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A Must-Not-Miss Zebra: Unilateral Pulmonary Edema
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A3481 - A Must-Not-Miss Zebra: Unilateral Pulmonary Edema
Author Block: J. Ninan, S. Karturi; Hospital Medicine, Mayo Clinic Health Systems, La Crosse, WI, United States.
The common causes for unilateral alveolar or interstitial opacities are infection, atelectasis, neoplasm, lung infarction, and aspiration. Unilateral pulmonary edema(UPE) due to mitral regurgitation is an extraordinarily lethal condition which may be overlooked in the pursuit of more common culprits of focal pulmonary conditions. We present a patient with unilateral pulmonary edema due to severe acute mitral regurgitation which proved to be fatal.
A 78-year-old gentleman presenting with the feeling of weakness was admitted for evaluation of a dense right lower lobe infiltrate. His vitals were within physiological limits and systemic examination significant for pansystolic murmur in the mitral area and egophony in the right infrascapular and interscapular regions. He became increasingly hypoxic during his hospital stay despite a stable pulmonary infiltrate and treatment with appropriate antibiotics. However, as he was not behaving like a patient with infection - afebrile, normal WBC counts, negative blood, and sputum cultures - a BNP was performed. The elevated BNP triggered the ordering of a transthoracic ECHO which revealed an anterior mitral valve leaflet prolapse and severe mitral regurgitation. The patient was transferred to a higher center for mitral valve surgery after transesophageal ECHO confirmed the eccentric mitral regurgitant jet directed at the inferior pulmonary vein. The patient, unfortunately, died from cardiogenic shock before surgery.
Unilateral pulmonary edema(UPE) has been observed in 2.1% of patients with acute cardiogenic pulmonary edema. UPE has a predilection for the right lung; involves the upper and lower lobe in 87.8% and 4.2% of the cases, respectively. Although mitral regurgitation(69.2%) was identified as the common culprit for UPE, other notable causes were acute or chronic heart failure, dissecting aortic aneurysm with pulmonary vein compression, paravalvular leakage after mitral valve replacement and dysfunctional St. Jude mitral valve. An asymmetric increase in the blood flow from the left atrium - eccentric mitral regurgitant jet directed at the right pulmonary veins - to the right lobe of the lung causes UPE. Patients with UPE have a 6.9 fold higher risk of death as compared to patients with bilateral pulmonary edema. The delay in diagnosis and consequently tardy management has been attributed as the cause for this high level of mortality. A right unilateral lung infiltrate sine signs of infection in the appropriate setting should be investigated with BNP and ECHO to exclude cardiogenic UPE. Unilateral pulmonary edema although rare, can be fatal if there is a delay in diagnosis and treatment.
Author Block: J. Ninan, S. Karturi; Hospital Medicine, Mayo Clinic Health Systems, La Crosse, WI, United States.
The common causes for unilateral alveolar or interstitial opacities are infection, atelectasis, neoplasm, lung infarction, and aspiration. Unilateral pulmonary edema(UPE) due to mitral regurgitation is an extraordinarily lethal condition which may be overlooked in the pursuit of more common culprits of focal pulmonary conditions. We present a patient with unilateral pulmonary edema due to severe acute mitral regurgitation which proved to be fatal.
A 78-year-old gentleman presenting with the feeling of weakness was admitted for evaluation of a dense right lower lobe infiltrate. His vitals were within physiological limits and systemic examination significant for pansystolic murmur in the mitral area and egophony in the right infrascapular and interscapular regions. He became increasingly hypoxic during his hospital stay despite a stable pulmonary infiltrate and treatment with appropriate antibiotics. However, as he was not behaving like a patient with infection - afebrile, normal WBC counts, negative blood, and sputum cultures - a BNP was performed. The elevated BNP triggered the ordering of a transthoracic ECHO which revealed an anterior mitral valve leaflet prolapse and severe mitral regurgitation. The patient was transferred to a higher center for mitral valve surgery after transesophageal ECHO confirmed the eccentric mitral regurgitant jet directed at the inferior pulmonary vein. The patient, unfortunately, died from cardiogenic shock before surgery.
Unilateral pulmonary edema(UPE) has been observed in 2.1% of patients with acute cardiogenic pulmonary edema. UPE has a predilection for the right lung; involves the upper and lower lobe in 87.8% and 4.2% of the cases, respectively. Although mitral regurgitation(69.2%) was identified as the common culprit for UPE, other notable causes were acute or chronic heart failure, dissecting aortic aneurysm with pulmonary vein compression, paravalvular leakage after mitral valve replacement and dysfunctional St. Jude mitral valve. An asymmetric increase in the blood flow from the left atrium - eccentric mitral regurgitant jet directed at the right pulmonary veins - to the right lobe of the lung causes UPE. Patients with UPE have a 6.9 fold higher risk of death as compared to patients with bilateral pulmonary edema. The delay in diagnosis and consequently tardy management has been attributed as the cause for this high level of mortality. A right unilateral lung infiltrate sine signs of infection in the appropriate setting should be investigated with BNP and ECHO to exclude cardiogenic UPE. Unilateral pulmonary edema although rare, can be fatal if there is a delay in diagnosis and treatment.
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