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An Unusual Case of Unilateral Pulmonary Edema With Contralateral Bronchial Obstruction FREE TO VIEW

Rami Jambeih, MD; Brent Brown, MD; David Huard, MD; Syed Naqvi, MD
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University of Oklahoma Health Sciences Center, Oklahoma City, OK

Chest. 2013;144(4_MeetingAbstracts):910A. doi:10.1378/chest.1701599
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SESSION TITLE: Miscellaneous Case Report Posters II

SESSION TYPE: Affiliate Case Report Poster

PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM

INTRODUCTION: Unilateral pulmonary edema (UPE) is a rare entity and it’s usually misdiagnosed as infection, or aspiration. We represent a unique case of UPE secondary to contralateral bronchial obstruction.

CASE PRESENTATION: A 61 year old male patient presented with right pulmonary infiltrates and was diagnosed with renal cell carcinoma and pulmonary metastasis. His CT scan showed multiple metastatic lesions with obstruction of the left main bronchus, patchy ground glass appearance of the right lung with prominent right pulmonary vasculature comparing to the left side, suggestive of right pulmonary edema. There was no significant left pulmonary artery or right pulmonary vein obstruction. Echocardiogram revealed no evidence of heart failure or valvular heart disease. Bronchoscopy showed almost complete obstruction of the left main bronchus by the endobronchial tumor which was partially destroyed using alternating rounds of APC and CO2 laser. There was a marked reduction in Oxygen requirement immediately during and after tumor destruction. BAL of the RML and LLL were negative for bacterial, fungal, viral and atypical infection. A repeat chest X ray several days later showed resolution of the right pulmonary infiltrates.

DISCUSSION: UPE is rare and accounts for only 2.1 % of cardiogenic pulmonary edema. In our case, the most likely explanation of the mechanism of pulmonary edema is a hypoxic vasoconstriction of the left pulmonary vessels secondary to the obstructing left main bronchus mass. This led to an increased pulmonary artery pressure, which was preferentially transmitted to the right pulmonary vasculature because of the increased vascular resistance on the left side. The destruction of a significant part of the left endobronchial tumor, resulted in resolution of the hypoxic vasoconstriction and improvement of the pulmonary edema. The pathophysiology of pulmonary edema in our case is different from other cases of bronchial obstructions where the negative intrapleural pressure, created by bronchial obstruction during inspiration, leads to ipsilateral pulmonary edema [1]. It’s also different from the pulmonary edema secondary to reexpansion which occurs after relief of bronchial obstruction [2]. To our knowledge, there’s only one similar case reported in the literature [3].

CONCLUSIONS: This case demonstrates a rare mechanism of UPE and emphasizes about the importance of considering pulmonary edema as a differential diagnosis of unilateral pulmonary infiltrates when there's a contralateral bronchial obstruction.

Reference #1: Sato F. Negative pressure pulmonary edema during tracheal Dumon stent implantation .J Bronchology Interv Pulmonol. 2012 Oct;19(4):345-8

Reference #2: Morikawa H. Re-expansion pulmonary oedema following removal of intrathoracic haematoma. Acta Anaesthesiol Scand. 1994 Jul;38(5):518-20.

Reference #3: Shikhani AH. Unilateral pulmonary edema as a complication of contralateral bronchial obstruction. Laryngoscope. 1987 Jun;97(6):748-51.

DISCLOSURE: The following authors have nothing to disclose: Rami Jambeih, Brent Brown, David Huard, Syed Naqvi

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