Unilateral pulmonary oedema, a forgotten presentation.

Transcription

1 Unilateral pulmonary oedema, a forgotten presentation. Poster No.: C-2146 Congress: ECR 2018 Type: Educational Exhibit Authors: C. A. Arboleda Vallejo, M. I. carvajal, M. Perez ; Medellin, Antioquia/CO, medellin/co Keywords: Computer Applications-Detection, diagnosis, CT, Thorax, Lung, Cardiac, Edema DOI: /ecr2018/C-2146 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 19

2 Learning objectives To identify patients susceptible to develop unilateral pulmonary edema, which should be considered among possible differential diagnoses. To describe the subtle image findings on chest radiography and chest tomography that suggest unilateral pulmonary edema. To show our experience in the diagnosis of patients with clinical and radiological findings of unilateral pulmonary edema, in addition to outlining the main causes of this finding. Background Acute pulmonary oedema is a manifestation of decompensated heart failure, the usual radiological pattern in chest X-rays corresponds to bilateral symmetrical opacity occupying the central areas of the lung parenchyma, hence the classic sign of "butterfly shadow". Fig. 1: Sign of "butterfly shadow", refer to a pattern of bilateral perihilar shadowing. There are two types of pulmonary edema: Pulmonary cardiogenic edema or increased hydrostatic pressure. Non-cardiogenic pulmonary edema or normal hydrostatic pressure edema due to increased pulmonary permeability, acute lung injury or acute respiratory distress syndrome. Tabla 1. Cardiogenic Pulmonary edema VS Non-cardiogenic pulmonary edema Radiological Description Cardiogenic Non-cardiogenic Cardiac Silhouette Normal or increased Normal Page 2 of 19

3 Width of the Vascular Pedicle Normal or increased Normal or diminished Vascular Distribution Normal or Inverted Normal Distribution of Edema Central Patches or Peripheral Pleural Effusion Present Absent Septal Lines Present Absent Air Broncogram Absent Present However the asymmetric pulmonary edema is another type of less common radiological manifestation, in some series corresponds up to 2.1% of patients with acute pulmonary edema. This entity is a challenge for diagnosis, with multiple differential diagnoses including pneumonia, bronchopaspiration and alveolar hemorrhage. Atypical pulmonary edema can occur in any pathology that affects the pulmonary parenchyma, circulation and lymphatic drainage. In the majority of the literature, there is an association with severe mitral regurgitation and superior right predominance. Unilateral pulmonary edema can occur in: Severe mitral valve insufficiency with eccentric regurgitant jet Re-expansion of a pneumothorax Diseases of the pulmonary parenchyma Unilateral sympathectomy Compression of the pulmonary veins by a myxoma or atrial thrombus Rapid drainage of a pleural effusion. Unilateral pulmonary edema due to mitral regurgitation is characterized by: Predominance in right upper lobe The Jet of blood flows through the incompetent mitral valve It is mainly directed to the right pulmonary vein causing increased pressure. Interferes in venous return Images for this section: Page 3 of 19

4 Fig. 1: Sign of "butterfly shadow", refer to a pattern of bilateral perihilar shadowing. Page 4 of 19

5 Findings and procedure details Case 1. Female, 66 years old Personal history of Diabetes Mellitus 2, arterial hypertension, Chronic occlusive arterial disease. She is admitted for marked dyspnea and generalized edema. Admission Diagnosis: Decompensated Heart Failure - Pulmonary Edema. Echocardiography: Mixed Cardiopathy (Ischemic and Severe Mitral Valvulopathy) with LVEF25%. Fig. 2: Chest X-ray: Bilateral alveolar opacities of right predominance The patient presents important clinical deterioration, with increased dyspnea and oxygen support requirement at high flow. With well score of 3, Thorax CT angiography is ordered due to suspicion of pulmonary embolism. Fig. 3: Thorax angiotc: Negative study for PE, alveolar opacities in both predominantly right fields. Evolution Coronariography: did not show significant injuries. Echocardiography: Severe mitral failure due to rupture of the chordae tendineae. Order heart failure management. Page 5 of 19

6 Fig. 4: Chest X-ray: control after 2 days, improvement of parenchymal opacities. It is scheduled for cardiac surgery. She dies due to hemodynamic instability. Case 2. Female, 74 years old. Personal history: Diabetes mellitus, hypertension, chronic kidney disease She is admitted for suspicion of critical ischemia of the lower left limb which is discarded. During the hospitalization, she presents marked dyspnea and clinical deterioration. Initial chest x-ray with findings suggestive of an infectious process, antibiotic management is initiated. Fig. 5: Chest X-ray: Bilateral alveolar opacities of right predominance - cardiomegaly Thorax tomography is requested for continuing respiratory deterioration despite management. Fig. 6: Thoracic tomography: Central alveolar occupation with predominance in the right upper lobe associated with septal thickening. Evolution: Echocardiogram: Mixed cardiopathy: ischemia and valvular (severe mitral regurgitation). Ejection fraction 29%. The patient continues with deterioration, she requires transfer to the intensive care unit. Page 6 of 19

