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Weekly Chest CasesArchive of Old Cases

Case No : 845 Date 2014-01-06

  • Courtesy of Jae Seung Seo / Chung-Ang University Hospital
  • Age/Sex 52 / M
  • Chief ComplaintChest pain, dyspnea, and cough for one week. Mild fever(37.8 degree) for one day
  • Figure 1
  • Figure 2
  • Figure 3
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  • Figure 5

initial chest PA

Diagnosis With Brief Discussion

Diagnosis
Atypical Pulmonary Edema caused by Mitral Regurgitation
Radiologic Findings
Initial chest radiograph shows asymmetric interstitial opacities in both lungs and bilateral pleural effusion. Follow up chest radiograph taken on three days later shows improvement of the asymmetric pericardiac interstitial opacities in both lungs, but progression of right pleural effusion. chest CT shows diffuse asymmetric pulmonary edema in both lungs and bilateral pleural effusion, severe on Rt.
Transthoracic echocardiography(Fig) shows mitral valvular prolapse caused by chordae rupture (mainly P3), resulting in severe mitral regurgitation, moderate pulmonary hypertension, IVC plethora, LA enlargement and grade I diastolic dysfunction.
The patient showed elevated hs-CRP(144.44), but normal WBC count and cardiac markers such as CK-MB and troponin-I, normal invasive coronary angiogram and nonspecific EKG.
After echocardiography confirmed mitral valvular prolapse, the patient underwent mitral valvular replacement four days later.
Brief Review
Cardiogenic pulmonary edema secondary to left ventricular heart failure tends to be located in the dependent portions of the lungs and typically is bilateral and symmetric [1].
Atypical radiologic findings of pulmonary edema have been described in the following various conditions;(1)gravitational effect (prolonged lateral decubitus),(2)alterations in lung perfusion (pulmonary thromboembolism, chronic obstructive pulmonary disease, Swyer-James syndrome), (3) alterations in pulmonary venous drainage (unilateral veno-occlusive disease, atrial myxoma),(4) alterations in intrapleural pressure (abrupt pneumothorax reexpansion), and (5) alterations in pulmonary ventilation (bronchial obstruction) [1,2].
References
1. Milne EN, Pistolesi M, Miniati M, Giuntini C. The radiologic distinction of cardiogenic and noncardiogenic edema. AJR Am J Roentgenol 1985;144:879-94.
2. Alarcon JJ, Guembe P, de Miguel E, Gordillo I, Abellas A. Localized right upper lobe edema. Chest 1995;107:274-6.
Keywords
Lung, Edema, Hydrostatic edema,

No. of Applicants : 84

▶ Correct Answer : 15/84,  17.9%
  • - Niigata City General Hospital , Japan Takao Kiguchi
  • - Yokohama-asahi-chuo-general hospital , Japan Kyoko Nagai
  • - Mallinckrodt Institute of Radiology , United States Naganathan Mani
  • - Asan Medical Center, Ulsan University , Korea (South) Mi Young Kim
  • - Asan medical center , Korea (South) Hyun Joo Lee
  • - Asan medical center , Korea (South) Sang Young Oh
  • - Seoul National University Hospital , Korea (South) Sang Min Lee
  • - Asan Medical Center, Department of Radiology , Korea (South) Hongseok Ko
  • - ACE DIAGNOSTICS , India DAMANDEEP CHAWLA
  • - Kyungpook National Univ. Hospital , Korea (South) Park jongmin
  • - chp st martin , France Mariotte benoit
  • - CLINIQUE STE CLOTILDE , Reunion patrick MASCAREL
  • - TCM HOSPITAL OF ZIGONG , China Cao Cunyou
  • - Kyungpook national universtiy hospital , Korea (South) Hong Jihoon
  • - Medicheck health care , Korea (South) Chae Lim
▶ Correct Answer as Differential Diagnosis : 21/84,  25.0%
  • - Avrasya Hospital , Turkey Murat Ulusoy
  • - Oita University, Faculty of Medicine , Japan Fumito Okada
  • - ICD,MCH CALICUT , India rikhy krishnan
  • - Diskapi Yildirim Beyazit Hospital, Ankara , Turkey Meric Tuzun
  • - Dong-A University Hospital , Korea (South) Ji-yeon Han
  • - Dong-A University Hospital , Korea (South) Kyun-Jae Lim
  • - University of British Columbia , Canada Amr Ajlan
  • - Onomichi Municipal Hospital , Japan Yoshihisa Masaoka
  • - Tokyo Metropolitan Police Hospital , Japan Akifumi Hagiwara
  • - Eren T캇p Merkezi Istanbul , Turkey Armagan Sarac
  • - Niigata University , Japan Atsushi Uehara
  • - kanto Rosai Hp , Japan Takana Yamakawa
  • - Kizawa Memorial Hospital , Japan Yo Kaneko
  • - IRSA LA ROCHELLE , France, Metropolitan BIGOT
  • - IRSA La Rochelle , France Denis Chabassiere
  • - CAC Rennes , France nicolas gautier
  • - Private sector , Greece Vasilios Tzilas
  • - Northern Yokohama Showa university , Japan Kota Watanabe
  • - Research Hospital, The Institute of Medical Science, The University of Tokyo , Japan Toshihiro Furuta
  • - C.B.H. Dpt of Imaging-"Clinica Mater Dei" Bari , Italy Carlo Florio
  • - Kyungpook National University Hospital , Korea (South) Jaekwang Lim
▶ Semi-Correct Answer : 2/84,  2.4%
  • - prince salman bin abdulaziz university , Saudi Arabia NABIL GHALEB
  • - Goa Medical College , India Paresh Desai
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