
management of uterine fibroids-
related abnormal uterine 
bleeding. Fertil Steril. 
2024;122(1):20-30. 
doi:10.1016/j.fertnstert.2024.04.041 
2. Awiwi MO, Badawy M, Shaaban AM, 
et al. Review of uterine fibroids: 
imaging of typical and atypical 
features, variants, and mimics with 
emphasis on workup and FIGO 
classification. Abdom Radiol (NY). 
2022;47(7):2468-2485. 
doi:10.1007/s00261-022-03545-x 
3. De La Cruz MS, Buchanan EM. 
Uterine Fibroids: Diagnosis and 
Treatment. Am Fam Physician. 
2017;95(2):100-107. 
4. Vilos GA, Allaire C, Laberge PY, 
Leyland N; SPECIAL CONTRIBUTORS. 
The management of uterine 
leiomyomas. J Obstet Gynaecol Can. 
2015;37(2):157-178. 
doi:10.1016/S1701-2163(15)30338-
8 
5. Gomez E, Nguyen MT, Fursevich D, 
Macura K, Gupta A. MRI-based 
pictorial review of the FIGO 
classification system for uterine 
fibroids. Abdom Radiol (NY). 
2021;46(5):2146-2155. 
doi:10.1007/s00261-020-02882-z 
6. Giuliani E, As-Sanie S, Marsh EE. 
Epidemiology and management of 
uterine fibroids. Int J Gynaecol 
Obstet. 2020;149(1):3-9. 
doi:10.1002/ijgo.13102 
7. Van den Bosch T, Van Schoubroeck D. 
Ultrasound diagnosis of 
endometriosis and adenomyosis: 
State of the art. Best Pract Res Clin 
Obstet Gynaecol. 2018;51:16-24. 
doi:10.1016/j.bpobgyn.2018.01.013 
Ortiz 5 
8. Orellana M, DSouza KN, Yap JQ, et al. 
"In our community, we normalize 
pain": discussions around 
menstruation and uterine fibroids 
with Black women and Latinas. BMC 
Womens Health. 2024;24(1):233. 
Published 2024 Apr 12. 
doi:10.1186/s12905-024-03008-z 


Leiomyoma: A Case Report

Bryant, Amber

Seattle University 
ScholarWorks @ SeattleU 
Bachelor of Science in Diagnostic Ultrasound 
Projects College of Nursing 
6-1-2025 
The Importance of Ultrasound Enhancement Agents: A Case 
Report of Recurrent Left Ventricular Thrombus 
Amber Bryant 
Seattle University 
Follow this and additional works at: https://scholarworks.seattleu.edu/dius-projects 
Recommended Citation 
Bryant, Amber, "The Importance of Ultrasound Enhancement Agents: A Case Report of Recurrent Left 
Ventricular Thrombus" (2025). Bachelor of Science in Diagnostic Ultrasound Projects. 12. 
https://scholarworks.seattleu.edu/dius-projects/12 
This Article is brought to you for free and open access by the College of Nursing at ScholarWorks @ SeattleU. It 
has been accepted for inclusion in Bachelor of Science in Diagnostic Ultrasound Projects by an authorized 
administrator of ScholarWorks @ SeattleU. 
 1 
The Importance of Ultrasound 
Enhancement Agents: A Case Report of 
Recurrent Left Ventricular Thrombus 
 
Abstract 
A male patient, 72 years old, with ischemic cardiomyopathy and heart failure with reduced 
ejection fraction (HFrEF) experienced a recurrent left ventricular thrombus (LVT) following a 
myocardial infarction (MI) and stent placement in the left anterior descending (LAD) coronary 
artery. An echocardiogram revealed mild concentric left ventricular hypertrophy with a severely 
reduced ejection fraction of 35% and an echogenic mass suspected to be a left ventricular 
thrombus. He was then discharged on anticoagulation therapy, including Xarelto, Rosuvastatin, 
and Effient. A follow-up Echocardiogram, performed three months later, showed thrombus 
resolution, severely reduced ejection fraction, and wall motion abnormalities (WMA) in the apical 
cap. However, a subsequent echocardiogram revealed thrombus recurrence. Despite 
echocardiography standard guideline recommendations, none of the three echocardiograms 
utilized ultrasound-enhancing agents (UEAs), which limited the accuracy of thrombus detection. 
This case highlights the critical role of contrast-enhanced echocardiography in left ventricular 
thrombus evaluation and its impact on clinical decision-making. 
 
