Prevalence, characteristics, and outcomes of patients presenting with cardiogenic unilateral pulmonary edema

An unusual case of unilateral pulmonary edema with contralateral bronchial obstruction

A 61 year-old man presented with progressive shortness of breath. Computed tomography scan of the chest showed diffuse ground glass infiltrates and dilated pulmonary vessels in the right lung in addition to bilateral pulmonary masses with obstruction of the left main pulmonary bronchus. The patient underwent bronchoscopy with destruction of the tumor obstructing the left main pulmonary bronchus, resulting in clinical improvement and resolution of the right pulmonary infiltrates. We hypothesize that the patient developed right pulmonary edema secondary to hypoxic vasoconstriction of the left lung. This case suggests a rare mechanism of unilateral pulmonary edema and supports inclusion of pulmonary edema in the differential diagnosis of unilateral pulmonary infiltrates in the setting of contralateral bronchial obstruction.

Negative Computed Tomography for Acute Pulmonary Embolism: Important Differential Diagnosis Considerations for Acute Dyspnea

Computed tomography pulmonary angiography (CTPA) is the principal means of evaluating dyspnea in the emergency department. As its use has increased, the number of studies positive for pulmonary embolism (PE) has decreased to less than 20%. Many of the negative PE studies provide an alternative explanation for dyspnea, most commonly pneumonia, pulmonary edema, pleural effusion, or atelectasis. Nonthrombotic emboli may also be suggested. Airway and obstructive lung disease may be detected on CTPA. Pleural and pericardial disease may also explain the dyspnea, but more detailed evaluation of the serosal surfaces may be limited on the arterial phase of a CTPA.

[Two Cases of Rapidly Progressive Community-acquired Pneumonia Due to Pseudomonas aeruginosa]

Pseudomonas aeruginosa is a significant causative bacterium in hospital-acquired pneumonia and nursing and healthcare-associated pneumonia, but it seems to be rare in community-acquired pneumonia (CAP). We report two cases of severe CAP due to P. aeruginosa. Case 1: A 52-year-old man was referred to our hospital for chest and back pain. He was being treated for diabetes mellitus and had a long history of smoking. Chest images showed consolidation in the right upper lobe. Soon after hospitalization, he developed sepsis shock and died seven hours later. Case 2: A 73-year-old man with a history of heavy smoking was referred to our hospital for right chest pain. Chest images showed right upper lobe pneumonia. Although wide-spectrum antimicrobial agents were administrated, he died ten hours after admission. In both cases, there was a rapid progression to death, despite administration of a broad spectrum of antibiotics and treatment for sepsis. In cases of CAP involving the right upper lobe, the possibility of bacteremia and rapid progress should be considered.

Diffuse alveolar hemorrhage with predominantly right-sided infiltration resulting from cardiac comorbidities

OBJECTIVE

Radiographic findings in patients with diffuse alveolar hemorrhage (DAH) are usually diffuse and bilateral, although they may occasionally be unilateral. The clinical aspects of predominantly unilateral DAH are not well known. Therefore, our objective was to describe the clinical characteristics of predominantly right-sided DAH.

METHODS

We retrospectively reviewed data for 460 bronchoalveolar lavage fluid (BALF) samples collected between January 2009 and July 2013. Patients who presented with increasingly hemorrhagic BALF were diagnosed with DAH, and unilateral predominance was determined based on the degree of infiltration on chest radiographs.

RESULTS

The records of 54 patients with DAH were evaluated. The leading etiology was pulmonary congestion due to heart failure (n=15). The radiographs showed right-sided infiltration in 18 patients (33%), left-sided infiltration in six patients (11%) and bilateral infiltration in 30 patients (56%). Predominantly right-sided DAH was often caused by pulmonary congestion resulting from heart failure (10 of 18 patients). A multivariate logistic regression analysis revealed a previous history of cardiovascular disease to be the only significant predictor of right-sided DAH (OR 13.1, 95% CI 2.9-95.4).

CONCLUSION

Predominantly right-sided DAH is frequently caused by pulmonary congestion resulting from heart failure and is significantly related to comorbidities with cardiovascular disease.

An unusual masquerade of community acquired pneumonia: Left-side unilateral pulmonary edema

The diagnosis of pneumonia is clinical, based on the history of lower respiratory tract symptoms, physical, and/or radiographic signs of consolidation. Several diseases such as congestive heart failure, pulmonary embolism, and chemical pneumonitis may present with similar symptoms, signs, and chest radiographs, thus delaying the definitive diagnosis and initiation of appropriate treatment. Unilateral pulmonary edema (UPE) is a rare clinical entity that is often misdiagnosed at first as a focal lung disease. We have presented an unusual case of left-sided UPE in a 76-year-old man who developed acute heart failure resulting from dietary and pharmacological noncompliance. The patient was successfully managed with decongestive therapy and non-invasive mechanical ventilation.

