48-year-old man with sudden onset of 3-4 episodes of massive hemoptysis. Overview
- Presenting Complaint
- Patient History
- Review of Systems
- Physical Examination
- Diagnostic Test
- Diagnostic Imaging
- Diagnosis and Management
- Discussion
A 48-year-old man was admitted to hospital with sudden onset of 3-4 episodes of massive hemoptysis.
- History of presenting
- Past Medical/Social hoistory
- Past surgical history
- Family history
- Current Medication
no previous diagnosed history of COPD, autoimmune disease, tuberculosis,
no previous bleeding disorders.
Previous PPD test negative.
Personal history-smoker
General
Heent
Neck
Cardiovascular
Lungs
Abdomen
Extremities
Skin
Neurological Exam
- Bio Chemistry
- Pathology
- Microbiology
- Hematology
- Miscellaneous
Sodium: 136 meq/L( normal 135-145 meq/L)
Potassium: 3.7 meq/L (normal 3.5-5.0 meq/L)
Chloride: 101 meq/L(normal 96-108 meq/L)
Bicarb: 23 meq/L(normal 22-30 meq/L)
Magnesium: 2.1 mg/dl ( normal 1.7 to 2.2 mg/dL )
Phos.: 2.9 mg/dl ( normal 2.8 to 4.5 mg/dL)
Bun: 22 mg/dl ( normal 6-23 mg/dL)
Creat: 1.5 mg/dl ( normal 0.7 -1.3 mg/dL)
Liver Enzymes - SGOT/AST: 22 U/L ( normal 1-35 )
SGPT/ ALT: 33 U/L ( normal 1-45 )
GGT: 24 U/L ( normal 8-38 )
Direct Bilirubin: 0.2 mg/dl ( normal 0.1-0.3 )
Total Bilirubin: 1.1 mg/dl ( normal 0.1 - 1.2 )
Hemoglobin: 9.5 mg/dl
Hematocrit: 22 %
White Count: 9000 ( normal 4,500 to 11,000 WBCs per microliter )
Platelets: 170,000 platelets per microliter of blood ( normal 150,000 to 450,000 platelets per microliter of blood)
Differential: normal
CRP: WNL
ESR: WNL
- CT Scan
- Xray
- MRI
- Ultrasound
- Echo
- Endoscopic
- Miscellaneous
airspace consolidations in the right upper and middle lobes with faint, bilateral ground glass opacity and left atrial enlargement
mild cardiomegaly and consolidations on the right lung
Ejection fraction of 45% with normal ventricular size, an enlarged left atrium and severe mitral regurgitation (Grade IV) with significant prolapse of the mitral valve (P1).pulmonary artery systolic pressure was elevated, with minimal aortic and tricuspid regurgitation
- fiberoptic bronchoscopy -DIFFUSE alveloar hemorrhage in right middle lobe with no evidence of endobronchial mass lesion seen on bronchoscopic examination , persistently pinkish color seen in the retrieved bronchoalveolar lavage fluid.
FINAL DIAGNOSIS
MITRAL VALVE REGURGITATION CAUSING HEMOPTYSIS
Etiology of this MR INCLUDE myxomatous infiltration of the valve with consequent mitral valve prolapse., ischemic MR, Marfan’s syndrome, Ehlers-Danlos syndrome, traumatic MR, endocarditis, and acute rheumatic myocarditis. He has no physical findings to suggest vasculitis and connective tissue.
disease. The patient fully recovered after valvuloplasty of mitral valve. Usually causes bilateral lung shadows, but approximately 8% of mitral regurgitation, the localized right upper lobar bleeding is observed which is attributable to the uneven distribution of regurgitant jet flow. This can often be explained by the anatomical features of the pulmonary vein. Regurgitant jet flow resulting higher hydrostatic pressure in the right upper and middle lobe pulmonary veins than in the right lower lobe. Also the drainage of the right middle lobar pulmonary vein into the right upper lobar pulmonary vein results in this combination.
The present case suggests that acute MR with sporadic primary mitral valve prolapse can be a cause of alveolar hemorrhage with unilateral pulmonary consolidation. In patients with hemoptysis and unilateral consolidation, careful physical examination and cardiac evaluation (such as echocardiography) may assist an early diagnosis. Surgical repair of the mitral valve should be considered, as hemoptysis may aggravate the condition resulting in relapse.