ACUTE MITRAL REGURGITATION DUE TO RUPTURED LEAFLET CAUSING ASYMMETRICAL UPPER LOBE PULMONARY EDEMA

Abstract

SESSION TITLE: Tuesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/22/2019 01:00 PM - 02:00 PM INTRODUCTION: Cardiogenic unilateral pulmonary edema (UPE) is a rare clinical entity that is often misdiagnosed initially. Most cases of cardiogenic edema occur in the right upper lobe and are caused by severe mitral regurgitation (MR). CASE PRESENTATION: An 82 year old male with diastolic heart failure, mitral regurgitation, atrial fibrillation, sick sinus syndrome, and chronic bronchiectasis presented with acute onset severe dyspnea without fever. He was discharged 12 hours prior from an outside hospital admission for recurrent multilobar pseudomonas pneumonia. He was euvolemic on exam, and chest X-ray showed bilateral upper lobe opacities consistent with outside CT scan. The patient was immediately placed on BiPAP for respiratory support and started empirically on ceftazidime/avibactam for possible pneumonia. Despite broad spectrum treatment his respiratory status acutely worsened and he was noted to have a new loud harsh systolic murmur. Repeat CXR showed new confluent edema in the right upper lung. Immediate transthoracic echocardiogram revealed rupture of the posterior mitral leaflet chordae secondary to degenerative changes. The patient was considered for urgent transfer to tertiary center for surgical repair of the mitral valve. Unfortunately, the patient’s status declined rapidly with a cardiogenic picture and end-organ failure. On hospital day 4 care was withdrawn and he passed away. DISCUSSION: The association of unilateral pulmonary infiltrates with leukocytosis and acute respiratory distress often leads to antibiotic therapy. A history of sudden onset dyspnea, organic murmur and elevated B-natriuretic peptide levels in the absence of fever may help differentiate upper lobe edema from other diagnoses. Furthermore, patients with UPE have a higher mortality than patient with bilateral pulmonary edema, and delay in adequate treatment may be contributory. It is studied that retrograde flow of blood directed across the left atrium toward the orifices of the right upper lobe pulmonary veins in severe MR results in a focal increase in the pulmonary venous pressure. Echocardiography is useful in determining the severity of MR and its cause. In this case, symptoms were initially attributed to pneumonia, but we later became suspicious of cardiogenic UPE based on new unilateral pulmonary infiltrate on CXR with new onset murmur. Indeed, ruptured chordae of the posterior leaflet in the setting of severe MR was confirmed on echocardiogram. CONCLUSIONS: Cardiogenic UPE can easily be mistaken for pneumonia or other pulmonary pathology. It is important to re-consider the differential diagnosis in sudden development of asymmetrical pulmonary infiltrate in a patient, taking into account physical examination findings and the clinical course. Upper lobe pulmonary edema could be a sign of severe mitral regurgitation that needs to be promptly recognized to avoid delays in life-saving intervention. Reference #1: Legriel S, Tremey B, Mentec H. Unilateral pulmonary edema related to massive mitral insufficiency. Am J Emerg Med. 2006;24:372. Reference #2: Handagala, R., Ralapanawa, U. & Jayalath. Unilateral pulmonary edema: a case report and review of the literature. T. J Med Case Reports. 2018; 12: 219. DISCLOSURES: no disclosure on file for Michael Casey; No relevant relationships by Janice Lee, source=Web Response No relevant relationships by Tanuja Yalamarti, source=Web Response