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Anteroposterior chest radiograph shows bilateral alveolar opacities in a patient with subarachnoid hemorrhage who developed neurogenic pulmonary edema. Axial, contrast-enhanced computed tomography (CT) scan shows alveolar and interstitial pulmonary edema. The correct diagnosis relies on clinical and radiologic findings, despite some overlap in the clinical and imaging findings between the different causes. An initial and rapid increase in pulmonary vascular pressure due to pulmonary vasoconstriction or pulmonary blood flow can lead to pulmonary microvascular injury. Two major components contribute to the pathogenesis of NPE: elevated intravascular pressure and pulmonary capillary leak. Whether the hemodynamic changes produce a pulmonary capillary leak through pressure-induced mechanical injury to the pulmonary capillaries or whether some direct nervous system control over pulmonary capillary permeability exists remains uncertain.
Gadolinium-based MRI contrast agents has been associated with several adverse effects, some of which can be serious.
In conjunction with the clinical presentation, radiographic findings are generally sufficient to arrive at a diagnosis of NPE. The specificity of chest radiographs, particularly portable, anteroposterior (AP) images, is low, and it may not be possible to differentiate the various causes of lung parenchymal shadowing on radiographs alone.
Most patients with NPE are generally ill, and there may be transportation problems to computed tomography (CT) scanning and magnetic resonance imaging (MRI) units. The heart is usually enlarged in cardiogenic pulmonary edema, but it may be normal in lung injury and NPE.
The infiltrates of cardiogenic pulmonary edema are usually diffuse, and air bronchograms are rare. One of 3 patterns is seen: a normal chest, bilateral perihilar pulmonary edema, or generalized pulmonary edema. Another feature that may be seen is cardiac enlargement, in cases of previous cardiac failure.
NPE is a known complication of lung transplantation.[2, 3] Herman and colleagues, however, found chest radiography to be helpful, but not definitive, in distinguishing problems after bilateral lung transplantation and found CT scanning to be excellent for the demonstration of airway problems. The reimplantation response (NPE due to ischemia, trauma, denervation, and lymphatic interruption) occurred in 12 patients and usually consisted of bilateral perihilar and basal consolidation. Radiographic findings associated with the reimplantation response and rejection were nonspecific and were mimicked by fluid overload and infection. The 3 principal features found were the distribution of pulmonary flow, the distribution of pulmonary edema, and the width of the vascular pedicle.
A study by Liebman et al indicated that it is hazardous to accept a portable radiographic diagnosis of congestive heart failure as a cause of pulmonary edema.
CT scanning is seldom used in assessing patients with NPE and ARDS, mostly because of problems in transporting and monitoring these severely ill individuals. Tagliabue and colleagues reviewed the findings of 74 patients with ARDS who underwent chest CT scanning.[9] Lung opacities were bilateral in almost all patients and in most cases (86%) were dependent.
In contrast with previous reports, pleural effusion was a frequent finding (50%) that did not worsen the patients' prognosis. Gattinoni and co-authors examined 10 patients with full-blown ARDS who were receiving mechanical ventilation with positive end-expiratory pressure (PEEP) and who underwent lung CT scanning.[10] Seven healthy subjects also were included in the study.
Stark and colleagues described the CT scan features of 28 patients with ARDS.[11] Diffuse lung consolidation, lobar or segmental disease, and multifocal, patchy involvement were observed. Research indicates that a variety of nuclear imaging techniques can be used to diagnose NPE. Raijmakers and co-investigators concluded that a 67Ga pulmonary leak index can be used in distinguishing ARDS from hydrostatic pulmonary edema. According to a study by Chen and Schuster, fluorodeoxyglucose (FDG)a€“positron emission tomography (PET) FDG-PET scanning may be useful for studying neutrophil kinetics during oleic acida€“induced lung injury.
Iodine-123 meta-iodobenzylguanidine (MIBG) results can be considered indicators of pulmonary endothelial cell function. Koizumi and colleagues studied serial scintigraphic assessment of 123I MIBG lung uptake in a patient with high-altitude pulmonary edema.[15] The initial evaluation was performed 7 days after the patient's admission.
