 Hi everyone, I am Dr. Radhika Narendra Barde, a second year radiology resident at VKL Vallavalka Rural Medical College and Hospital Ratnagiri. The study that I shall be discussing today is Cartagena Syndrome, a Radiological Perspective. So this case came to us in the month of September. A 39 year old unmarried female, known case of cytosine versus presented the chief complaints of shortness of breath and frequent episodes of lower respiratory tract infections throughout her life. The surgical history included pulmonary lobectomy done in childhood, no family history of cytosine versus bronchic cases or sinusitis was present. The investigations performed were chest x-ray, a high resolution CT thorax, CT of the paranesal sinuses, contrast ring hand CT and ultrasound of abdomen and pelvis. The chest x-ray findings revealed a right sided cardiac apex and a right sided aortic arch, indicative of textrocardia, a left sided stomach bubble, hyper implanted lump fields, flattened domes of diaphragm and resection of a sixth strip on the right side consistent with history of lobectomy. On high resolution CT of thorax, we see hyper implanted lump fields with emphysematis changes in both lower lobes. Significant cystic and tubular bronchic tated changes are seen in the left lower lobe and tubular bronchic tated changes are seen in the right lower lobe. Inspecated mucus plugs are seen in few of the dilated airways giving it a classic finger and glove appearance. Multiple central lobular nodules are seen scattered bilaterally, collapsed consolidation involving the posterior and medial basal segments of the left lower lobe are seen with few dilated air bronchograms within. Another interesting finding was that of a multi-loculated, multi-septated cystic lesions within the superior mediastinum in the left paratracheal location. There's a communication seen at five o'clock position with the trachea, suggestive of tracheal divertically. Another finding was that of a dilated thoracic esophagus. Here we can see dextrocardia with reversed positions of the vertebrae vessels, a right-sided aortic arch and pulmonary artery, along with left-sided superior vena keva, inferior vena keva and azygous wave. On ultrasound, we can see reversal of the position of vertebrae vessels with the IVC being on left and aorta on the right. There's also reversal of the position of superior mesentric vein, which is on the left, and superior mesentric artery, which is on the right. Another finding was that of a midline liver extending in bilateral hypochondriac regions, along with myelipatomegaly and polysplenia in the left hypochondriac regions. CT of the paranasal sinuses revealed hypoplastic sinuses and bilateral maxillary spinoid and frontal sinusitis. A relatively hypoplastic middle nasal turbinate is seen here. Coming to the diagnosis, so our patient presented with history of frequent colds, chronic cough with expectoration and recurrent pulmonary infections leading presenting from early childhood. The radiological findings in our case are dextrocardia with cytosine versus bronchic cases, bronchoceles, central lobular nodules, pan sinusitis and hypoplastic paranasal sinuses, tracheal diverticulum, midline liver and polysplenia. So, diagnosis of Cartagena syndrome was made based on the clinical presentation and imaging features. Cartagena syndrome is an autosomal recessive genetic disorder, a subset of primary cillury dyskinesia, characterised by a triad of bronchic cases, paranasal sinusitis and cytosine versus tetanus. The estimated incidence is 1 in 30,000 live words, male-female ratio is 1 to 1. A gene mutation at DNA I1 and DNA H5 leads to impaired cillury motility and mucosillury clearance. This predisposes the patient to recurrent sinus pulmonary infections, infertility and errors with left-right body orientation. Coming to features of Cartagena syndrome, bronchic cases in patients of Cartagena syndrome is an acquired condition. It results in airflow limitation, obstruction and impaired clearance of secretions, leading to repeated respiratory infections. Chronic bronchitis bronchiolitis and emphysema are often associated with bronchic cases. The second finding was that of central lobular nodules and bronchoceles in both lower lobes as a result of super added secondary infection. Acquired tracheal diverticulum is due to increased intraluminal pressure and weakened tracheal wall, resulting from chronic kerb, bronchitis, bronchic cases, emphysema and recurrent respiratory infections. Pancytus occurs in almost 100% patients of Cartagena syndrome, which results from accumulation of secretions inside the paranesal sinuses, eventually leading to hypoplasia or a genesis of paranesal sinuses. Textrocardia with cytosine versus is present in nearly 50% patients of primary CLE dyskinesia. This immediately raises the suspicion of a genetic disorder with multi-organ involvement in patients since it's a very uncommon radiological finding. Another finding in our patient was that of midline liver and polysplenia, which again is a rare coincidence in Cartagena syndrome. A diagnosis is based on patients' history and radiological findings that is X-ray, CT and ultrasound, which can further be confirmed by genetic testing. So following the diagnosis, goals of management are improvement of the lung function and limitation of the disease progression. The treatment strategy includes aggressive antibiotic therapy, prophylaxis immunization, strong pulmonary toilet, regular physiotherapy and in patients with recurrent pneumonia and hemoptysis, we advise segmental lung resection or lobectomy. So to conclude, early diagnosis and symptomatic treatment as well as prevention of the infections is important in patients of Cartagena syndrome. Granting access to proper diagnostics and referral to a higher center is necessary. These are my references. Thank you.