Papillary muscle dysfunction due to coronary slow-flow phenomenon presenting with acute mitral regurgitation and unilateral pulmonary edema

Case Report IntroductIonAcute cardiogenic pulmonary edema usually presents with bilateral infiltrates on the chest radiograph described as a "butterfly shadow."[1] Unilateral pulmonary edema (UPE) of cardiac origin is relatively rare and often misdiagnosed as primary respiratory disease leading to delay in the initiation of appropriate therapy.[2] We report a young man who presented with breathlessness and unilateral lung infiltrates following an overdose with alprazolam and review the literature on UPE of cardiac origin. case reportA 30-year-old man presented to our emergency department with breathlessness following an overdose with alprazolam.He had been evaluated earlier at another hospital, where he was found to be hypotensive.Ischemic changes were noted on electrocardiography (ECG); he was cardioverted as he was found to be in atrial fibrillation.Following this, he was transferred to our hospital.On initial evaluation in our emergency department, he had mild dyspnea, with a respiratory rate of 32/min and oxygen saturation of 88% on room air.His heart rate was regular at 105/min with a blood pressure of 86/52 mm Hg.Systemic examination was otherwise unremarkable.He was administered supplemental oxygen, commenced on an infusion of noradrenaline, and transferred to the intensive care unit.His ECG performed earlier at the referring hospital, showed atrial fibrillation with ST-segment elevation in leads II and III, and ST-segment depression in leads V3-V4 [Figure 1].A chest radiograph revealed diffuse infiltrates confined to the right lung fields, suggestive of UPE [Figure 2].On transthoracic echocardiography, he had significant hypokinesia of the basal, Cardiogenic pulmonary edema usually presents with characteristic clinical features and bilateral infiltrates on the chest radiograph.Rarely, pulmonary edema may manifest unilaterally, leading to a mistaken diagnosis of a primary lung pathology.We present a 30-year-old man who developed acute coronary syndrome following an overdose of alprazolam.He developed breathlessness with unilateral infiltrates on the chest radiograph.Echocardiography revealed regional wall motion abnormalities related to underlying ischemia and acute mitral regurgitation with an eccentric jet.Besides, he had significant impairment of left ventricular systolic function.His coronary angiogram revealed a slow-flow phenomenon in the right coronary and left anterior descending artery territories.Ischemia-related dysfunction of the posterolateral papillary muscle probably led to a floppy posterior mitral leaflet and an eccentrically directed regurgitant jet, leading to unilateral pulmonary edema.He was commenced on dual antiplatelet therapy, heparin infusion, atorvastatin, frusemide, and ramipril, following which he showed gradual clinical improvement along with resolution of the radiological infiltrates.His left ventricular function improved, and the mitral valve function normalized on echocardiography within a week.