Saturday, April 02, 2011

Interesting Chest Xray (8)

A 40 year-old lady presented with intermittent hemoptysis for 2 days and was referred from a district clinic with impression of possible tuberculosis. She denies any fever or TB contact, though she noted hoarseness of voice for the past 3 weeks but she thought it was just URTI. Further history revealed that she has feeling of palpitation for many months but she did not seek any treatment. After looking at the chest Xray, what do you think is the abnormality and possible full diagnosis? (Click image to enlarge)


Tan Yee Ping said...


pure guessing... haha:

left atrial aneurysm??

aortic aneurysm
lung tumor
foreign body

Zzzyun said...

left atrial myxoma invading the left recurrent laryngeal nerve (causing the hoarseness of voice)?

Chong_86 said...

Aortic aneurysm which compresses on the recurrent laryngeal nerve causing hoarseness of voice.

About the hemoptysis? May be due to rupture of the aneurysm into the lung.

I guess rupture of the aneurysm need not to cause hemodynamic instability all the time....

Full diagnosis :

Rupture of aortic arch aneurysm into the lung.

Differentials :

Left atrial myxoma
Left atrial aneurysm

Darren Lee said...

Hmm. Well it's not aneurysm..
Add one clue: she has got a mid-diastolic everything? HEHE

Tan Yee Ping said...

I think zzzyun is right then, left atrial myxoma, right?

Tommy said...

Mitral stenosis causing Left atrial dilatation that is dilated enough to compress the right RLN. Ordner's syndrome.

Chong_86 said...

Oops..I've missed the big picture. :P

Hemoptysis can be a manifestation of Rheumatic heart disease.

Plus she has palpitation for several months - onset of Atrial fibrillation.

Hoarsness of voice - dilated left atrium compresses on recurrent laryngeal nerve

Plus, a tip from Dr.Darren about the patient having mid-diastolic murmur.

Mitral stenosis secondary to rheumatic heart disease.

Darren Lee said...

Good! It's getting really close to the answer ;)

The sequence of events should be she actually has a undiagnosed severe mitral stenosis causing markedly dilated left atrium with severe pulmonary hypertension (hence the hemoptysis) and atrial fibrillation (the palpitation).

Hoarseness of voice is due to the left (not right!) recurrent laryngeal nerve compression by dialted LA - giving the full diagnosis of Ortner's syndrome.

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