Other causes of unilateral pulmonary edema

Correspondence 129

will generate artifact in different location, whereas a true dissection will be consistent. Reconstruction by a multi- detector row CT (helical CT) in a sagittal view will also give a more accurate assessment of aortic artifact [12,13]. Cardiac gating has been shown to reduce the artifact at the aortic root [14]. However, in emergency condition, its application has not yet been validated [12]. Transesophageal echocardiogram could also assist in proper diagnosis. The sensitivity and specificity of TEE have been reported to be as high as 98% and 63% to 96%, respectively [15]. The main limitation of TEE is its strong dependence on the experience of the investigator.

Missed diagnosis of aortic dissection leads to a poten- tially lethal outcome, whereas misjudgment of artificial images results in unnecessary thoracotomy. Familiarity with these diagnostic pitfalls of CT facilitates correct recognition of aortic dissection.

Wen-Chu Chiang MD, MPH

Pei-Chieh Kao MD Chan-Ping Su MD

Department of Emergency Medicine National Taiwan University Hospital, Yun-Lin Branch

Taipei 100, Taiwan E-mai address: [email protected]

Juan Hsu MD

Department of Cardiovascular Surgery National Taiwan University Hospital, Yun-Lin Branch

Taipei 100, Taiwan

doi: 10.1016/j.ajem.2006.04.011


  1. Klompas M. Does this patient have an acute thoracic aortic dissection?

JAMA 2002;287:2262 – 72.

  1. Khan IA, Nair CK. Clinical, diagnostic, and management perspectives of aortic dissection. Chest 2002;122:311 – 28.
  2. Trauma radiology misread/over-read images and reviews. Available at: [accessed on Mar 30, 2006].
  3. Hagan PG, Nienaber CA, Isselbacher EM, et al. The International

Registry of Acute Aortic Dissection (IRAD): new insights into an old disease. JAMA 2000;283:897 – 903.

  1. Spittell PC, Spittell Jr JA, Joyce JW, et al. Clinical features and

differential diagnosis of aortic dissection: experience with 236 cases (1980 through 1990). Mayo Clin Proc 1993;68:642 – 51.

  1. Bickerstaff LK, Pairolero PC, Hollier LH, et al. Thoracic aortic aneurysms: a population-based study. Surgery 1982;92:1103 – 8.
  2. Nienaber CA, von-Kodolitsch Y, Nicolas V, et al. The diagnosis of thoracic dissection by noninvasive imaging procedures. N Engl J Med 1993;328:1 – 9.
  3. Batra P, Bigoni B, Manning J, et al. Radiographics 2000;20:309 – 20.
  4. Duvernoy O, Coulden R, Ytterberg C. Aortic motion: a potential pitfall in CT imaging of dissection in the Ascending aorta. J Comput Assist Tomogr 1995;19:569 – 72.
  5. Qanadli SD, Hajjam M, Mesurolle B, et al. motion artifacts of the aorta simulating aortic dissection on spiral CT. J Comput Assist Tomogr 1999;23:1 – 6.
  6. Wheat MW. acute dissection of the aorta. Cardiovasc Clin 1987; 17:241 – 62.
  7. Willoteaux S, Lions C, Gaxotte V, et al. Imaging of aortic dissection by

helical computed tomography (CT). Eur Radiol 2004;14:1999 – 2008.

  1. Kapustin AJ, Litt HI. Diagnostic imaging for aortic dissection. Semin Thorac Cardiovasc Surg 2005;17:214 – 23.
  2. Morgan-Hughes GJ, Owens PE, Marshall AJ, et al. thoracic aorta at multi-detector row CT: motion artifact with various reconstruction windows. Radiology 2003;228:583 – 8.
  3. Keren A, Kim CB, Hu BS, et al. Accuracy of biplane and multiplane transesophageal echocardiography in diagnosis of typical acute aortic dissection and intramural hematoma. J Am Coll Cardiol 1996; 28:627 – 36.

