Article Text

Download PDFPDF
Image challenge
Seventy-six-year-old man with progressive dyspnoea
  1. Juan Martínez-Milla,
  2. Ángel José Maestre Bastardo,
  3. Marcelino Cortés
  1. Department of Cardiology, University Hospital Fundación Jiménez Díaz, Madrid, Spain
  1. Correspondence to Dr Juan Martínez-Milla, Department of Cardiology, University Hospital Fundación Jiménez Díaz, Madrid 28040, Spain; j.martinez.milla{at}


Clinical introduction A 76-year-old man with 50 years of smoking history was diagnosed in 2012 with diffuse interstitial lung disease, with radiological data of usual interstitial pneumonia. He came to the emergency room presenting with progression of dyspnoea for 1 week, concomitant with loss of 5 kg of weight, anorexia and poor general condition. He had tachypnoea at rest (30 breaths/min), peripheral cyanosis, speech interfered by cough and breathlessness, baseline oxygen saturation 90%, heart rate 40 beats/min and blood pressure 130/70 mm Hg. Chest X-ray was performed and there was basal atelectasia of the right lung. ECG and urgent echocardiogram (transthoracic echocardiogram, TTE) were also performed (figure 1).

Question Which of the following best explains the patient’s situation?

Figure 1

(A) ECG. (B) Long-axis parasternal view from the transthoracic echocardiogram (TTE). (C) Four-chamber view from the TTE.

  1. Acute pulmonary embolism

  2. Non-ST elevation myocardial infarction

  3. Cardiac lymphoma

  4. Cardiac myxoma

  5. Mobitz type II AV block

  • cardiac computer tomographic (CT) imaging
  • echocardiography
  • bradyarrhythmias

Statistics from

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.


  • Contributors JMM: selection of the images, case writting, case edition. AJMB and MC: selection of the images and case edition. Alvaro Trascasa: pathology images. Marta Repollés: CT images.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.