RIGHT UPPER LOBE PULMONARY EDEMA: AN UNDERRECOGNIZED PRESENTATION OF ACUTE ISCHEMIC MITRAL VALVE REGURGITATION

Abstract

SESSION TITLE: Monday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Unilateral pulmonary edema due to acute mitral valve insufficiency can create a diagnostic challenge for clinicians. While this presentation is uncommon, many case reports have demonstrated this radiologic finding, suggesting this may be an underrecognized phenomenon1. CASE PRESENTATION: An 80-year-old male with a history of hypertension and coronary artery disease status post three-vessel bypass in 2010 was admitted and treated for an inferior wall myocardial infarction with a bare metal stent to the left circumflex artery. One week later he presented to the emergency department with new onset shortness of breath and cough that began the day after his recent discharge. Physical examination was notable for a healthy appearing male in mild respiratory distress on 3 liters of oxygen, a 3/6 holosystolic murmur, no JVD, no peripheral edema and diminished lung sounds in the right lung fields with bibasilar crackles. Laboratory evaluation was notable for a WBC of 10.8, a procalcitonin of <0.10, and a troponin of 5.81. Chest radiograph revealed diffuse airspace disease with predominate right upper lobe infiltrate. A transesophageal echocardiogram revealed a non-dilated left ventricle with an ejection fraction of 35-40%, pulmonary arterial systolic pressure of 63mmHg, a severely enlarged left atrium, severe mitral regurgitation in the setting of a posterior mitral valve leaflet that appears tethered; consistent with ischemic mitral regurgitation with systolic reversal of flow in the right upper and lower pulmonary veins. The troponin level down trended throughout the admission, and the new mitral valve regurgitation was deemed ischemic in etiology given the patient’s recent inferior wall infarct less than 7 days prior. The right upper lobe infiltrate and shortness of breath markedly improved with diuresis and afterload reduction. The patient was discharged in improved condition with plans for outpatient evaluation for a mitral clip procedure. DISCUSSION: Classically cardiogenic pulmonary edema is symmetrically distributed in both lung fields with central predominance. In our patient, the pulmonary edema was primarily found in the right upper lobe, which has been established in the literature as a radiologic finding seen in up to 9% of acute mitral valve regurgitation cases2. This report emphasizes this classic radiologic finding as it is often misdiagnosed as pneumonia. The absence of fever and leukocytosis and the presence of a holosystolic murmur should raise clinical suspicion for a pulmonary infiltrate of non-infectious etiology. CONCLUSIONS: Unilateral pulmonary edema due to acute mitral valve insufficiency can create a diagnostic challenge for clinicians. This report highlights the unique clinical presentation to facilitate a broadened differential when faced with this clinical dilemma. Reference #1: 1. Gamsu G, Peters DR, Hess D, Lehman DH, Amend WJ. Isolated right upper lobe pulmonary edema. West J Med. 1981;135(2):151-4. Reference #2: 2. Morris PD, Warriner DR, Channer KS. Focal pulmonary edema: an unusual presentation of acute mitral regurgitation Thorax 2013; 68:498. DISCLOSURES: No relevant relationships by Kenneth Brownell, source=Web Response No relevant relationships by Arjun Kalaria, source=Web Response No relevant relationships by Parth Shah, source=Web Response