Case of the Month 3 September 2015 History

Case of the Month 3 September 2015 History: 76 -year-old male with severe mitral insufficiency, pulmonary arterial hypertension, acute dyspnea 9 th Jan 2013 Authors: Paola Franchi Anna Rita Larici

Case of the Month 3 11 th Jan 2013

Case of the Month 3 30 th Jan 2013

Case of the Month 3 Diagnosis What is your diagnosis ?

Case of the Month 3 September 2015 History: 76 -year-old male with severe mitral insufficiency, pulmonary arterial hypertension, acute dyspnea 9 th Jan 2013 Question: Which are the abnormalities on this chest X-ray? Authors: Paola Franchi Anna Rita Larici

Case of the Month 3 § Alveolar opacity in the right parahilar region with air bronchogram (arrows)

Case of the Month 3 § The opacity is predominantly located in the right upper lobe (RUL)

Case of the Month 3 § Thickening of the minor fissure

Case of the Month 3 § Enlargement of the pulmonary arterial vessels

Case of the Month 3 § Cardiomegaly § Predominantly of the left heart chambers

Case of the Month 3 § Aortic dilation

Case of the Month 3 Question: What is shown on the CT images? 11 th Jan 2013

Case of the Month 3 11 th Jan 2013 § GGO with air bronchogram mainly located in the RUL § Relative sparing of the subpleural areas

Case of the Month 3 Question: Some days later… what is shown on the CT images? 30 th Jan 2013

Case of the Month 3 30 th Jan 2013 § Areas of GGO in the RUL § Smooth interlobular septal thickening in the RUL

Case of the Month 3 30 th Jan 2013 § Bilateral pleural effusion, greater on the right

Case of the Month 3 31 mm Question: Which information adds the use of the contrast medium? 30 th Jan 2013

Case of the Month 3 31 mm § Pulmonary artery dilatation § Reflux of contrast medium in the IVC and hepatic veins due to cardiac ovreload

Case of the Month 3 20 th Feb 2013 Before and… 28 th Feb 2013 … after mitral valve replacement

Case of the Month 3 Diagnosis Unilateral Pulmonary Edema secondary to severe mitral valve regurgitation Differential Diagnosis - Pulmonary infection - Alveolar hemorrhage - Carcinomatous lymphangitis - Aspiration pneumonitis

Case of the Month 3 Discussion § Cardiogenic unilateral pulmonary edema (UPE) is a rare entity, frequently leading to initial misdiagnosis § UPE represents about 2. 1% of cardiogenic pulmonary edema § UPE is always associated with severe mitral regurgitation § UPE is related to an independent increased risk of mortality and should be promptly recognized to avoid delays in treatment

Case of the Month 3 Discussion § Left ventricle, mitral valve, left atrium, right superior pulmonary vein, and the RUL are aligned along the path expected for a regurgitant jet caused by mitral insufficiency, with a resulting increase in hydrostatic pressure in the right superior pulmonary vein § Asymmetric pulmonary edema concentrated in the right upper lobe is typically associated with mitral regurgitation resulting from a flail posterior leaflet, which can be caused by rupture of the chordae tendineae or papillary muscle

Case of the Month 3 Discussion CHEST RADIOGRAPHY § Loss of definition of segmental and subsegmental vessels § Enlargement of peribronchovascular spaces and peribronchial cuffing § Kerley lines § Areas of increased opacity § Pleural effusion § All findings are more conspicuous on the right HIGH-RESOLUTION CT § Ground-glass opacity § Smooth interlobular septal thickening § Peribronchovascular interstitial thickening § Increased vascular diameter § Pleural effusion § All findings are more conspicuous in the RUL

Case of the Month 3 Further Reading UNILATERAL PULMONARY EDEMA DUE TO MITRAL VALVE REGURGITATION 1) Gurney JW, Goodman LR. Pulmonary edema localized in the right upper lobe accompanying mitral regurgitation Radiology 1989; 171: 397 -9 2) Alarcón JJ et al. Localized right upper lobe edema Chest 1995; 107: 274 -6 3) Raman S, Pipavath S. Images in clinical medicine. Asymmetric edema of the upper lung due to mitral valvular dysfunction N Engl J Med 2009; 361: e 6 4) Attias D et al. Prevalence, characteristics, and outcomes of patients presenting with cardiogenic unilateral pulmonary edema. Circulation 2010; 122: 1109 -15 5) Bagate F et al. Febrile unilateral pulmonary edema: a potential misdiagnosis Int J Cardiol 2014; 174: 867 -8 6) Bishara H et al. An 80 -year-old man with a right upper lobe opacity Clin Respir J 2015 doi: 10. 1111/crj. 12293

Case of the Month 3 Diagnosis Unilateral Pulmonary Edema Differential Diagnosis - Pulmonary infection - Alveolar hemorrhage - Carcinomatous lymphangitis - Aspiration pneumonitis

Case of the Month 3 Discussion § Cardiogenic unilateral pulmonary edema (UPE) is a rare entity, frequently leading to initial misdiagnosis § UPE represents about 2. 1% of cardiogenic pulmonary edema § UPE is always associated with severe mitral regurgitation § UPE is related to an independent increased risk of mortality and should be promptly recognized to avoid delays in treatment

Case of the Month 3 Discussion § Left ventricle, mitral valve, left atrium, right superior pulmonary vein, and the RUL are aligned along the path expected for a regurgitant jet caused by mitral insufficiency, with a resulting increase in hydrostatic pressure in the right superior pulmonary vein § Asymmetric pulmonary edema concentrated in the right upper lobe is typically associated with mitral regurgitation resulting from a flail posterior leaflet, which can be caused by rupture of the chordae tendineae or papillary muscle

Case of the Month 3 Discussion CHEST RADIOGRAPHY § Loss of definition of segmental and subsegmental vessels § Enlargement of peribronchovascular spaces and peribronchial cuffing § Kerley lines § Areas of increased opacity § Pleural effusion § All findings are more conspicuous on the right HIGH-RESOLUTION CT § Ground-glass opacity § Smooth interlobular septal thickening § Peribronchovascular interstitial thickening § Increased vascular diameter § Pleural effusion § All findings are more conspicuous in the RUL

Case of the Month 3 Further Reading UNILATERAL PULMONARY EDEMA DUE TO MITRAL VALVE REGURGITATION 1) Gurney JW, Goodman LR. Pulmonary edema localized in the right upper lobe accompanying mitral regurgitation Radiology 1989; 171: 397 -9 2) Alarcón JJ et al. Localized right upper lobe edema Chest 1995; 107: 274 -6 3) Raman S, Pipavath S. Images in clinical medicine. Asymmetric edema of the upper lung due to mitral valvular dysfunction N Engl J Med 2009; 361: e 6 4) Attias D et al. Prevalence, characteristics, and outcomes of patients presenting with cardiogenic unilateral pulmonary edema. Circulation 2010; 122: 1109 -15 5) Bagate F et al. Febrile unilateral pulmonary edema: a potential misdiagnosis Int J Cardiol 2014; 174: 867 -8 6) Bishara H et al. An 80 -year-old man with a right upper lobe opacity Clin Respir J 2015 doi: 10. 1111/crj. 12293