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A 90-year-old male patient who had been treated at our institution for chronic heart failure associated with mitral regurgitation and chronic atrial fibrillation presented at the outpatient clinic with aggravated wheezing, dyspnea upon exertion, and facial/lower leg edema that had started 3 days earlier. The vital signs upon presentation were as follows: blood pressure, 125/77mmHg; pulse, 90/min with irregularity; respiratory rate, 24/min; temperature, 36.2°C; SpO2, 90% (without oxygen). Apical holosystolic murmur of Levine grade 3/6 was heard. Coarse crackles were heard in the right upper lung. The blood test results were as follows: WBC 5,470/µl; C-reactive protein 1.0mg/dl; brain natriuretic peptide 394pg/ml. Results of the sputum culture were negative. The chest radiograph showed heart enlargement, bilateral pulmonary vascular congestion and remarkable localized right upper lobe consolidation (Figure 1a). Echocardiography revealed mitral regurgitation worse than that detected in the previous examination. The patient was admitted with aggravated chronic heart failure. The symptoms improved with diuretic treatment. The chest radiograph at 5 days showed a decreased shadow (Figure 1b).
Right upper lobe pulmonary edema is caused by selective entry of a regurgitation jet into the right upper lobe vein in the presence of mitral insufficiency.1,2 Mitral valve insufficiency should be suspected when the chest radiograph shows right upper lobe pulmonary edema, especially in combination with findings suggestive of left-sided heart failure.
Conflict of interest: None declared.