Keywords 
Left Ventricular Thrombus (LVT), Myocardial Infarction (MI), Heart Failure with Reduced 
Ejection Fraction (HFrEF), Ultrasound Enhancing Agent (UEA), Wall Motion Abnormalities 
(WMA) 
 
 2 
Despite advances in cardiovascular care, diagnosing, preventing, and treating left ventricular 
thrombus (LVT) remains complex.6 LVT often arises in patients with myocardial infarction and 
reduced ejection fraction, driven by Virchow’s Triad—blood stasis, endothelial injury, and 
hypercoagulability.3 LVT significantly increases the risk of systemic embolization, stroke, 
peripheral arterial occlusion, and sudden cardiac death. It 
occurs in 6.3% of STEMI patients and 19.2% of those with 
anterior wall STEMI and LVEF <50%.2 On the other hand, 
some challenges remain in detecting thrombus, managing 
treatment duration, and preventing recurrence. Early 
detection and accurate monitoring through imaging, 
particularly with the use of ultrasound-enhancing agents, 
are essential to optimizing clinical outcomes and 
preventing adverse events.1 Examples of a normal heart assessing LVT are provided (See 
Figures 1, 2, and 3). 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Figure 1. The apical four-chamber view shows the 
four chambers of the heart, including all wall 
segments to assess for wall motion abnormalities. 
 
Figure 2. The apical two-chamber view shows the two 
chambers of the left heart, including the left ventricle 
(LV) and left atrium (LA), with all wall segments to 
assess for wall motion abnormalities. 
Figure 3. The apical three-chamber view shows the 
left ventricle (LV), left atrium (LA), and aorta (Ao). 
When Color Doppler is applied, it confirms normal 
blood flow pattern, supporting the assessment for 
blood stasis. 
 3 
Case Study 
 
A 72-year-old male with previous ischemic 
cardiomyopathy, hypertension, mixed 
hyperlipidemia, coronary artery disease, 
and heart failure with reduced ejection 
fraction presented post-myocardial 
infarction following stent placement in a 
100% occluded left anterior descending 
artery.  
The patient underwent an initial 
Transthoracic Echocardiography post-
surgery, which revealed a severely reduced 
left ventricular ejection fraction of 35%, mild 
regurgitation, and mild concentric left 
ventricular hypertrophy. The patient’s 
International Normalized Ratio (INR), which 
assesses blood clotting time, was within 
normal limits.	However, an Echocardiogram 
two days later showed a small pericardial 
effusion and echogenic mass suggestive of 
an LVT. (See Figure 4). Due to the risk of  
thromboembolic events, the patient was 
placed on Rosuvastatin, Eliquis, Xarelto,  
and Effient with an order for a repeat 
Echocardiogram.  
An outpatient Echocardiogram 
revealed thrombus resolution three months 
later. Still, akinesis of the apical cap and 
mid to inferoseptal wall persisted, and the 
LVEF slightly improved to 35-40%. (See 
Figures 5A and B). Current guidelines 
recommend administering systemic 
anticoagulation for at least six months, 
followed by follow-up imaging.3 Therefore, 
the patient’s anticoagulation therapy was 
discontinued.  
Six months later, another 
Echocardiogram was performed which 
Figure 4. The image, obtained using the apical four-
chamber view with a zoomed-in view of the left ventricle 
(LV), reveals a left ventricular thrombus (LVT). The 
thrombus is located in the apex. Image obtained 
(postop). 
 4 
revealed a slightly increased left ventricular 
ejection fraction of 44%, a recurring 
echogenic mass measured to be 1.77 cm x 
2.11 cm, akinetic apical walls, Grade I 
diastolic dysfunction, mild concentric left 
ventricular hypertrophy, moderate mitral 
regurgitation, and normal right ventricular 
systolic pressure. (See Figures 6 and 7).  
 
