Intended for healthcare professionals

Endgames Spot Diagnosis

New onset atrial fibrillation, prominent chest wall veins, and dyspnoea

BMJ 2018; 363 doi: (Published 11 October 2018) Cite this as: BMJ 2018;363:k3779
  1. Charlotte Marriott, clinical teaching fellow1,
  2. Christopher George, consultant radiologist2
  1. 1St Helier Hospital, Sutton, UK
  2. 2Epsom General Hospital, Epsom, UK
  1. Correspondence to c.marriott2{at}

A 74 year old man presented with palpitations concurrent with new onset atrial fibrillation. He also complained of increasingly visible markings on his chest and occasional breathlessness on waking.

His comorbidities included chronic obstructive pulmonary disease and hypertension with left ventricular hypertrophy.

On examination, he had prominent vessels over his chest wall but nothing else of note. He underwent chest radiography (fig 1)

Fig 1

Chest radiograph

What is the most likely diagnosis?


A large retrosternal goitre causing venous and tracheal compression, with atrial fibrillation secondary to hyperthyroidism.

Retrosternal goitres are anterior mediastinal masses (anterior to the pericardium and great vessels), and can usually be distinguished on plain film from posterior mediastinal …

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