Abstract: A rare congenital case of vascular ring diagnosed in a 2-year-old patient who presented to our clinic with misdiagnoses of GERD and asthma. Patient had a chronic cough since birth and was given asthma inhalers for 2 2-year duration prior to admission as a suspected case of pneumonia. Diagnostic confirmation was achieved with CT-angiography, and open heart surgery was done accordingly.Introduction: A Vascular ring is a congenital anomaly of the aortic arch system where the aorta or its branches abnormally encircle the trachea and the esophagus, compressing them, resulting in difficulty breathing or swallowing. (1) (2) It's a rare condition of the aortic arch with an estimated prevalence of 1 in 10,000 live births. (3) Depending on the severity of the compression, disease presentation ranges from asymptomatic to clinical manifestations, including respiratory symptoms such as stridor, persistent cough, and wheezing that is typically unresponsive to bronchodilators. In addition, gastrointestinal symptoms may occur, including dysphagia, feeding difficulties, and poor weight gain in infants. (4)Case Report: This is a very interesting case of a 2-year-old patient who presented to our clinic with a wet cough since birth. Patient was initially misdiagnosed with gastroesophageal reflux (GERD) by pediatrician and started on GERD treatment with no improvement.Upon failure to improve he was switched to asthma diagnoses started on asthma inhalers including salbutamol and steroid inhalers. Patient continued to have the cough, montelukast was added and he was given multiple courses of oral steroid with no improvement.A chest X-ray was done, and he was admitted with suspicious pneumonia, where we saw the patient for the first time as a consult. Upon examination, the patient was found to have stridor exacerbated with sleeping and lying down; the stridor went away once the patient sat up. Chest and neck CT angiography demonstrated a right-sided aortic arch and a dilated left subclavian artery consistent with Kommerell diverticulum. The aortic arch, left subclavian artery, and left common carotid artery formed an incomplete ring around the trachea and esophagus.The echocardiogram showed additional anomalies, including partial anomalous pulmonary venous return (PAPVR), with the right pulmonary veins draining into the superior vena cava-right atrial (SVC-RA) junction. The right atrium (RA) and right ventricle (RV) were dilated, while systolic function remained normal. Given the clinical presentation, surgical intervention was indicated. The patient underwent open-heart surgery and showed significant improvement.Discussion: This case was presented to emphasize the importance of considering other diagnoses when patients present with chronic use of asthma medications with no improvement. Congenital anomalies can still be diagnosed after years of birth, thus it is a necessity to keep congenital anomalies in the differential diagnosis of any case presenting with persistent respiratory symptoms. It is crucial to recognize subtle symptoms, such as cough and stridor improvement with position changes during clinical evaluation.This case report is a valuable contribution to the available literature, as it shows the uniqueness of late diagnoses of a congenital anomaly and the rare coexistence of a right-sided aortic arch and Kommerell diverticulum along with PAPVR. (5)
