Photo Quiz

An Abnormal Chest Radiograph


FREE PREVIEW. AAFP members and paid subscribers: Log in to get free access. All others: Purchase online access.


FREE PREVIEW. Purchase online access to read the full version of this article.

Am Fam Physician. 2014 Jul 1;90(1):47-48.

A 24-year-old asymptomatic man requested a chest radiograph for routine tuberculosis screening. He did not have difficulty breathing, palpitations, chest pain, or edema. His medical history was significant for scoliosis and Rubinstein-Taybi syndrome, a rare genetic condition that causes short stature, broad thumbs and toes, hirsutism, and often intellectual disabilities.

On examination, his lungs were clear to auscultation. He had a regular heart rate and rhythm with no murmurs. There was no jugular venous distension. The heart sounds were shifted to the right, and the apical impulse was located to the right of the sternum. There were normal pulses in all four extremities. Chest radiography was performed (see accompanying figure).


Figure.

Question

Based on the patient's history, physical examination, and radiography findings, which one of the following is the most likely diagnosis?

A. Dextrocardia.

B. Dextroposition.

C. Right heart failure.

D. Situs inversus totalis.

Discussion

The answer is A: dextrocardia. Dextrocardia is the most common congenital positional abnormality of the heart, occurring in about one out of 12,000 persons.1,2 Dextrocardia refers to the rightward pointing of the cardiac apex.3,4 The malpositioning of the heart occurs during fetal development. Rubinstein-Taybi syndrome is associated with cardiac abnormalities in 32% of patients.5

Dextrocardia cannot be diagnosed from a single chest radiograph. Further evaluation of cardiac position and anatomy with computed tomography and echocardiography is necessary to confirm the diagnosis. In this patient, cardiac auscultation and palpation raised initial suspicion about cardiac placement. In this case, further evaluation with echocardiography demonstrated dextrocardia. This finding is incidental and not of clinical concern, unless it is associated with other anatomic abnormalities that may compromise functional capability.

Dextroposition refers to a shifting of the heart into the right hemithorax, often from mechanical causes.6 Although congenital dextroposition may be associated with hypoplastic right lung, it also increasingly occurs with congenital heart disease from left to right shunts.6

Right heart failure causing enlargement of the right heart may present with the cardiac silhouette in the right thorax. The most common cause of right heart failure is left heart failure.6

Situs inversus totalis is a mirror-image arrangement of normal organs. It is caused by an abnormal rotation of the organs during fetal development and is associated with dextrocardia.7 The gastric bubble will appear on the right side.

View/Print Table

Summary Table

ConditionCharacteristics

Dextrocardia

Cardiac apex points to the right hemithorax; associated with severe cardiac malformations

Dextroposition

Shifting of the heart into the right hemithorax

Right heart failure

Enlargement of the right heart; most commonly caused by left heart failure

Situs inversus totalis

Mirror-image arrangement of normal organs; gastric bubble will appear on the right side

Summary Table

ConditionCharacteristics

Dextrocardia

Cardiac apex points to the right hemithorax; associated with severe cardiac malformations

Dextroposition

Shifting of the heart into the right hemithorax

Right heart failure

Enlargement of the right heart; most commonly caused by left heart failure

Situs inversus totalis

Mirror-image arrangement of normal organs; gastric bubble will appear on the right side

Author disclosure: No relevant financial affiliations.

Address correspondence to David Garcia, CAPT, MC, USAF, at david.s.garcia.mil@health.mil. Reprints are not available from the authors.


The opinions and assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the U.S. Air Force Medical Department or the U.S. Air Force at large.

REFERENCES

show all references

1. Moore KL, Arthur FD, Agur AM. Clinically Oriented Anatomy. Philadelphia, Pa.: Lippincott Williams & Wilkins; 2006....

2. Bohun CM, Potts JE, Casey BM, Sandor GG. A population-based study of cardiac malformations and outcomes associated with dextrocardia. Am J Cardiol. 2007;100(2):305–309.

3. Longo DL. Harrison's Principles of Internal Medicine. New York, NY: McGraw-Hill; 2012.

4. Wolfgang D. Radiology Review Manual. Philadelphia, Pa.: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2011.

5. Hennekam RC. Rubinstein-Taybi syndrome. Eur J Hum Genet. 2006;14(9):981–985.

6. Brant WE, Helms CA. Fundamentals of Diagnostic Radiology. Philadelphia, Pa.: Lippincott Williams & Wilkins; 2007.

7. Carlson BM, Kantaputra PN. Human Embryology and Developmental Biology. 5th ed. Philadelphia, Pa.: Saunders; 2014.

Contributing editor for Photo Quiz is John E. Delzell, Jr., MD, MSPH.

A collection of Photo Quizzes published in AFP is available at http://www.aafp.org/afp/photoquiz.

The editors of AFP welcome submissions for Photo Quiz. Guidelines for preparing and submitting a Photo Quiz manuscript can be found in the Authors' Guide at http://www.aafp.org/afp/photoquizinfo. To be considered for publication, submissions must meet these guidelines. E-mail submissions to afpphoto@aafp.org.



Copyright © 2014 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact afpserv@aafp.org for copyright questions and/or permission requests.

Want to use this article elsewhere? Get Permissions


Information From Industry

More in AFP


Editor's Collections


More in Pubmed

Email Alerts

Don't miss a single issue. Sign up for the free AFP email table of contents.

Sign Up Now

Navigate this Article