,
, CASE 1
A B
History: No patient history is available. 3. If this patient presented with severe chest pain and
no infectious symptoms, what would be the most
1. What should be included in the differential likely diagnosis?
diagnosis for ground-glass opacity? (Choose all A. Right upper lobe pulmonary edema
that apply.) B. Atypical pneumonia
A. Pulmonary edema C. Pulmonary hemorrhage
B. Pneumonia D. Adenocarcinoma in situ (bronchioloalveolar cell
C. Pulmonary hemorrhage carcinoma)
D. Adenocarcinoma in situ (bronchioloalveolar cell
carcinoma) 4. If acute mitral regurgitation is the suspected
diagnosis based on the chest radiograph and clinical
2. If this patient presented with fever and a productive presentation, what is the next best step in
cough, what is the most likely diagnosis? management?
A. Right upper lobe pulmonary edema A. CT
B. Atypical pneumonia B. Echocardiography
C. Pulmonary hemorrhage C. Follow-up radiograph
D. Adenocarcinoma in situ (bronchioloalveolar cell D. MRI
carcinoma)
3
, ANSWERS
CASE 1
Severe and Acute Mitral Regurgitation
1. A, B, C, and D
2. B
3. A
4. B
Reference
Schnyder PA, Sarraj AM, Duvoisin BE, et al: Pulmonary edema associ-
ated with mitral regurgitation: prevalence of predominant involve-
ment of the right upper lobe, AJR Am J Roentgenol 161(1):33–36,
1993.
Cross-Reference
Cardiac Imaging: The REQUISITES, ed 3, pp 191–194.
Comment
Pathophysiology
Asymmetric right upper lobe pulmonary edema is seen
in 9% of adults and 22% of children with severe mitral
regurgitation. In adults, it is usually caused by a flail
posterior valve leaflet secondary to myocardial infarc-
tion. A flail posterior leaflet causes the mitral regurgitant
jet to be preferentially directed into the right superior
pulmonary vein; this leads to focal increased hydrostatic
pressure and pulmonary edema within the right upper
lobe. In the setting of chest pain, acute mitral regurgita-
tion must be considered and can be confirmed with
echocardiography.
Imaging
The radiograph (Fig. A) and CT scan (Fig. B) show asym-
metric right upper lobe ground-glass opacity. The dif-
ferential diagnosis varies depending on the patient’s
clinical presentation. In the setting of fever and produc-
tive cough, the imaging findings are consistent with
atypical pneumonia. In this case, the patient had severe
chest pain and acute myocardial infarction. Echocardiog-
raphy confirmed severe mitral regurgitation.
Notes
4
, CASE 1
A B
History: No patient history is available. 3. If this patient presented with severe chest pain and
no infectious symptoms, what would be the most
1. What should be included in the differential likely diagnosis?
diagnosis for ground-glass opacity? (Choose all A. Right upper lobe pulmonary edema
that apply.) B. Atypical pneumonia
A. Pulmonary edema C. Pulmonary hemorrhage
B. Pneumonia D. Adenocarcinoma in situ (bronchioloalveolar cell
C. Pulmonary hemorrhage carcinoma)
D. Adenocarcinoma in situ (bronchioloalveolar cell
carcinoma) 4. If acute mitral regurgitation is the suspected
diagnosis based on the chest radiograph and clinical
2. If this patient presented with fever and a productive presentation, what is the next best step in
cough, what is the most likely diagnosis? management?
A. Right upper lobe pulmonary edema A. CT
B. Atypical pneumonia B. Echocardiography
C. Pulmonary hemorrhage C. Follow-up radiograph
D. Adenocarcinoma in situ (bronchioloalveolar cell D. MRI
carcinoma)
3
, ANSWERS
CASE 1
Severe and Acute Mitral Regurgitation
1. A, B, C, and D
2. B
3. A
4. B
Reference
Schnyder PA, Sarraj AM, Duvoisin BE, et al: Pulmonary edema associ-
ated with mitral regurgitation: prevalence of predominant involve-
ment of the right upper lobe, AJR Am J Roentgenol 161(1):33–36,
1993.
Cross-Reference
Cardiac Imaging: The REQUISITES, ed 3, pp 191–194.
Comment
Pathophysiology
Asymmetric right upper lobe pulmonary edema is seen
in 9% of adults and 22% of children with severe mitral
regurgitation. In adults, it is usually caused by a flail
posterior valve leaflet secondary to myocardial infarc-
tion. A flail posterior leaflet causes the mitral regurgitant
jet to be preferentially directed into the right superior
pulmonary vein; this leads to focal increased hydrostatic
pressure and pulmonary edema within the right upper
lobe. In the setting of chest pain, acute mitral regurgita-
tion must be considered and can be confirmed with
echocardiography.
Imaging
The radiograph (Fig. A) and CT scan (Fig. B) show asym-
metric right upper lobe ground-glass opacity. The dif-
ferential diagnosis varies depending on the patient’s
clinical presentation. In the setting of fever and produc-
tive cough, the imaging findings are consistent with
atypical pneumonia. In this case, the patient had severe
chest pain and acute myocardial infarction. Echocardiog-
raphy confirmed severe mitral regurgitation.
Notes
4
