An Unusual Presentation of Scimitar Syndrome in a Military Service Member

This is the case of a twenty-two-year-old active duty male soldier with nonexertional chest pain and worsening performance on his physical fitness test. His history was significant for a diagnosis of dextrocardia upon entry to the military. On acute presentation to the emergency department, he was deemed a candidate for the expedited coronary computed tomographic angiography (CCTA) protocol to assess for a possible anatomic cause of his symptoms. CCTA revealed the presence of an anomalous right pulmonary vein draining into the inferior vena cava. Additionally, the imaging showed dextroversion of the heart, dilation of the inferior vena cava, right atrium, and right ventricle, as well as a hypoplastic right lung, a collection of findings consistent with scimitar syndrome and not dextrocardia. 1. Case Report This is a case report of a twenty-two-year-old male soldier with nonexertional chest pain and worsening performance on his physical fitness test. His history was significant for a diagnosis of dextrocardia upon entry to the military. On physical examination, heart sounds were louder over the right hemithorax; there was a fixed split S2, and the point of maximal impulse was displaced to the right. He had normal lung sounds and no peripheral edema. An electrocardiogram was remarkable for left axis deviation of the p-wave, normal QRS axis, and a nonspecific intraventricular conduction delay. Because of his history of recurrent chest pain and vague history of dextrocardia not confirmed with ECG, patient underwent a cardiac computed tomographic angiography (CCTA) protocol to assess for a possible anatomic cause of his symptoms. CCTA, performed with sequential gating and a window of 40–80% to accommodate the large area under investigation, revealed the presence of an anomalous right pulmonary vein draining into the inferior vena cava. Additionally, the imaging showed dextroversion of the heart, dilation of the inferior vena cava, right atrium, and right ventricle, as well as a hypoplastic right lung, a collection of findings consistent with scimitar syndrome and not dextrocardia (Figure 1). There was no evidence of pulmonary sequestration or an atrial septal defect. Figure 1: Axial and coronal images with sequential gating; cardiac phases utilized of 40–80% on CCTA ( with care dose variable mAs and slice thickness of 0.7？mm with 0.4 overlap). They revealed the presence of an anomalous pulmonary venous connection between the right lower lobe pulmonary vein (APV) and the enlarged inferior vena cava (IVC) [a, b, and c]. Review of the patient’s chest radiograph