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Dysphagia and Dyspnea in a Middle-aged Woman

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A woman in her early 60s presented with progressive dysphagia to solid foods for 2 years and new-onset dyspnea associated with cough and fever for 1 week. She had mild weight loss but denied symptoms of anorexia, vomiting, heartburn, chest pain, dyspepsia, hematemesis, or hemoptysis. She had poorly controlled hypertension for 10 years. There was no history of tobacco, alcohol, or drug consumption. Chest radiography results before admission revealed multiple exudative foci in both lungs. Physical examination results on admission showed wheezes and rales in both lung fields and were otherwise normal. There were no abnormalities on routine blood tests. A barium esophagram was performed to evaluate the dysphagia (Figure 1).

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Right aortic arch with a Kommerell diverticulum

C. Perform computed tomography angiography of the aorta

The key to the correct diagnosis is the barium esophagram showing a twisted and spiral esophagus with multiple indentations and a long section of compression; the esophageal mucosa was smooth without niche or irregular folds. Findings such as these indicated that the esophagus was extrinsically compressed. These findings, combined with the manifestations of airway obstruction, prompted consideration of an anomaly of the aorta. Aortic computed tomography angiography is a convenient and noninvasive technique for evaluating anomalies of the great vessels as well as compression of the trachea and esophagus. Aortic computed tomography angiography (Figure 2) demonstrated a right aortic arch, right descending aorta and aberrant left subclavian artery (ALSA) originating from the aneurysmal descending aorta (the largest diameter of a descending aorta was 46 mm). There was dilation of the origin of the ALSA, which is termed Kommerell diverticulum. In addition, the trachea and esophagus were encircled and severely compressed by the ascending and descending aorta (Figure 2).

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Article Information

Corresponding Author: Wei Zhang, MD, Department of Cardiovascular Surgery, The Second Affiliated Hospital of Xi’an Jiaotong University, No. 157 W Fifth Rd, Xi’an 710004, Shaanxi Province, PR China (zhangwei1213@126.com).

Published Online: July 22, 2020. doi:10.1001/jamacardio.2020.2677

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank the patient for providing permission to share this information.

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