Due to the recurring LVT, the patient 
was placed on lifelong anticoagulation 
therapy to mitigate the risk of 
thromboembolic complications. To closely 
monitor the thrombus, assess any changes 
in cardiac function, and optimize the 
patient’s treatment options, the patient was 
referred for repeat echocardiograms every 
three to six months. 
  
Discussion 
The left ventricle contracts well in a healthy 
heart, with an Ejection Fraction greater than 
Figure 5. (A) The apical three-chamber view reveals a 
resolved left ventricular thrombus (LVT) after three 
months of anticoagulation therapy. (B) Color Doppler 
imaging showing blood flow in the apex to eliminate 
blood stasis. 
 
Figure 6. Image obtained in the apical four-chamber 
view with an increased depth on the left ventricular 
apex to appropriately assess thrombus recurrence. 
Figure 7. The image was obtained using the apical 
two-chamber view with a slightly increased depth 
showing left ventricular thrombus recurrence 
 5 
52%, smooth endocardial motion, and 
unhindered blood flow that avoids stasis. 
The risk of clotting is minimal, and the 
endocardial surface is undamaged. The 
condition known as left ventricular thrombus 
is primarily associated with myocardial 
infarction, cardiomyopathy, or a significantly 
decreased ejection fraction. These 
situations involve abnormalities of 
ventricular wall motion, such as akinesis or 
dyskinesis, which result in endothelial 
damage and blood stasis, two components 
of Virchow's triad that promote thrombus 
formation. 
 
