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A 66-year-old man presented with dyspnoea and haemoptysis. Auscultation revealed a pansystolic murmur at the apex and right lung crepitations. Given a CRP of 89, white cell count 20.2 × 109/L, and the chest X-ray findings (Panel A), the patient was initially treated for a pneumonia. Computed tomographic pulmonary angiography showed no embolism but confirmed right lung ‘consolidation’ (Panel B). A diagnosis of alveolar haemorrhage (AH) was made and the patient commenced on methylprednisolone. Subsequent ANA, anti-GBM, anti-MPO, and anti-PR3 antibody titres and viral serology were normal. A transthoracic echocardiogram showed posterior mitral valve leaflet prolapse and severe mitral regurgitation (MR) (Panels C–F). A revised diagnosis of acute pulmonary haemorrhage secondary to severe MR was made. The patient was commenced on diuretics and later underwent mitral valve repair.

Acute MR is a rare cause of diffuse AH and may occur with rheumatic heart disease, infective endocarditis, trauma, spontaneous, or ischaemic papillary muscle/chordae tendinae rupture. Here, the non-compliant left atrium is exposed to an abrupt pressure increase, which is transmitted via the pulmonary veins into the capillaries of the pulmonary circulation. This may result in pulmonary oedema or rarely diffuse AH as a result of disruption of the alveolar-capillary membrane and red blood cell extravasation. Unilateral right upper lobe lung changes may be encountered due to preferential flow of the MR into the right upper pulmonary vein. On computed tomography, this manifests as confluent ground glass opacification with sparing of the peripheral lung parenchyma, which has been referred to as a ‘Window-Frame effect’.

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