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All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This 69-year-old white male with well-controlled Type I diabetes mellitus (insulin-dependent) presented with upper abdominal and lower chest pain of four hours duration and accompanied by shortness of breathShortness of breath is a common clinical manifestation of heart failure. Significant findings at postmortem examination were old and recent myocardial infarctions and evidence of congestive heart failure. This gross photograph demonstrates the frothy exudate that is being extruded from the lung tissue. This is a higher-power photomicrograph showing edema-filled alveoli in the right portion of this section (arrows).
This high-power photomicrograph illustrates the edema fluid within the alveoli (1) and the congestion (RBCs) in the alveolar capillaries (arrows).
Noninflammatory edema is caused by alterations in hemodynamic forces across the capillary wall (hemodynamic edema). Anasarca: severe and generalized edema which includes marked swelling of the subcutaneous tissues. Introduction Of Myocardial Diseases: Although the myocardium is involved in most types of heart disease, the term myocarditis and cardiomyopathy are usually reserved for conditions that primerly affect the heart muscle. CARDIOMYOPATHY Cardiomyopathies are a group of diseases of the myocardium that affect the mechanical or electrical function of the heart.

Signs: ¦ double apical pulsation (forceful atrial contraction producing a fourth heart sound).
Investigations: ¦ ECG abnormalities of HCM include left ventricular hypertrophy, ST and T wave changes, and abnormal Q waves especially in the infero-lateral leads. Treatment: The management of HCM includes treatment of symptoms and the prevention of sudden cardiac death in the patient and relatives. Restrictive cardiomyopathy In this rare condition, ventricular filling is impaired because the ventricles are 'stiff'. The latter, noncardiogenic pulmonary edema (NPE), is caused by changes in permeability of the pulmonary capillary membrane as a result of either a direct or an indirect pathologic insult (see the images below).
An increase in vascular permeability consequently results in edema formation, as suggested by the frequent observation of pulmonary hemorrhage in NPE (ie, the blast theory). The neuro-effector site for nervous systema€“induced pulmonary edema appears to be relatively well established in regions about the caudal medulla, where nuclei regulating systemic arterial pressure, as well as afferent and efferent pathways to and from the lungs, are located. The use of chest radiography and other tests is key to establishing the diagnosis and to distinguishing between the 2 types of pulmonary edema.
It has extremely rare life-threatening systemic complications, which can lead to bronchospasm, hypersensitivity reactions, and cardiovascular arrest. Conventional chest radiography is readily and universally available, and it has the added advantage of portability; chest radiography is the examination of choice. Moreover, because these patients may be restless, sedation may be required to obtain images that are not degraded by motion artifacts. However, the heart may also be of normal size in cardiogenic edema after acute myocardial infarction. Infiltrates in nephrogenic pulmonary edema are classically described as having a bat-wing distribution, whereas those in lung injury tend to be more peripheral. The early signs of pulmonary edema (interstitial edema) are the septal lines (Kerley B lines), which are horizontal lines seen laterally in the lower zones. In their study, the authors reviewed the postoperative chest radiographic and CT scan findings in 13 patients who underwent bilateral lung transplantation.[4] Portable chest radiography was performed daily for about 10 days, after which upright posteroanterior studies were performed daily for about 10 days and then as clinically required. Twelve episodes of acute rejection, an imprecise clinical diagnosis, occurred in 10 patients.
The cause of the pulmonary edema can be determined with a high degree of accuracy by paying careful attention to certain radiographic features. The ancillary features were pulmonary blood volume, peribronchial cuffing, septal lines, pleural effusions, air bronchograms, lung volume, and cardiac size. In their report, the authors assessed the usefulness of portable chest radiographs in defining the amount of physiologic shunting and the severity of NPE.[6, 7] Ten of their 11 patients had acute respiratory failure. High-resolution CT (HRCT) scanning demonstrates widespread airspace consolidation, which may have predominant distribution in the dependent lung regions.
Large lung cysts and small cysts producing a Swiss-cheese appearance of the parenchyma were detected.
In their study, the investigators examined the effectiveness of a noninvasive, bedside, dual-radionuclide method (67Ga circulating transferrin and technetium-99m [99mTc]a€“labeled RBCs) of measuring pulmonary microvascular permeability, in differentiating between hydrostatic pulmonary edema and pulmonary edema due to ARDS.[13] Patients in the study suffered from respiratory insufficiency and bilateral, alveolar pulmonary edema, as demonstrated on chest radiographs. With various definitions, a supranormal pulmonary leak index for ARDS had a sensitivity of 100%, while its specificity ranged from 46-75%.
