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

2. Case of the Month 3 11 th Jan 2013

3. Case of the Month 3

4. 30 th Jan 2013 Case of the Month 3

5. 30 th Jan 2013 Case of the Month 3

6. Diagnosis What is your diagnosis ?

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

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

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

11.  Thickening of the minor fissure

12.  Enlargement of the pulmonary arterial vessels Case of the Month 3

13.  Cardiomegaly Case of the Month 3  Predominantly of the left heart chambers

14.  Aortic dilation Case of the Month 3

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

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

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

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

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

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

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

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

23. 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

24. 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

25. 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

26. 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

27. 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:e6 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

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

29. 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

30. 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

31. 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

32. 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:e6 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