Other causes of unilateral pulmonary edema

To the Editor,

We read with interest the article bUnilateral pulmonary edema related to massive mitral insufficiencyQ wherein the authors describe the occurrence of unilateral pulmonary edema after mitral insufficiency [1]. We describe a case of unilateral pulmonary edema related to end-stage renal disease that improved rapidly with hemodialysis and review the literature for the causes of unilateral pulmonary edema. A 34-year-old man, with a known case of end-stage renal disease (secondary to chronic glomerulonephritis) requiring maintenance hemodialysis, presented in the emergency department with severe dyspnea. Over the previous 12 hours, he experienced progressive orthopnea and cough with mucoid expectoration. The last session of hemodialysis was administered 24 hours ago, and the patient denied any history of undue salt or water intake, hemoptysis, or fever. On examination, the patient was pale, in severe respiratory distress, and had to sit in an upright position as a result of orthopnea. Blood pressure was 160/90 mm Hg, pulse rate 110/min, respiratory rate 34/min, and oral temperature

37.28C. Auscultation revealed diminished breath sounds over the lower two thirds of the left lung and crackles in the lower one third of the right lung. Auscultation of the heart was normal. The progressive orthopnea led to the Initial diagnosis of pulmonary edema, and the patient was shifted to the respiratory intensive care unit where he was treated with oxygen, intravenous diuretics, and morphine. Preliminary investigations revealed a white blood cell count

of 12000/lL with 70% neutrophils, hemoglobin level of

9.3 g/dL, creatinine level of 8.2 mg/dL, sodium level of 141 mEq/L, potassium level of 5.8 mEq/L, and Creatine phosphokinase (MB isozyme) of 20 IU/L. Arterial blood gas analysis revealed a pH of 7.2, Pao2 of 62 mm Hg, Paco2 of 25 mm Hg, and HCO3 of 10 mEq/L, at Fio2 of 0.28. The electrocardiogram demonstrated sinus tachycardia. Chest x-ray revealed a unilateral homogenous pulmonary opacity occupying the right lower lobe and left pleural effusion (Fig. 1). Bedside echocardiography was normal with a left ventricular ejection fraction of 56%. Although the patient’s

130 Correspondence

temperature was normal, in the presence of a unilateral pulmonary infiltrate, as pneumonia could not be ruled out, treatment with intravenous cefpirome and azithromycin was initiated. In view of metabolic acidosis and hyperkalemia the patient underwent hemodialysis. After the dialysis, the patient’s disease course was characterized by rapid recov- ery: within a few hours, breathing improved dramatically and repeated arterial blood gas analysis revealed a pH of 7.32, Pao2 of 72 mm Hg, Paco2 of 35 mm Hg, and HCO3 of 18 mEq/L, at FiO2 0.21. Repeat chest x-ray obtained 12 hours after admission showed resolution of the pulmo- nary opacity with residual left pleural effusion (Fig. 2). These findings, together with the lack of fever, suggested that pneumonia was not a likely diagnosis. Moreover, sputum for culture and Gram stain was negative and we terminated the antibiotic treatment. The patient was inves- tigated for the left pleural effusion. Pleural biopsy showed caseous granulomas with acid-fast bacilli. The patient was started on antituberculous therapy and discharged unevent- fully after 7 days of hospitalization with advice for regular maintenance hemodialysis.

Unilateral pulmonary edema is an uncommon, if not rare,

entity that can be mistaken for other causes of unilateral alveolar and interstitial infiltrates, especially pneumonia. It has been described after congestive heart failure [2], prolonged rest on one side in a patient with cardiac decompensation or receiving large amounts of fluids [3], in patients with mitral valve insufficiency [1], in cases of rapid expansion of the lung after Pleural effusions and pneumothorax [4], in the normal lung in patients with

Fig. 1 Chest radiograph shows prominent right hila and dense homogenous opacity in the right lower lobe; also present are left pleural effusion and a central venous catheter for dialysis.

Fig. 2 Chest radiograph shows complete clearing of the opacities on the right side.

unilateral pulmonary disease such as MacLeod syndrome

[5] and unilateral pulmonary agenesis [6], after talc pleurodesis [7], trauma [8], epilepsy [9], upper airway obstruction [10], pulmonary artery compression from aortic dissection [11,12], pulmonary venous obstruction from mediastinal fibrosis [13] or postlobectomy [14], unilateral main stem intubation [15], Neurogenic pulmonary edema [16], nitrogen mustard [17], amiodarone-related [18] and heroin-related [19] pulmonary edema, pregnancy [20], and in cases of fluid overload [21-23].

Unilateral pulmonary edema can result from myriad of causes. Thus, even if the pulmonary opacities are unilateral, if the clinical manifestation is compatible with pulmonary edema and not with pneumonia, early and aggressive treatment should be initiated for pulmonary edema.

