anomalous right coronary artery ( rca ) from pulmonary artery is a rare congenital coronary anomaly . anomaly such as aortopulmonary window , tetralogy of fallot , and septal defects has been reported in one - third of anomalous rca originating from the pulmonary artery ( arcapa ) patients . whereas patients with anomalous pulmonary origin of the left coronary artery ( alcapa ) usually present with signs of left ventricular ischemia and congestive heart failure in infancy , most arcapa patients are diagnosed during childhood with cardiac murmur , chest pain , or congestive heart failure . however , arcapa may present with subclinical myocardial ischemia or is at the risk of sudden cardiac death even in early childhood . she was born with 40 weeks of gestational age and 2.7 kg of body weight without significant perinatal illness . she has been completely well without irritability , dyspnea , tachypnea , or cyanosis prior to illness . the height was 57.7 cm ( 10th25th percentile ) and body weight was 5.4 kg ( 10th25th percentile ) . the blood pressure and the pulse rate were 84/60 mmhg and of 148 beats per minute respectively . the cardiac examination was unremarkable except for sinus tachycardia and breathing sounds was equal bilaterally . the laboratory results were as follows : white blood cell , 9,640/l ; hemoglobin , 9.3 g / dl ; platelet , 571,000/l , erythrocyte sedimentation rate , 61 mm / hr ; c - reactive protein , 12.9 mg / dl ; procalcitonin , 1.96 ng / ml ; prohormone of brain natriuretic peptide , 2,077 pg / ml ; creatinine phosphokinase , 19 iu / l ; troponin i , 0.024 ng / ml . electrocardiography showed sinus tachycardia without st - t changes or abnormal q wave ( fig . the chest x - ray showed normal heart contour and size . because of concern of kawasaki disease and infective endocarditis for prolonged febrile exanthema , transthoracic echocardiogram was done . the origin of the rca was from the main pulmonary artery with rca to pulmonary artery steal , predominantly diastolic ( fig 2 ) . it showed a dilated left coronary artery with normal origin and collaterals from left anterior descending coronary artery to rca on short axis view ( fig . the cardiac structure , function , and dimension were within normal range but ischemic change of posterior wall of left ventricle was noted ( fig . the fever was subsided on 4th hospital day and the causative infectious agent was concluded as rhinovirus . aortogram demonstrated prominent left main coronary artery , normal left anterior descending artery and circumflex artery . the left main coronary artery arose from the appropriate sinus without aneurysm or stenosis ( fig . 5a ) . after a slight delay , the posterior descending and rca were filled up in a retrograde fashion through collaterals of the left coronary artery ( fig . the patient underwent direct reimplantation of anomalous rca to aortic root establishing dual ostial circulation ( fig . 6 ) . on the last follow - up , 5 months after the surgery , she was perfectly well on acethyl salicylic acid therapy . the prevalence of coronary anomaly is based on angiographic studies of adult from 0.6% to 1.3%4 ) . alcapa , first described by brooks3 ) , is more common than arcapa and is mostly fatal in infancy . the arcapa is rare , only about one - tenth as common as alcapa1 ) . unlike the alcapa presented with heart failure and myocardial ischemia in early infancy , many patients are asymptomatic5 ) this anomaly was usually diagnosed on the basis of heart murmur , mostly continuous in 50% of cases1 ) . other presenting symptoms and signs of arcapa are angina , dyspnea on exertion , congestive heart failure , and sudden cardiac arrest . radke et al.6 ) noted that 41% of patients of arcapa were asymptomatic , but 40% showed the ischemia . our case was asymptomatic and diagnosed incidentally by echocardiography during the evaluation of prolonged fever . the timing and severity of symptoms depend on the type of anomaly , direction of blood flow in the anomalous vessels , and extent of collateralization7 ) . its small perfusion area results in the patient generally asymptomatic , compared with patients having alcapa . but some increase in oxygen demand leads to exhaustion of the coronary physiologic reserve , which triggers extensive cardiac ischemia and causes ventricular arrhythmia similar to the alcapa . our patient showed the ischemia of left ventricular posterior wall even in asymptomatic 2 months old . the arcapa can be associated with other congenital anomaly like aortopulmonary window ( 30% of associated defects)8910 ) , tetralogy of fallot ( 19% ) , and isolated valvular anomalies1112 ) . the associated structural heart anomaly was not noted in the patient . unlike alcapa , there are no characteristics of electrocardiogram findings associated with arcapa . although the diagnosis of arcapa is made incidentally during heart surgery or on autopsy prior to 1965 , it is diagnosed by angiography or echocardiography during evaluation of the cardiac murmur , chest pain or dyspnea . both cardiac magnetic imaging and multislice computed tomography are becoming increasingly popular imaging modality for discovering coronary artery anomalies . because of the risk of myocardial ischemia or sudden death and improvement in operative morbidity , surgical correction with reestablishment of dual coronary ostial circulation , we treated a asymptomatic 2-month - old infant presenting with prolonged fever who was incidentally diagnosed with arcapa . the myocardial ischemia of left ventricular posterior wall was noted even in early and asymptomatic infant .
isolated anomalous right coronary artery originating from the pulmonary artery ( arcapa ) is a rare congenital coronary anomaly that is asymptomatic and discovered incidentally in most cases . 
 arcapa is generally not considered a fatal defect in infancy or childhood , although cases of sudden death have been reported . here 
 , we report a 2-month - old female infant who presented with a prolonged fever that was determined to be caused by rhinovirus infection . 
 myocardial ischemia of the left ventricular posterior wall was already seen on echocardiography , and arcapa was discovered incidentally . 
 the patient underwent successful surgical reimplantation of the right coronary artery to the aortic root to re - establish dual ostial circulation .