LVT can manifest asymptomatically; 
most cases are discovered with cardiac 
imaging. Patients who have symptoms may 
present with chest pain, labored breathing, 
hemoptysis, and cardiac arrhythmias.2 If left 
untreated, left ventricular thrombus can 
detach and travel through the bloodstream, 
creating an embolism that increases 
morbidity and mortality in patients with both 
ischemic and nonischemic 
cardiomyopathies. 5 LVT risk is highest 
during the first three months after acute 
myocardial infarction. 4 The prognosis is 
dependent upon anticoagulation therapy or 
the severity of heart failure. Due to a known 
issue of recurrence, it’s protective to 
continue anticoagulants after resolution.7  
 Surgical excision of the LVT an 
option for patients with a high risk of 
embolism who have other open-heart 
surgery or are switching from a peripheral to 
a central VA-ECMO configuration, surgical 
excision of the left ventricular thrombus is 
an option. However, the high morbidity and 
mortality of performing surgery solely for the 
indication of LVT outweigh the benefits of 
doing so.7 
 A post-op Transthoracic 
Echocardiogram without contrast revealed 
Figure 8. The apical four-chamber view with 
decreased depth. Taken to assess left ventricular 
thrombus three months after the start of 
anticoagulation therapy. 
 6 
an LVT for this patient. The patient was 
discharged on anticoagulation therapy, but 
repeat imaging showed thrombus 
resolution. (See Figure 8). Although the 
Transthoracic Echocardiogram showed 
thrombus resolution with all endocardial 
walls visualized, the patient’s severely 
reduced ejection fraction and apical akinesis 
post-myocardial infarction warranted the 
use of an ultrasound-enhancing  
agent to better rule out recurring LVT. This 
initially allowed the patient to discontinue 
the anticoagulation therapy, but later 
resumed lifelong treatment after a repeat 
non-contrast imaging confirmed thrombus 
recurrence. 
Ultrasound-enhancing agents are 
said to up to double the sensitivity of left 
ventricular thrombus detection6 and, 
according to the American Society of 
Echocardiography, the use of contrast-
enhanced imaging in cases where LVT is 
suspected is recommended, even if the 
standard Echocardiogram appears 
adequate.1 While Transthoracic 
Echocardiogram is the standard imaging 
technique, studies show that Cardiac 
Magnetic Resonance with contrast is the 
most accurate for detecting LVT, with a 
sensitivity of 88% and specificity of 99%, 
compared to TTE’s lower sensitivity (24-
33% without contrast, 23-61% with contrast) 
and specificity (94-99%).8 The ability of 
Cardiac Magnetic Resonance to define 
tissue, such as the lack of Late Gadolinium 
Enhancement in avascular thrombi, allows 
for the differentiation between the thrombus 
and surrounding myocardium.6 However, its 
limited availability and higher cost may 
delay diagnosis and treatment initiation. 
Conclusion 
The underutilization of ultrasound-
enhancing agents during transthoracic 
echocardiography can lead to missed or 
incorrect diagnoses, especially for patients 
with recurrent LVT. In this case, although 
standard TTE imaging was done, the lack of 
contrast may have prevented the detection 
of the thrombus returning. This highlights 
 7 
the importance of better education and 
training for healthcare providers on the 
value of using ultrasound-enhancing agents 
in improving diagnostic accuracy. By 
offering more focused training on how 
contrast-enhanced imaging can make a 
difference, we can ensure that patients 
receive the best possible care and 
treatment. Incorporating contrast into 
regular practice can help catch problems 
early, ultimately preventing severe 
complications and improving patient 
outcomes. 
Ethics Approval 
Ethical approval was not sought for the 
present study because the information 
provided is for medical and educational 
purposes.  
Informed Consent 
Informed consent was not sought for the 
present study because all case data was 
de-identified and/or aggregated and 
followed ethics committee or IRB guidelines 
(also referred to as the Honest Broker 
System). 
Declaration of Conflicting Interests 
The author declares there are no conflicts of 
interest with respect to the research, 
authorship, and/or publication of the article. 
Funding 
The author received no financial support for 
the research, authorship, and/or publication 
of this article.  
References 
1. American Society of 
Echocardiography (ASE). Guidelines 
for the use of contrast 
echocardiography in the assessment 
of left ventricular thrombus. J Am 
Soc Echocardiogr. 
2014;27(10):1101-1109. 
doi:10.1016/j.echo.2014.06.024 
2. Camaj A, Szabo L. Left ventricular 
thrombus after ST-segment 
elevation myocardial infarction: 
prevalence, risk factors, and clinical 
outcomes. J Clin Cardiol. 
 8 
2022;45(4):517-523. 
doi:10.1016/j.jclin.2022.04.004 
3. Crider C. Intracardiac Thrombosis: 
Diagnosis, Symptoms, Treatments. 
Healthline. Published March 8, 2023. 
https://www.healthline.com/health/int
racardiac-thrombosis#causes-and-
risk-factors 
4. Delewi R, Zijlstra F, Piek JJ. Left 
ventricular thrombus formation after 
acute myocardial infarction. Heart. 
2012;98(23):1743-1749. 
doi:https://doi.org/10.1136/heartjnl-
2012-301962 
5. Hu T, Chen C, Kellina Maduray, Han 
W, Chen T, Zhong J. Comparative 
effectiveness and safety of DOACs 
vs. VKAs in treatment of left 
ventricular thrombus- a meta-
analysis update. Thrombosis journal. 
2024;22(1). 
doi:https://doi.org/10.1186/s12959-
024-00585-9 
6. Levine GN, McEvoy JW, Fang JC, et 
al. Management of Patients at Risk 
for and With Left Ventricular 
Thrombus: A Scientific Statement 
From the American Heart 
Association. Circulation. 
2022;146(15). 
doi:https://doi.org/10.1161/cir.00000
00000001092 
7. Rodriguez JBC, Okajima K, 
Greenberg BH. Management of left 
ventricular thrombus: a narrative 
review. Annals of Translational 
Medicine. 2021;9(6):520-520. 
doi:https://doi.org/10.21037/atm-20-
7839 
8. Roifman I, Connelly KA, Wright GA, 
Wijeysundera HC. 
Echocardiography vs Cardiac 
Magnetic Resonance Imaging for the 
Diagnosis of Left Ventricular 
Thrombus: A Systematic 
Review. Canadian Journal of 
Cardiology. 2015;31(6):785-791. 
doi:https://doi.org/10.1016/j.cjca.201
5.01.0
 9 
 


