Intended for healthcare professionals

Endgames Spot Diagnosis

An unexpected finding on a chest radiograph

BMJ 2020; 368 doi: (Published 20 February 2020) Cite this as: BMJ 2020;368:m426
  1. Chris J Kapelios, cardiology fellow1 2,
  2. Maria Bonou, consultant cardiologist1,
  3. John Barbetseas, consultant cardiologist1,
  4. Konstantinos Makrilakis, associate professor in internal medicine3
  1. 1Cardiology Department, Laiko General Hospital, Athens, Greece
  2. 2Department of Health Policy, The London School of Economics and Political Science, London, UK
  3. 3First Department of Propaedeutic Medicine, National and Kapodistrian University of Athens Medical School, Athens, Greece
  1. Correspondence to CJ Kapelios chriskapel{at}

A 92 year old man presented with recent onset of productive cough and fever up to 38.2°C.

He had a history of atrial fibrillation and symptomatic tachycardia-bradycardia syndrome, for which he had undergone percutaneous implantation of a single chamber cardiac pacemaker six months earlier.

At presentation he was afebrile and had a systemic arterial pressure of 130/75 mm Hg, regular heart rate (60 beats/min) and rhythm, and normal lung sounds. Jugular venous pressure was normal, he had no peripheral oedema, and his extremities were warm. There were no signs or symptoms of pacemaker dysfunction (dizziness, syncope, palpitations, dyspnoea, or thoracic or abdominal muscle twitching).

Table 1 shows his laboratory results.

View this table:
Table 1

Relevant blood results

Electrocardiogram (ECG) …

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