Mistletoe sign

Case contributed by Ferenc Imre Suhai
Diagnosis certain


Stable chest pain

Patient Data

Age: 70 years
Gender: Female

Coronary CTA


CT images show perivascular soft-tissue masses around the proximal part of the LAD artery and the RCA, which do not cause luminal obstruction. In the LAD artery proximal to the site of the perivascular mass, a partially calcified coronary plaque causes moderate stenosis. Mild stenosis is visible in the RCA at the site of the pericoronary mass.


The volume rendered images of the coronary tree and the curved multiplanar reconstruction of the LAD and RCA nicely demonstrates the mistletoe sign.


Cardiac MRI images show soft tissue masses around the LAD and RCA. The pericoronary mass around the LAD shows intense gadolinium enhancement.


Abdominal CT shows confluent irregularly shaped, retroperitoneal soft-tissue mass around the aorta and common iliac arteries consistent with retroperitoneal fibrosis. On the abdominal scan you can see a right ureteric catheter and hydronephrosis with a dilated ureter on the left side.

Case Discussion

This patient presented with symptoms of presumed cardiac involvement of idiopathic retroperitoneal fibrosis, otherwise known as Ormond disease. Distinct pericoronary tissue proliferations were depicted at cardiac magnetic resonance imaging and coronary computed tomographic (CT) angiography.

On images, the coronary manifestation has been termed the “mistletoe sign”. The presence of the mistletoe sign on cardiac MRI and coronary CT angiography is probably rare, but it might be a characteristic manifestation of retroperitoneal fibrosis. With the increasing number of non-invasive cardiac imaging tests performed worldwide, the recognition of the mistletoe sign could be helpful in diagnosing retroperitoneal fibrosis.

Our case reports cardiac MRI and coronary CT angiographic visualization of presumed coronary involvement in retroperitoneal fibrosis with a normal IgG4 level.

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