Pulmonary oedema mimicking bronchiectasis

A previously completely fit and well 62-year-old man presented with a 4-week history of lethargy and increasing shortness of breath. This had been preceded by a flu-like illness that had been treated in the community with ciprofloxacin to no effect. There was no history of smoking, tuberculosis exposure or significant exposure to birds. Clinically the patient appeared well and was comfortable and conversant with no peripheral oedema. Chest auscultation revealed normal breath sounds and a loud pansystolic murmur over the cardiac apex. A chest radiograph and a subsequent CT scan showed widespread fibrotic and bronchiectatic changes, predominantly in the right upper lobe, with bilateral pleural effusions. Echocardiography revealed a posterior mitral valve prolapse. He was treated with loop diuretics and a mitral valve repair that resolved his symptoms and radiographic findings. This is the first English language case report of pulmonary oedema causing bronchiectatic lung appearances.

Initial misdiagnosis of acute flail mitral valve is not infrequent: The role of echocardiography

BACKGROUND

Acute flail mitral valve frequently results in severe mitral regurgitation. However, its clinical presentation can be similar to other disease processes, potentially leading to initial misdiagnosis and a morbid outcome. We sought to analyze baseline characteristics, clinical presentations, time to diagnosis, and in-hospital mortalities of patients with the acute flail mitral valve.

METHODS

Two hundred and sixty two consecutive echocardiograms with severe mitral regurgitation performed between February 2005 and October 2010 at the Jack D. Weiler Hospital (Bronx, New York, USA) were reviewed. Adult patients who had presented with new onset flail mitral valves were selected for this retrospective study.

RESULTS

Fifteen patients were found to have acute flail mitral valve. The majority was elderly male. Over half presented to the emergency room with a sudden onset of dyspnea. A mitral regurgitant murmur was appreciated in only a third of the patients. The chest X-ray of five patients had no acute pulmonary findings, whereas, two were found to have gross unilateral pulmonary edema. Clinically, 60% were misdiagnosed on admission. Using echocardiogram, the correct diagnosis of flail mitral valve was made in all cases, however, only 40% on the day of presentation. The maximum time to echocardiographic diagnosis was 4 days. The main cause of acute flail mitral valve was degenerative disease. Seven patients were managed surgically. Overall, there was only one mortality (7%) during incident hospitalization.

CONCLUSIONS

Initial misdiagnosis of acute flail mitral valve happens frequently. Early echocardiographic exam is essential in the timely diagnosis and management of acute flail mitral valve.

Unilateral pulmonary edema: a rare initial presentation of cardiogenic shock due to acute myocardial infarction

Cardiogenic unilateral pulmonary edema (UPE) is a rare clinical entity that is often misdiagnosed at first. Most cases of cardiogenic UPE occur in the right upper lobe and are caused by severe mitral regurgitation (MR). We present an unusual case of right-sided UPE in a patient with cardiogenic shock due to acute myocardial infarction (AMI) without severe MR. The patient was successfully treated by percutaneous coronary intervention and medical therapy for heart failure. Follow-up chest Radiography showed complete resolution of the UPE. This case reminds us that AMI can present as UPE even in patients without severe MR or any preexisting pulmonary disease affecting the vasculature or parenchyma of the lung.

Rare roentgenologic manifestations of pulmonary edema

PURPOSE OF REVIEW

Unilateral pulmonary edema (UPE) is an unusual manifestation of pulmonary edema that is frequently confused with other causes of unilateral alveolar and interstitial infiltrates. Until now limited data existed regarding the prevalence, cause, and outcome of patients presenting with cardiogenic UPE. The purpose of this review is to give insights into this rare entity.

RECENT FINDINGS

In a recent retrospective study, the prevalence of UPE was 2.1% of all cases of cardiogenic pulmonary edema. UPE was right-sided in 89%. All patients with UPE had severe mitral regurgitation. In patients with UPE, blood pressure was significantly lower, whereas noninvasive or invasive ventilation and catecholamines were used more frequently compared with patients with bilateral pulmonary edema. In-hospital mortality was higher for patients with UPE (39 vs. 8% for bilateral pulmonary edema) and UPE was independently related to death (a 6.5-fold higher risk of death). Delayed treatment of UPE could be one of the explanations for this increased mortality.

SUMMARY

UPE is not that rare as considered to be and is mostly related to severe organic or functional mitral regurgitation. Probably because of initial misdiagnosis and delayed appropriate treatment, UPE is related to increased mortality. History, absence of signs of infection, and elevated serum cardiac markers such as B-natriuretic peptide may help to differentiate UPE from other diagnoses. The key examination remains bedside transthoracic echocardiography, although transesophageal echocardiography can also provide additional information regarding the severity and mechanism of mitral regurgitation and documentation of the differential pressure between the right and left pulmonary veins.