The investigators measured neutrophil glucose uptake with FDGa€“PET scanning in anesthetized dogs after intravenous, oleic acida€“induced, acute lung injury (n = 6) or after low-dose, intravenous endotoxin (which is known to activate neutrophils without causing lung injury) followed by oleic acid (n = 7).
Lung transplantation: indications, donor and recipient selection, and imaging of complications. Limitations of portable roentgenography of the chest in patients with acute respiratory failure. Adult respiratory distress syndrome due to pulmonary and extrapulmonary causes: CT, clinical, and functional correlations.
Positron emission tomography with [18F]fluorodeoxyglucose to evaluate neutrophil kinetics during acute lung injury. Serial scintigraphic assessment of iodine-123 metaiodobenzylguanidine lung uptake in a patient with high-altitude pulmonary edema. Topics are richly illustrated with more than 40,000 clinical photos, videos, diagrams, and radiographic images. The articles assist in the understanding of the anatomy involved in treating specific conditions and performing procedures. Check mild interactions to serious contraindications for up to 30 drugs, herbals, and supplements at a time. Plus, more than 600 drug monographs in our drug reference include integrated dosing calculators. The right and left lungs weighed 950 gramsA normal right lung weighs 450 grams (range: 360 to 570 grams.
They are not secondary to coronary artery diseases, hypertension, or congenital, valvular or pericardial abnormalities.
Hypertrophic cardiomyopathy (HCM) It is characterized by marked vantricular hypertrophy in the absence of an alternate cause (e.g. Risk factors for sudden death: ¦ massive left ventricular hypertrophy (> 30 mm on echocardiography). This leads to ? high atrial pressures with atrial hypertrophy ? dilatation ? later atrial fibrillation. It consists of two separate layers, the inner visceral pericardium and the outer parietal pericardium. Classically, fibrinous material is deposited into the pericardial space and pericardial effusion often occurs.
Viral pericarditis is usually painful but has a short time course and rarely long-term effects. Note the dramatically enlarged size of the heart now showing Zoie in advanced stages of congestive heart failure.
Over time the heart begins to enlarge and the heart muscle has a harder time pumping in a stretched state causing secondary heart failure. Since we were closely monitoring Zoie and her disease progression, we were able to start her on medication as soon as her signs of congestive heart failure started, and extend her life and quality of life by a significant amount of time.
The combination of Benazapril and Pimobendin (which Zoie was on) increases survival even greater than dogs on the individual medications alone. These components often work in concert, as in pulmonary edema after epileptic convulsions or intracranial pressure elevation. Pulmonary vascular plethora often occurs with upper lobe blood diversion in cardiogenic cases; vessels of the upper lobe are balanced to cephalic in fluid overload but are normal in lung injury.
Although the peripheral infiltrate is fairly specific for lung injury, the diffuse variety is seen with equal frequency in lung injury.
The septal lines arise from the pleural surface and are typically 1 mm thick and 10 mm long; unlike blood vessels, these reach the edge of the lung.
However, over the course of 24-48 hours following the onset of tachypnea, dyspnea, and hypoxia, ARDS becomes more widespread and uniform. Radiographic changes consisted of bibasal (n = 2) and right middle and lower (n = 2) or left basal consolidation (n = 1); no changes were observed in 7 episodes.

In general, chest radiography was inaccurate in the assessment of these complications, and CT scanning was accurate in such assessments. Differing constellations of these features, each characteristic of a specific type of edema, were found.
Radiographic assessment of the amount of pulmonary edema and the severity of left ventricular failure was compared with the physiologic shunt fraction, tracer-measured lung water, and pulmonary arterial wedge pressure.
Therefore, the radiographic findings were predictive for the shunt value of the preceding day.
The most consistent morphologic finding in ARDS was attenuating in the dependent regions of the lung. On receiver operating characteristic curves, the pulmonary leak index performed best when ARDS and hydrostatic pulmonary edema were defined only on the basis of risk factors. The authors concluded that the rate of FDG uptake in the lungs during lung injury reflects the state of neutrophil activation. Customize your Medscape account with the health plans you accept, so that the information you need is saved and ready every time you look up a drug on our site or in the Medscape app. An electrocardiogram revealed multiple premature ventricular contractions (PVCs)Premature ventricular contractions (PVCs) are a common cardiac arrhythmia. They are frequently genetic and may produce inappropriate ventricular hypertrophy or dilatation and can be primarily a cardiac disorder or part of a multi-system disease.
