A 73-year-old woman with chronic obstructive pulmonary disease presented with 4 weeks of exertional dyspnoea. A plain chest x-ray revealed a right hilar enlargement with enlarged pulmonary outflow tract (Fleischner sign; Figure, A [arrow]) and mild cardiomegaly. A computed tomography pulmonary angiogram confirmed the presence of marked dilatation of the pulmonary trunk (Figure, B [arrow]) and arteries with a large mural thrombus (Figure, B [star]). An echocardiogram indicated pulmonary hypertension with an elevated pulmonary artery pressure of 88 mmHg.
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