Intended for healthcare professionals

Endgames Picture Quiz

Breathlessness and plethora

BMJ 2011; 343 doi: (Published 26 July 2011) Cite this as: BMJ 2011;343:d4466
  1. Janet Dua, core medical trainee year 21,
  2. Wui-hang Cheung, specialist registrar year 41,
  3. Sabina Russell, consultant in endocrinology and general medicine1,
  4. Zaid Dabbagh, consultant radiologist1
  1. 1Chase Farm Hospital, London EN2 8JL, UK
  1. Correspondence to: J Dua janetdua3000{at}

A 61 year old man presented to the emergency department with sudden onset breathlessness associated with cough productive of purulent sputum. He had been diagnosed with squamous cell carcinoma of the bronchus one month earlier. His staging was T4N2M1. Two weeks earlier he had developed a pathological clavicular fracture and was due to start radiotherapy. On admission he had no haemoptysis or chest pain. However, his blood pressure was 80/40 mm Hg, pulse rate was 140-160 beats/min, and respiratory rate was 18 breaths/min.

On examination he had swelling and plethora of the face and neck. Crepitations were heard in the right mid zone of his lung field. Heart sounds were normal. His jugular venous pressure was non-pulsatile and was raised to the level of his ear lobes. His breathlessness and facial swelling were exacerbated by lying flat and coughing.

Electrocardiography showed sinus tachycardia. Arterial blood gas on room air showed a partial pressure of oxygen of 7 kPa, and a partial pressure of carbon dioxide of 4.2 kPa.

Chest radiography was performed (fig 1).

Fig 1 Chest radiograph on admission

An echocardiogram showed no pericardial effusion but moderate left ventricular function and no right ventricular dysfunction. Figure 2 is a picture of the patient at admission.

Fig 2 Patient on admission


  • 1 What is the most likely diagnosis?

  • 2 What are the likely causes of this condition?

  • 3 What further investigation would you do?

  • 4 How would you manage this patient?


1 What is the most likely diagnosis?

Short answer

Obstruction of the superior vena cava.

Long answer

This patient has obstruction of the superior vena cava. His chest is plethoric, and on closer inspection he has some distended thoracic veins (fig 3).

Fig 3 Patient’s chest showing plethora and distended thoracic veins

His chest radiograph on admission shows a widened mediastinum and a right hilar …

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