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

Abstract

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.

Keywords: Acute Myocardial Infarction; Heart Failure; Mitral Regurgitation; Unilateral Pulmonary Edema.

Fig. 1

Initial 12-lead electrocardiogram showing: ST depression in V4-6 and II, III, aVF leads, QS pattern in V1-3 leads, ST elevation in aVR and VPC bigeminy.

Fig. 2

Chest x-ray. (A) Anteroposterior radiograph of the chest at admission showing alveolar-interstitial infiltrates limited to the right lung. (B) Anteroposterior radiograph of the chest post-successful PCI showing a unilateral homogenous pulmonary opacity occupying the right lobe, and right pleural effusion. (C) Posteroanterior radiograph of the chest at discharge showing complete resolution of the unilateral pulmonary edema.

Fig. 3

Transthoracic echocardiography on admission and four days later after percutaneous coronary intervention (PCI). Echocardiography on admission showing global hypokinesia, mild mitral regurgitation (MR) and left atrium (LA) enlargement (LA volume, 54 mL) (A, B). Four days later after PCI, left ventricular contraction and LA enlargement have improved (LA volume, 34 mL), and MR has resolved (C, D).

Fig. 4

Coronary artery angiography during the primary percutaneous coronary intervention. (A) Left coronary angiography showing significant stenosis from the distal left main coronary artery to the mid left anterior descending artery with thrombolysis in myocardial infarction (TIMI) 2 flow and total occlusion at the ostium of the left circumflex artery with TIMI 0 flow. (B) Final coronary angiography showing successful revascularization without periprocedural complications.

Fig. 5

Computed tomography scan revealing consolidation and ground-glass opacity in the dependent portion of the right lung, with pleural effusion limited to the right lung.