Visual Diagnosis: A 7-year-old Boy with Dyspnea and an Unusual Chest Radiograph

Abstract

1. Katherine B. Salciccioli, MD* 2. Athar M. Qureshi, MD*,† 3. Hugh D. Allen, MD*,† 1. *Department of Cardiology, Texas Children’s Hospital, Houston, TX 2. †Baylor College of Medicine, Houston, TX A 7-year-old boy presents to his pediatrician with gradually worsening shortness of breath and exercise intolerance over months to years. He was admitted for right-sided pneumonia twice during childhood with seemingly complete recovery each time, but otherwise he has been generally healthy and developmentally appropriate. Current medications include albuterol inhalers taken as needed since early childhood for wheezing during viral illnesses. With the recent worsening of his symptoms, albuterol is again tried without any improvement in his symptoms. He does not have fever, cough, nasal congestion, chest pain, palpitations, vomiting, diarrhea, or weight changes. On physical examination, the patient has normal vital signs. He is small for his age but is following his growth curve appropriately with height in the 15th percentile and weight in the 11th percentile. He has normal findings on head and neck examination. His cardiac examination is notable for a fixed split S2 with no murmurs, rubs, or gallops. He has diminished breath sounds on the right with a soft, intermittent expiratory wheeze and a clear left lung. He has no abdominal organomegaly. Pulses are 2+ and symmetric in all extremities. In addition to his physical examination findings, a chest radiograph (Fig 1) is interpreted as showing dextrocardia, so the patient is referred to the cardiology clinic where echocardiography reveals the diagnosis. Figure 1. Chest radiograph interpreted as dextrocardia, prominent right-sided pulmonary vasculature, and hyperinflation of the left lung. In the cardiology clinic, echocardiography shows the heart located in the right chest, with the cardiac apex pointing leftward, partial anomalous venous return to the inferior vena cava (IVC) (Video 1), and mild right heart dilation (Video 2 …