Ritesh Agarwal MD, DM Ashutosh N. Aggarwal MD, DM

Dheeraj Gupta

Department of Pulmonary Medicine Postgraduate Institute of Medical Education and Research

Chandigarh-160012, India

E-mail addresses: [email protected]

[email protected]



  1. Legriel S, Tremey B, Mentec H. Unilateral pulmonary edema related to massive mitral insufficiency. Am J Emerg Med 2006;24(3):372.

Correspondence 131

  1. Nitzan O, Saliba WR, Goldstein LH, Elias MS. Unilateral pulmonary edema: a rare presentation of congestive heart failure. Am J Med Sci 2004;327(6):362 – 4.
  2. Leeming BW. Gravitational edema of the lungs observed during assisted respiration. Chest 1973;64(6):719 – 22.
  3. Murat A, Arslan A, Balci AE. Re-expansion pulmonary edema. Acta Radiol 2004;45(4):431 – 3.
  4. Saleh M, Miles AI, Lasser RP. Unilateral pulmonary edema in Swyer- James syndrome. Chest 1974;66(5):594 – 7.
  5. Nana-Sinkam P, Bost TW, Sippel JM. Unilateral pulmonary edema in a 29-year-old man visiting High altitude. Chest 2002;122(6):2230 – 3.
  6. Scalzetti EM. Unilateral pulmonary edema after talc pleurodesis. J Thorac Imaging 2001;16(2):99 – 102.
  7. Dempster AG. Unilateral pulmonary edema complicating chest compression and cardiac avulsion. Am J Forensic Med Pathol 1986; 7(4):350 – 3.
  8. Koppel BS, Pearl M, Perla E. Epileptic seizures as a cause of unilateral pulmonary edema. Epilepsia 1987;28(1):41 – 4.
  9. Morisaki H, Ochiai R, Takeda J, Nagano M. Unilateral pulmonary edema following acute subglottic edema. J Clin Anesth 1990;2(1):42 – 4.
  10. McTigue C, Scurry JP, Silberstein M. Unilateral pulmonary edema associated with pulmonary arterial compression. Australas Radiol 1988;32(3):390 – 3.
  11. Takahashi M, Ikeda U, Shimada K, Takeda H. Unilateral pulmonary edema related to pulmonary artery compression resulting from acute dissecting aortic aneurysm. Am Heart J 1993;126(5):1225 – 7.
  12. Routsi C, Charitos C, Rontogianni D, Daniil Z, Zakynthinos E. Unilateral pulmonary edema due to pulmonary venous obstruction from fibrosing mediastinitis. Int J Cardiol 2006;108(3):418 – 21.
  13. Gyves-Ray KM, Spizarny DL, Gross BH. Unilateral pulmonary edema due to postlobectomy pulmonary vein thrombosis. AJR Am J Roentgenol 1987;148(6):1079 – 80.
  14. Kramer MR, Melzer E, Sprung CL. Unilateral pulmonary edema after intubation of the right mainstem bronchus. Crit Care Med 1989; 17(5):472 – 4.
  15. Perrin C, Jullien V, Venissac N, Lonjon M, Blaive B. Unilateral neurogenic pulmonary edema. A case report. Rev Pneumol Clin 2004; 60(1):43 – 5.
  16. Goodman LR, Shanser JD. Unilateral pulmonary edema. An unusual complication of nitrogen mustard therapy. Radiology 1976; 120(1):166.
  17. Herndon JC, Cook AO, Ramsay MA, Swygert TH, Capehart J. Postoperative unilateral pulmonary edema: possible amiodarone pulmonary toxicity. Anesthesiology 1992;76(2):308 – 12.
  18. Sporer KA, Dorn E. Heroin-related Noncardiogenic pulmonary edema: a case series. Chest 2001;120(5):1628 – 32.
  19. Choi HS, Choi H, Han S, et al. Pulmonary edema during pregnancy: unilateral presentation is not rare. Circ J 2002;66(7):623 – 6.
  20. Balogun SA, Balogun RA. Acute unilateral pulmonary edema from dietary salt and water load: a case report and review of the literature. Conn Med 2001;65(11):653 – 6.
  21. Di Benedetto C, Brunner W, Kuhn M. Unilateral pulmonary edema in a dialysis patient with massive fluid overload and mitral valve insufficiency. Schweiz Rundsch Med Prax 2003;92(29-30): 1265 – 8.
  22. Wong KS, Lin GJ, Lai CH, Lien R. Unilateral pulmonary edema: an uncommon presentation of poststreptococcal glomerulonephritis. Pediatr Emerg Care 2003;19(5):337 – 9.

Leave a Reply

Your email address will not be published. Required fields are marked *