The Importance of Ultrasound
Enhancement Agents: A Case Report of
Recurrent Left Ventricular Thrombus

Heimbrodt, Beatrice

Seattle University 
ScholarWorks @ SeattleU 
Bachelor of Science in Diagnostic Ultrasound 
Projects College of Nursing 
6-1-2025 
Uterine Fibroids: A Case Study 
Beatrice Heimbrodt 
Seattle University 
Follow this and additional works at: https://scholarworks.seattleu.edu/dius-projects 
Recommended Citation 
Heimbrodt, Beatrice, "Uterine Fibroids: A Case Study" (2025). Bachelor of Science in Diagnostic 
Ultrasound Projects. 13. 
https://scholarworks.seattleu.edu/dius-projects/13 
This Article is brought to you for free and open access by the College of Nursing at ScholarWorks @ SeattleU. It 
has been accepted for inclusion in Bachelor of Science in Diagnostic Ultrasound Projects by an authorized 
administrator of ScholarWorks @ SeattleU. 
Case Study 
 
Uterine Fibroids: A Case Study 
 
Abstract:  
Uterine fibroids are a prevalent gynecological condition in women and can have symptoms that 
greatly affect an individual's quality of life. African American women are more likely than their 
counterparts of other races to develop fibroids, experience related symptoms, and have worse 
treatment outcomes. This case study examines the continuing diagnostic care and treatment of an 
African American woman with multiple large, symptomatic fibroids and her care in the United 
States. It will also highlight the inequality in treatment options and outcomes for African 
American women in comparison to their white counterparts.  
 
Key Words: Uterine fibroids, leiomyoma, women, African American, uterus 
 
Uterine fibroids are a disorder in which 
noncancerous growths form in a person's 
uterus.1 It is widely accepted that fibroids 
originate from the myometrium of the 
uterus, and their growth is dependent on 
estrogen and progesterone levels.2  Because 
these hormonal levels change over a 
woman's life, a major risk factor for the 
development of fibroids is increasing age up 
until menopause.2  Another major risk factor 
for fibroids is being of African descent. 
When compared to white women, black 
women have a higher prevalence of and 
more severe symptoms due to fibroids.2   
 
The patient was a thirty-eight-year-old 
African American woman who presented to 
urgent care with sharp left lower quadrant 
pain. The patient's history includes painful 
and heavy periods, iron deficiency anemia, 
multiple symptomatic fibroids, a uterine 
polyp, a polypectomy, and a partial 
myomectomy. The patient reported that she 
was trying to conceive and had been trying 
for approximately six months. She reported 
no other major conditions or diagnoses 
considered relevant, and this was the first 
time she had felt this pain.  
 
Case Study 
Once admitted, labs were ordered, and all 
relevant lab values were within the normal 
range. The patient's last pelvic ultrasound, 
approximately four months prior, was 
available for review. The prior exam 
indicated the presence of two fibroids, the 
largest dimensions of which were 3.1cm and 
2.6cm, respectively. 
 
 
 
Figure  I. A sagittal midline image of the patient's 
uterus was obtained transvaginally.   
 
The patient was referred for an updated 
pelvic ultrasound to assess if her fibroids 
had grown and could be causing this new 
1 
Heimbrodt 
 
onset of pain. Transabdominal and 
transvaginal images were obtained to 
evaluate the uterus, ovaries, and adnexa. The 
ultrasound exam showed a heterogeneous 
uterus as well as four fibroids.  
 
Two were subserosal fibroids in the 
posterior uterus, a submucosal fibroid 
appearing to displace the endometrium, and 
an intramural fibroid in the anterior uterus. 
The two fibroids seen on the prior had 
grown, and their largest dimensions were 
7.4cm and 3.9cm, respectively. The 
endometrium was difficult to characterize 
due to the fibroids distorting it. The left 
ovary and adnexa were unremarkable. The 
right ovary was unable to be visualized due 
to overlying bowel gas, and the adnexa was 
unremarkable.  
 
