Patient with total anomalous pulmonary venous return (TAPVR). .
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Snowman image from www.clipartlord.com. (Free for public use and domain).
The shape of the snowman superimposed over the CXR demonstrates the origin of this sign.
CXR image contributed by Dr M Sanal Kumar: http://radiopaedia.org/cases/total-anomalous-pulmonary-venous-return-2