A man aged 45 years presented with progressive shortness of breath and peripheral edema. Physical examination revealed diffusely decreased breath sounds with signs of respiratory distress, peripheral cyanosis, and anasarca. Chest radiography was performed (Figure) and showed evidence of surgical aortic valve replacement and tricuspid valve repair by annuloplasty. There was also evidence of severe coronary disease with ischemic cardiomyopathy, left ventricular ejection fraction less than 35%, and prolonged QRS complex greater than 150 milliseconds as evidenced by the presence of a biventricular pacemaker defibrillator. The patient had end-stage kidney disease requiring hemodialysis and a prior gastrointestinal bleed necessitating gastric clipping. The Chinese dragon sign was present on radiography, which signifies a calcified splenic artery. This sign is typically seen in patients with diabetes and older patients.1 The presence of the subcutaneous defibrillator indicates that this patient may have had infective endocarditis or cardiomyopathy at a young age.2 As the patient was acutely ill, he was placed on a ventilator and given nutrition via nasogastric tube. The patient was treated for acute systolic heart failure with hemodialysis for volume removal.
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Published Online: May 24, 2023. doi:10.1001/jamacardio.2023.1104
Corresponding Author: Damian Valencia, MD, Department of Cardiovascular Medicine, Kettering Health, Main Campus, 3535 Southern Blvd, Kettering, OH 45429 (email@example.com).
Conflict of Interest Disclosures: None reported.
Additional Contributions: We thank the patient for granting permission to publish this information.
Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:
It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.
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