Acute mitral regurgitation due to flail mitral leaflet mimicking: a diagnosis of pneumonia

Abstract

A 47-year-old man admitted to our department with the persisting complaints of shortness of breath and dry cough. He had been treated with sulbactam-ampicillin with the diagnosis of pneumonia for 3 weeks. He began to define paroxysmal nocturnal dyspnea and orthopnea despite treatment for 4 days. On physical examination, he had an apical systolic murmur and fine crackles heard over the mid-upper chest. Electrocardiography demonstrated sinus rhythm with left atrial abnormality. Chest X-ray revealed bilateral symmetric pulmonary infiltration and pleural effusion with normal cardiac contours (Fig. 1a). Transthoracic echocardiography was obtained immediately and showed probable ruptured chorda tendineae resulting in severe mitral regurgitation with normal systolic functions. Further investigation with transesophageal echocardiography disclosed flail posterior mitral leaflet with eccentric mitral insufficiency jet flow directing to opposite site of affected leaflet (Fig. 1b,c). The patient responded well to mitral valve repair after an uneventful surgery. This case is a very good example of the radiographic features of bilateral mid-upper lobe pulmonary edema caused by mitral valve regurgitation mimicking pneumonia. The pulmonary edema associated with mitral valve regurgitation is usually bilateral but can also be seen isolated or predominantly in right upper lobe [1–3]. Because our patient presented with a confusing medical history and the possibility of cardiac disease is not considered, the initial diagnosis of pneumonia was made incorrectly. We think that careful cardiac auscultation might help the exact diagnosis, in fact the centerpiece of physical examination. In conclusion, this presenting case emphasizes the mitral regurgitation as an etiologic factor in the differential diagnosis of bilateral pulmonary infiltration and the role of proper cardiac auscultation. So, familarity with the pulmonary findings in patients with acute mitral regurgitation is crucial for rapid diagnosis and optimal patient care.