CME INDIA Case Presentation by Dr Deepak Gupta, DM, Card, Pulse Hospital, Ranchi.
CME INDIA Case Study:
Case presented in CSI, Jharkhand and CME INDIA groups
In this COVID era, Severe SOB. Fever, high count. Patient presented with chest pain on 30th October, 2020. What could be the diagnosis?
Most of physicians thought about COVID Pneumonia
Dr D P Khaitan, Gaya: ECG
- Inferoposterior MI. I wish to clear my doubts on one point.
- Is there associated atrial Flutter ,to me visible on V1 – just proximal to QRS.( V1 a good lead to see atrial activity).
Dr Sanjeev Yadav, Heamatologist, SGPGI, Lucknow: Do repeat sampling for COVID19 RT PCR
Query about Pulmonary embolism/Pneumothorax
Dr Deepak Gupta: No. Trop T positive.
Is it pneumonia or pulmonary oedema? Few days back patient came from another hospital
Dr P G Sarkar, DM Card., RIMS, Ranchi:
- It is hard to say pneumonia vs pulm oedema. Even acute severe MR can cause unilateral pulmonary oedema due to eccentric jet. Maybe echocardiography will reveal
- From ECG looks like acute inf post MI.
- Is MR present? What about LV function?
Dr Varun Kumar, DM Card., Ranchi: If it is pulmonary oedema then such unilateral presentation?
Dr Deepak Gupta, Ranchi:
What is needed? CCT admission or cardiology admission?
Fever, raised TC DC, Corade 5 in CT. CCT wants to give antibiotic and Iv fluid Vs ECG changes, Trop T positive, Cardiologist wants to give diuretic only and ACS treatment.
Echo in ER bed side: RWMA in LCX territory with moderate MR, LVEF 40%
Dr Varun Kumar, Ranchi: Well here you have to first make out what is the dominant problem. A patient with LVEF of 40% & Mod MR should not be in gasping condition. There would have been other problems as well.
CAG done/Further course
- Ecg showed inf post MI. CAG done LCX 100 % blocked.
- Advised PTCA. Pt refused PTCA in another hospital and gradually went into unilateral pulmonary oedema. He came in severe breathless condition and intubated in ER itself. High dose diuretic given with inotropes.
- Pt gradually improved and extubated but kept on conservative treatment. Echo showed eccentric MR that is reason of unilateral pulmonary oedema. If refractory it is advisable for mitral valve repair. Patient became asymptomatic after 1 week on anti-failure treatment. What next …
Further Course
Dr Satish Kumar,Bokaro:
- Looks like Lt Posterior Fascicular VT.The 4 parameters supporting the diagnosis of LPF-VT include.
- Atypical RBBB–like V1 morphology, (2) Positive QRS in aVr, (3) V6 R/S ratio ≤1, and (4) QRS ≤140 ms.* QRS is bit wider, though.
Dr Sanjay Kumar, Cardiothoracic Surgeon, Ranchi:
- MR has to be repaired.
- We had operated similar type of case in which MR developed after PTCA to RCA ( giving rise PLB).
- Patient deteriorated in CCU started desaturating in peak Covid times.
- Then developed AKI , went on ventilator, Anuria on dialysis on IABP , on TEE severe MR so immediately CABG and MVR done. After that Patient behaved well and urine opened up and no need of dialysis in post op. If timely intervened results dramatic .
Dr Varun Kumar, Ranchi: This is secondary VT , due to scarred myocardium.Would need AICD.
Dr Deepak Gupta, Ranchi: This VT is not responding to DC shock or amiodarone or betablocker . What next
Dr Varun Kumar, Ranchi: Give Xylocard/ Patient had severe MR but earlier you wrote moderate MR.
Dr Deepak Gupta: Echo in ER with ventilated patient. Yes, that’s why I wrote that if it is pulmonary oedema due to cardiac cause then patient would have been in right lateral position resulting in unilateral shadow in X-ray.
Dr Satish Kumar, Bokaro: Verapamil 😉
Dr Varun Kumar, Ranchi: This is not idiopathic VT.
Dr P G Sarkar: 👍🏼👍🏼👍🏼: Can this Xray give a clue to which leaflet is flail sir?
Dr Deepak Gupta:
- Post leaflet. After Xylocard, ECG reverted to sinus rhythm.
- This was also a case of unilateral pulmonary oedema due Inf posterior wall MI and chordal rupture of papillary muscle developed after 2nd to 3rd days of MI.
- Responded very well with IV diuretic. Extubated after 2 days.
CME INDIA Take home message:
It is unilateral pulmonary edema( UPE) not effusion
- Consider this diagnosis if background history suggest cadriogenic.
- Post MI pt if deteriorate on 3rd to 5th day , must consider mechanical complication.
- Post MI fever and raised count and lung opacity some time misdiagnosed as pneumonia/Antibiotics ok but fluid over load may be hazardous.
CME INDIA Learning Points:
(Dr DP Khaitan, Gaya)
- If a patient comes with ECG evidence of such acute Inferoposterior MI with cardiogenic shock with basal bilateral pul crepitations and reduced EF on cardiac echo and MR on auscultation ,one should think in the term of ruptured Chordae tedinae , so always try to exclude pulmonary oedema and it was interesting there to find unilateral pulmonary oedema over the Rt. pulmonary field in this case.
- Even with minimal resources available one can save a life in a critical situation if one’s clinical suspicion and diagnosis overrides the supplementary evidence.
- UPE is a completely reversible condition with good patient outcome if it is suspected early and treated early.
CME INDIA Tail Piece:
- UPE [Unilateral Pulmonary Oedema] is a rare entity that can be mistaken for other causes of unilateral infiltrate on chest radiography, especially pneumonia.
- UPE has been reported after congestive heart failure, prolonged rest on one side in patients with cardiac decompensation or receiving large amounts of fluids, in cases of rapid expansion of the lungs after pleural effusion, and pneumothorax
- It is also seen in a normal lung in patients with unilateral pulmonary disease such as MacLeod syndrome and unilateral pulmonary artery hypoplasia or agenesis, pulmonary artery compression from aortic dissection or LV pseudo aneurysm, and pulmonary venous obstruction from mediastinal fibrosis. However, it is mainly reported in association with severe MR
- During the early phase of acute myocardial infarction (AMI), transient ischemic MR is common and sometimes causes hemodynamic compromise. However, when several chordate tendineae or papillary muscle rupture occurs, this can lead to abrupt hemodynamic deterioration with cardiogenic shock. It is important to have a high index of suspicion for acute MR in any patient with acute pulmonary oedema in the setting of AMI, especially if LV systolic function is well preserved
- A unilateral radiography pattern may lead to a false diagnosis of pneumonia and so delay management. Although the induction of an acute phase reaction and an elevated peripheral leukocyte count, especially of neutrophils, in patients with AMI has been reported to be related to the extent of myocardial infarction and with prognosis, the association of unilateral pulmonary infiltrates with leucocytosis and/or acute respiratory distress often leads to antibiotic therapy, despite the absence of fever, especially in older patients
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6090641/
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A rare case ofRt lung non tuberculous upper unilateral pulmonary oedema due to Mitral valve prolapse after MR from infarct.The site is typically in the upper and middle lobes.The response to treatment with xylocard and diuretics came as a welcome surprise.
An eye opener. More so it was managed conservatively. The thought of chordal rupture and not being complacent with the diagnosis of pneumonia is worth learning.