Pneumonia and atrial flutter in a 71- year-old-man.

Konik E, et al. BMJ Case Rep 2017. doi:10.1136/bcr-2017-220691 Description A 71-year-old man with a medical history of hypertension and 80 pack-years of tobacco smoking was presented with dyspnoea and coughof 3-week duration. He was tachycardic, with heart rate 127 beats per minute. ECG revealed atrial flutter. Chest x-ray showed right upper lobe consolidation consistent with pneumonia. Transesophageal echocardiogram (TEE)-guided cardioversion was ordered. The echocardiogram revealed normal biventricular systolic function without significant valvular disease. The left atrial appendage was enlarged but no thrombus was present. Doppler pulsed-wave interrogation of the right superior pulmonary vein (RSPV) demonstrated increased velocity (1.2 m/s, figure 1). The source-elevated Doppler velocities were found to be compression of the RSPV by an extracardiac mass (video 1). At the conclusion of the examination, multiple well-circumscribed lesions were visualised,adjacent to the aortic arch and distal ascending aorta (video 2), which appeared consistent with enlarged lymph nodes. Given the unexpected findings on the echocardiogram, the cardioversion was deferred and the primary team was contacted regarding recommendation for evaluation of profound lymphadenopathy and extracardiac mass. Follow-up chest CT showed a large, approximately 5 cm, right perihilar mass suspicious for malignancy with extensive mediastinal adenopathy (figure 2). There was encasement and narrowing of right upper lobe pulmonary arteries as well as the right superior pulmonary vein. In addition, the right upper lobe bronchus Pneumonia and atrial flutter in a 71year-old-man