 
 
Figure II. A sagittal midline view of the patient's 
uterus was obtained transvaginally.  
 
 
 
 
 
 
 
 
Figure III. A coronal view of the body of the 
patient's uterus obtained transvaginally.  
 
 
Figure IV. A sagittal and coronal view of the largest 
fibroid, present in the posterior uterine body. 
Obtained transvaginally  
 
 
Figure V.  A sagittal and coronal view of the 
second-largest fibroid, present in the posterior uterine 
body. Obtained transvaginally. 
 
 
2 
Heimbrodt 
 
As a result of the ultrasound, a 
hysterosalpingogram and hysterosonogram 
were ordered to further evaluate the effect of 
the fibroids on the patient's endometrium 
and to assess the patency of the fallopian 
tubes. The hysterosonogram had not yet 
been scheduled, but the 
hysterosalpingogram had been completed.  
The hysterosalpingogram demonstrated that 
the uterine cavity was irregular and 
consistent with the fibroid uterus seen on the 
ultrasound.  
 
 
Figure VI. This is an image of the pelvis from the 
hysterosalpingogram  
 
There was also nonopacification of the right 
fallopian tube, indicating a mechanical 
obstruction or tubal spasm.  After reviewing 
the results of the hysterosalpingogram, the 
patient was referred to a fertility specialist. 
After discussing with a gynecologist, a 
partial myomectomy was scheduled to 
attempt to relieve symptoms caused by the 
fibroids and preserve fertility. 
 
Discussion 
The cause of fibroids is not known, but 
according to widely accepted scientific 
research, it is believed that fibroids could be 
caused by abnormal muscles present in the 
uterus that are exposed to excess estrogen 
and progesterone, resulting in benign 
growths known as fibroids.1 The hormones 
estrogen and progesterone together allow for 
the development of fibroids.  
 
There are different types of uterine fibroids 
that are classified depending on where they 
are located and how they attach to the 
uterus.4  The different types are intramural 
fibroids, submucosal fibroids, subserosal 
fibroids, and pendunculated fibroids.4 
Intramural fibroids are fibroids that are 
embedded in the myometrium.4 Submucosal 
fibroids develop under the mucosa of the 
uterus. Subserosal fibroids develop under 
the serosa of the uterus.4 Pendunculated 
fibroids attach to the uterus with a “stem” 
akin to a polyp.4 
 
Some risk factors for the development of 
fibroids include early menarche, obesity, and 
chronic stress.5 Another significant risk 
factor is being a person with a uterus of 
African descent.2  Statistically, when 
contrasted with white women, black women 
have a higher prevalence of fibroids and 
more severe symptoms as a result of 
fibroids.2  
 
Symptoms of fibroids include heavy 
bleeding, sometimes associated with pain, 
abdominal discomfort, dysuria, dyschezia, 
pain or discomfort during sexual intercourse, 
back pain, leg pain, pelvic pain, 
menorrhagia, increased urinary frequency, 
infertility, and bowel and bladder pressure.1 
The road to a diagnosis of fibroids starts 
with clinical associations and leads to a 
pelvic ultrasound, diagnostic hysterocopy, 
3 
Heimbrodt 
 
and, when necessary for further evaluation, 
magnetic resonance imaging.5 Ultrasound is 
the go-to imaging technique for fibroid 
diagnosis because it is low-cost, 
noninvasive, and widely available.5 For 
those experiencing symptoms, a 
hysterosonogram could be considered in the 
place of hysteroscopy as it helps further 
characterize the uterine cavity.5 
 
At this time, there is no widely agreed-upon 
standard of care for fibroids.6 The course of 
treatment is often dictated by symptom 
severity, fibroid location, and patient 
characteristics.6 There are no pharmacologic 
interventions approved by the US Food and 
Drug Administration (FDA) for the 
treatment of fibroids beyond a pre-operative 
indication.  
 
