Waqas Ali, MD, MBBBS
Resident Physician, University of Pittsburgh-McKeesport
UPMC McKeesport
McKeesport, Pennsylvania
Disclosure information not submitted.
Khubaib Ahmad, MBBS
Medical Student
Services Institute of Medical Sciences, United States
Disclosure information not submitted.
Pranali Pachika, MD
Resident Physician
University of Pittsburgh- McKeesport, United States
Disclosure information not submitted.
Anjana Pillai, MD
Faculty
University of Pittsburgh- McKeesport, United States
Disclosure information not submitted.
Title: Pus or Water: A Case of Severe Mitral Regurgitation Leading to Right-sided Pulmonary Edema Case
Report Body:
Introduction: Causes of unilateral pulmonary airspace disease include pneumonia, bronchial obstruction (eg. Malignancy), pulmonary contusion, infarction, re-expansion edema, atelectasis, aspiration, and veno-occlusive diseases. We present an interesting case of severe mitral regurgitation leading to right-sided pulmonary edema initially misdiagnosed as aspiration pneumonia.
Case Presentation: 88-year-old woman with medical history of heart failure with preserved ejection fraction presented with acute shortness of breath and hypoxia. Her EKG showed sinus tachycardia. Labs were significant of elevated BNP 1900 & troponin 0.037. Her white blood cell count was 10. Chest x-ray revealed patchy airspace disease throughout the right lung. Her exam revealed a holosystolic murmur at apex radiating to axilla. She had no JVD or hepatojugular reflux or lower extremity edema. There was a concern of aspiration pneumonitis or pneumonia given right greater than left airspace disease for which she was treated with ceftriaxone and azithromycin. Her transthoracic echocardiogram (TTE) and subsequent transesophageal echocardiogram (TEE) revealed severe mitral regurgitation with eccentric regurgitant jet (Coanda effect), reversal of flow in pulmonary veins & posterior mitral leaflet tethering consistent with ischemic mitral regurgitation. She was treated with IV diuretics with improvement in her symptoms and x-ray findings. Antibiotics were subsequently stopped as she continued to have no clinical signs of infection including leukocytosis and fever. One week later, she again presented with similar symptoms and chest x-ray findings. She again attained clinical and radiologic improvement with diuretics. The patient was eventually referred for mitral valve clip procedure.
Discussion: The reversal of blood flow in right pulmonary veins during systole caused by eccentric regurgitant jets leads to the development of right-sided pulmonary edema secondary to mitral regurgitation. TEE with pulse-wave Doppler is a useful tool in establishing the diagnosis. Pulmonary edema secondary to severe mitral regurgitation should be considered in differentials of unilateral right-sided pulmonary airspace disease (especially right upper lobe) to prevent misdiagnosis as pneumonia especially in the absence of clinical signs of infection.