7 They initiate management of cardiac failure Order control RX Fig. 7: Chest x-ray: 3 days later, improvement of parenchymal opacities with respect to previous studies She has cardiogenic shock and dies Case 3: Male, 69 years old Personal history of chronic kidney disease in hemodialysis, hypertension and heart failure FE 14%. I have consulted the emergency department for dyspnea and cough. Chest x-ray ordered to rule out infectious process Fig. 8: Chest x-ray: Mixed bilateral opacities of right predominance - cardiomegaly Chest tomography: requested to confirm diagnosis and to rule out other causes of dyspnea Fig. 9: Chest tomography: Alveolar occupation of right hemitorax with septal thickening. Evolution Patient with acute phase reactants in normal values. Page 7 of 19

8 Normal smear microscopy and PCR for mycobacteria negative. They optimize the management of heart failure with clinical improvement and control xrays Fig. 10: Control chest radiography: improvement of parenchymal involvement when compared with previous study - cardiomegaly. Case 4. Patient of 80 years History of congestive heart failure, type 2 diabetes, hypertension and chronic kidney disease. He is admitted to the emergency department for dyspnea, productive cough and edema in lower limbs. Chest X ray is requested. Fig. 11: Chest x-ray: bilateral pleural effusion, the left in abundant amount Echocardiography: mixed heart disease with LVEF 25%. Chest tomography: requested for clinical deterioration. Fig. 12: Chest tomography: Cardiomegaly - Pericardial effusion - Bilateral pleural effusion of free distribution, the left in abundant quantity - Consolidation of the left air space with ground glass opacities. Evolution Page 8 of 19

9 Reactants of acute phase without significant elevation. They started management for congestive heart failure. Subsequent clinical deterioration he dies due to ventilatory failure and cardiogenic shock. Images for this section: Fig. 2: Chest X-ray: Bilateral alveolar opacities of right predominance Page 9 of 19

10 Fig. 3: Thorax angiotc: Negative study for PE, alveolar opacities in both predominantly right fields. Page 10 of 19

11 Fig. 4: Chest X-ray: control after 2 days, improvement of parenchymal opacities. Page 11 of 19

12 Fig. 5: Chest X-ray: Bilateral alveolar opacities of right predominance - cardiomegaly Page 12 of 19

13 Fig. 6: Thoracic tomography: Central alveolar occupation with predominance in the right upper lobe associated with septal thickening. Page 13 of 19

14 Fig. 7: Chest x-ray: 3 days later, improvement of parenchymal opacities with respect to previous studies Page 14 of 19

15 Fig. 8: Chest x-ray: Mixed bilateral opacities of right predominance - cardiomegaly Page 15 of 19

16 Fig. 9: Chest tomography: Alveolar occupation of right hemitorax with septal thickening. Fig. 10: Control chest radiography: improvement of parenchymal involvement when compared with previous study - cardiomegaly. Page 16 of 19

17 Fig. 11: Chest x-ray: bilateral pleural effusion, the left in abundant amount Page 17 of 19

18 Fig. 12: Chest tomography: Cardiomegaly - Pericardial effusion - Bilateral pleural effusion of free distribution, the left in abundant quantity - Consolidation of the left air space with ground glass opacities. Page 18 of 19

19 Conclusion Asymmetric pulmonary edema is a rare entity, with subtle radiologic findings; which leads to misdiagnoses initial delay marked the beginning of an optimal therapeutic, directly impacting the prognosis of patients. Although this entity is strongly associated with severe mitral valve disease, this is not the only cause; so a high clinical and radiological suspicion is essential for accurate diagnosis. Personal information References Mehra M, Ventura H. Cardiac Unilateral Pulmonary Edema: Is It Really a Rare Presentation?. CHF. 2005;11: Bahl OP, Oliver GD, Rockoff SD. Localized unilateral pulmonary edema: an unusual presentation of left heart failure. Chest. 1971;60:277#280. Young A, Langston C. Mitral Valve Regurgitation Causing Right Upper Lobe Pulmonary Edema. Tex Heart Inst J 2001;28:53-6 Tutschka M, Bainbridge D. Unilateral Postoperative Pulmonary Edema After Minimally Invasive Cardiac Surgical Procedures: A Case-Control Study. Ann Thorac Surg 2015;99: Solís C, Jaramillo D. Edema pulmonar unilateral; una rara presentación de la disfunción sistólica. Reporte de un caso. Rev Mex Cardiol 2010; 21 (2): Attias D, Mansencal N, Auvert B. Prevalence, characteristics, and outcomes of patients presenting with cardiogenic unilateral pulmonary edema. Circulation 2010;122: DoshiH, El Accaoui R, Unilateral pulmonary edema in acute coronary syndrome: A sinister sign, Eur J InternMed (2015). Muthalaly R#, Nasis A. Unilateral pulmonary oedema: A case report of a commonly missed and highly consequential condition. International Journal of Cardiology 207 (2016) Page 19 of 19