Sporadic DCM can be caused by multiple conditions: ¦ myocarditis – Coxsackie, adenoviruses, erythroviruses, HIV, bacteria, fungae, mycobacteria, parasitic (Chagas’ disease) ¦ toxins – alcohol, chemotherapy, metals (cobalt, lead, mercury, arsenic) ¦ autoimmune. The visceral pericardium reflects back upon it self at the level of the great vessels to join the parietal pericardium, thus forming a sac. Acute pericarditis has numerous aetiologies Most commonly in the UK, it is due to viral infection and myocardial infarction, although in many cases the cause is unknown. The hemodynamic component is relatively brief and may unmask pure NPE, such as that seen in experimental seizures. As the edema progresses, alveolar edema is observed in a butterfly pattern characterized by the central predominance of shadows, with a clear zone at periphery lobes. A useful characteristic for differentiating cardiac pulmonary edema from NPE, as well as from pneumonia and other widespread exudates, is the amount of time it takes for the edema to develop and to vanish. Following the intravenous administration of steroids, radiographic resolution occurred in 4 cases.
The radiographic scores for edema were not predictive for the shunt fraction or for the tracer-measured lung water.
Pulmonary air cysts (30%), always multiple and mostly bilateral, were associated with a mortality rate (55%) higher than that of the whole study group (35%). Assuming that the 3 levels were a representative sample of the whole lung, the authors computed lung weight from the mean CT scan number and lung gas volume. The index was better than hemodynamic measures, and its performance equaled that of ventilatory variables in discriminating between edema types (if definitions were based primarily on hemodynamic and ventilatory variables, respectively). Easily compare tier status for drugs in the same class when considering an alternative drug for your patient. Family members should be screened for evidence for evidence of disease by ECG and echocardiography. NB : Restriction to ventricular filling (especially right) results in persistently elevated venous pressures, consequent hepatic enlargement, ascites, and dependent oedema. 3.Echocardiogram shows symmetrical myocardial thickening and often a normal systolic ejection fraction, but impaired ventricular filling. The pericardial sac contains up to 50 mLof pericardial fluid in the normal heart, although this is a potential space for fluid to collect.
It may be difficult to differentiate this pain from recurrent angina when it occurs early (day 1-2 post- infarct) but a good history of the pain and serial ECG monitoring is helpful. Septal lines indicative of interstitial edema are more frequent with cardiogenic causes than with others. If substantial improvement occurs within 24 hours, this is virtually diagnostic of cardiac pulmonary edema. The highest accuracy was obtained in distinguishing capillary permeability edema from all other varieties (91%). The radiographic score for congestive heart failure was correlated with the wedge pressure but not well enough to be clinically useful.
Compared with chest radiography, CT scanning often yielded additional information (66%), with direct influence on patient treatment in 22% of cases. However, in patients with heart disease, PVCs can be significant indicators of disease processes. However, since enteroviral infection is common in the general population, the diagnosis depends on the demonstration of acutely rising titres. The hypertrophic non-compliant vantricles impair diastolic filling, so that stroke volume is reduced. 4.Cardiac catheterization and haemodynamic studies help distinction from constrictive pericarditis. The pericardium serves to lubricate the surface of the heart, prevents deformation and dislocation of the heart and acts as a barrier to the spread of infection.
The lowest accuracy (81%) was obtained in distinguishing chronic cardiac failure from renal failure.
For example, increased numbers of PVCs are common following an acute myocardial infarction.. Increasingly, evaluation of relatives of DCM patients is allowing identification of early asymptomatic disease, prior to the onset of these complications.
Most cases are familial, autosomal dominant and caused by mutation in genes coding for proteins that regulate conraction, e.g troponin and B-myosin. 5.Endomyocardial biopsy in contrast with other cardiomyopathies is often useful in this condition and may permit a specific diagnosis such as amyloidosis to be made. In 15 patients, CT scans provided additional information not obvious on bedside chest radiographs and led to a change in care for 5 patients. Clinical evaluation should include a family history and construction of a pedigree where appropriate. Autoimmune: An autoimmune form with autoactivated T cells and organ specific antibodies may occur.
The terminal event was cardiac arrestCardiac arrest is the sudden standstill of cardiac function.. Specific diagnosis requires demonstration of active viral replication within myocardial tissue.

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