Treatment is often dictated by symptom 
severity, fibroid location, and patient 
characteristics.6 Surgical treatments for 
fibroids include hysterectomy and 
procedures that attempt to preserve the 
uterus, including myomectomy, endometrial 
ablation, and uterine artery embolization.6 
Both paths of surgical treatment have 
downsides; a hysterectomy results in the loss 
of fertility, and more conservative 
uterine-sparing procedures have an 
increased risk of more surgeries in the 
future.6 
 
Conclusion 
Fibroids are two to three times more 
common among African American women 
than their white counterparts.8 African 
American women not only have a higher 
prevalence of fibroids they also have a 
greater burden of uterine fibroids. Their 
cases of fibroids are often more severe and 
have worse treatment outcomes compared to 
white women. 8 This increased incidence is 
believed to be linked with many things, 
including differential exposures to suspected 
etiologic agents, lack of adequate access to 
competent health care, and bias and 
discrimination within the health care system.  
 
To eliminate these health disparities, their 
root cause must be addressed through policy 
and educational programs for providers to 
ensure that all patients receive culturally 
informed and competent care.7 
 
Ethics Approval  
Ethical approval was not sought for the 
present study because it did not involve 
altering the patient’s healthcare plan.  
 
Informed Consent 
Informed consent was not sought for the 
present study because all case data was 
deidentified and/or aggregated and followed 
ethics committee or IRB guidelines (also 
referred to as the Honest Broker System). 
 
Declaration of Conflicting Interests 
The author(s) declare(s) that there are no 
conflicts of interest with respect to the 
research, authorship, and/or publication of 
the article.  
 
Funding 
The author(s) received no financial support 
for the research, authorship, and/or 
publication of this article 
 
References 
4 
Heimbrodt 
 
1. Ugwu FE, P. H. Uterine Fibroids-A 
Comprehensive Review. Journal of 
Advanced Scientific Research. 
2023;14(2):1-8.doi:10.55218/JASR.2023142 
01 
 
2. Cruz, M. S. D. D. L., & Buchanan, E. M. 
(2017). Uterine Fibroids: Diagnosis and 
Treatment. American Family Physician, 
95(2), 100–107. https://www.aafp.org/pubs/ 
afp/issues/2017/0115/p100.html 
 
3. Dolmans M-M, Petraglia F, Catherino 
WH, Donnez J. Pathogenesis of uterine 
fibroids: current understanding and future 
directions. Fertility & Sterility. 
2024;122(1):6-11. doi:10.1016/j.fertnstert. 
2024.02.048 
 
4. Cleveland Clinic. (2020, August 24). 
Uterine Fibroids: Causes, Symptoms & 
Treatment. Cleveland Clinic.  
https://my.clevelandclinic.org/health/disease
s/9130-uterine-fibroids 
 
5. Centini G, Cannoni A, Ginetti A, et al. 
Tailoring the Diagnostic Pathway for 
Medical and Surgical Treatment of Uterine 
Fibroids: A Narrative Review. Diagnostics 
(2075-4418). 
2024;14(18):2046.doi:10.3390/diagnostics1
4182046 
6. Bonine NG, Banks E, Harrington A, 
Vlahiotis A, Moore-Schiltz L, Gillard P. 
Contemporary treatment utilization among 
women diagnosed with symptomatic uterine 
fibroids in the United States. BMC Women’s 
Health. 2020;20(1):1-13. doi:10.1186/s129 
05-020-01005-6 
 
7. Katon, J. G., Plowden, T. C., & Marsh, E. 
E. (2023). Racial disparities in uterine 
fibroids and endometriosis: a systematic 
review and application of social, structural, 
and political context. Fertility and Sterility, 
119(3), 355–363. https://doi.org/10.1016/j. 
fertnstert.2023.01.022 
 
8. Laughlin-Tommaso, S. K., Jacoby, V. L., 
& Myers, E. R. (2017). Disparities in 
Fibroid Incidence, Prognosis, and 
Management. Obstetrics and Gynecology 
Clinics of North America,44(1), 81–94. 
https://doi.org/10.1016/j.ogc.2016.11 
 
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Mitral Valve Vegetation: A Case Study

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Uterine Fibroids: A Case Study

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