A gentleman born in 1979 had an asymptomatic murmur during childhood. Investigations confirmed hemianomalous pulmonary venous drainage to the right atrium without an atrial septal defect. The parents were Jehovah's witnesses and refused cardiac surgery with use of blood products. When aged 15 years, an adult cardiologist advised surgery and the patient was operated on by a general cardiac surgeon unused to congenital heart disease but willing not to use blood. The atrial septum was confirmed to be intact at operation and the oval fossa was enlarged to allow redirection of blood from the right pulmonary veins using a baffle of autologous pericardium to the left atrium. Recovery was uncomplicated. Seven months later he complained of increasing dyspnoea on effort and chest infections. He was reviewed once by a respiratory physician without further investigations or referral to cardiology. He trained and worked as a stonemason.
He presented again aged 28 years, with a three-week history of right-sided pleuritic chest pain, high fever and a dry cough. On examination there was reduced air entry, coarse crepitations and a pleural rub at the right base. Chest radiography showed a dense patchy consolidation of the right lower lobe, probably also involving the middle lobe (Figure 1). He was treated with intravenous cefuroxime and oral clarythromycin but failed to respond as symptoms continued over several weeks with febrile exacerbations. An infectious disease specialist was involved and several alterations in the antibiotic regime were made. Tuberculosis was excluded on serial sputum cultures and infective endocarditis was considered possible but a transthoracic echocardiogram was reported as normal. Contrast computerised tomography scan of the thorax reported extensive consolidation within the right lung and probable chronic posterior pleural effusion. Bronchoscopy showed hyperaemic right main bronchial mucosa with inflammation especially around the right upper lobe bronchus. No lesions or pus were found to explain the situation. 
Despite the "normality" of the heart but because of past cardiac surgery, he was referred to the monthly Grown Up Congenital Heart (GUCH) clinic. A diagnosis of obstructed right pulmonary venous drainage was made from the chest X-ray (Figure 1). This stimulated review of his previous investigations. Computerised tomography scan cuts at the level of the heart and pulmonary vessels showed completely obstructed right pulmonary veins (Figure 2). No pericardial baffle was identified upon review of cross-sectional transthoracic echocardiographic images. There was also no flow to be seen across the atrial septum at the level of the created "atrial septal defect" on colour Doppler. A repeat transthoracic echocardiogram with spectral Doppler interrogation of the pulmonary arteries showed normal antegrade flow from the main pulmonary artery into the left pulmonary artery but none into the right pulmonary artery.