[Spontaneous mediastinal hematoma as initial presentation of cystic adenoma of ectopic parathyroid]

Spontaneous mediastinal hematoma as initial presentation of cystic adenoma of ectopic parathyroid Atraumatic spontaneous mediastinal hematomas are uncommon. They are secondary to trauma, rupture of great vessels or heart and associated to iatrogenic events. We report a case of a 61 year-old woman who consults for mediastinal hematoma without previous trauma. Imaging studies ruled out cardiac or vascular lesions. At exploratory thoracotomy, a large mediastinal hematoma was evidenced without obvious mass or bleeding vessel. The material sent to the Pathology service was diagnosed as cystic adenoma of ectopic parathyroid gland. Mediastinal hematomas are related to traumatic causes, cardiac or great vessels rupture or iatrogenic proceedings. Once these causes are ruled out, an injury of ectopic parathyroid tissue must be considered in the differential diagnosis because mediastinum is the most frequent ectopic location. Histopathological and immunohistochemical studies are useful in determining the cause-related hematoma, as in this case determined the parathyroid origin of the lesion, and to rule out involvement by other tumors.

Anthracosis and large mediastinal mass in a patient with healed pulmonary tuberculosis

A Mexican woman, aged 71 years, with life-long exposure to soot from a wood cook stove in a closed environment, who was treated for tuberculosis 4-years prior, presented with prominent mediastinal lymphadenopathy with anthracosis. Mediastinal lymphadenopathy is a common presentation of diverse granulomatous, malignant and infectious conditions like tuberculosis. Anthracotic pigment is found in different conditions such as tuberculosis or domestically acquired particulate lung disease. Accurate assessment of chronology and causative factors presents a challenge. Recognizing that pneumoconiosis can mimic or coexist with other granulomatous, infectious and malignant conditions presenting as mediastinal lymphadenopathy is important. Misdiagnosis may result in under- or over-treatment of potentially curable conditions such as tuberculosis, under-treatment of a lethal condition such as melanoma, or exposure of patients to inappropriate administration of costly therapy with potential untoward effects.

Management of descending mediastinal infections with an unusual cause: a report of 3 cases

Mediastinal infections are a life-threatening and distinctly rare event, especially when they are caused by a dental abscess or by a foreign body that has not perforated the esophagus. We evaluated how best to treat descending mediastinal infections occurring from an unusual cause. We report 3 female patients with mediastinal infections: two aged 45 and 80 years, each with a dental abscess, and one 62 with a foreign-body injury of the retropharyngeal wall. A retropharyngeal abscess and descending necrotizing mediastinitis developed in two of these patients. The mediastinal abscess was detected by computed tomographic scanning. All patients were successfully treated by drainage of their abscesses via cervicotomy or thoracotomy. A mediastinal abscess can be a serious complication. Mediastinitis is associated with a high mortality rate if the diagnosis is not quickly established and adequate therapy is not provided. In this report, we discuss the management and possible pathophysiological mechanisms of descending mediastinal infections that have an unusual cause. Clinicians should be aware of the possibility of descending mediastinal infections in patients with a retropharyngeal abscess or a dental abscess associated with persistent signs, such as fever. Imaging modalities must be used as soon as possible to enable early diagnosis. Aggressive treatment includes surgical drainage, and medical management in an intensive care unit may prevent a catastrophic outcome.

[Treatment of mediastinal abscess caused by removal foreign bodies in esophagus]

OBJECTIVE

To evaluate the clinical feature and treatment of Mediastinal Abscess caused by removal foreign bodies in esophagus.

METHOD

Retrospective analysis 12 patients of the last ten years, to observe the clinical manifestation and curative effect.

RESULT

Ten patients were cured and 2 patients died.

CONCLUSION

The clinical manifestation of mediastinal abscess caused by removal foreign bodies in esophagus is characteristic, should be operated in general anesthesia.

Association of chest radiographic abnormalities with tuberculosis disease in asymptomatic HIV-infected adults

SETTING

Francistown and Gaborone, Botswana.

OBJECTIVE

Chest radiography is used to screen for tuberculosis (TB) in asymptomatic persons living with the human immunodeficiency virus (PLWH) seeking isoniazid preventive therapy (IPT). We describe radiographic features in PLWH in a TB-endemic setting and identify features associated with TB disease.

DESIGN

Asymptomatic PLWH seeking IPT under program conditions for a clinical trial between 2004 and 2006 received chest radiographs (CXRs) that were read using the standardized Chest Radiograph Reading and Recording System (CRRS). Clinical characteristics, including TB disease, were compared with the radiographic findings.

RESULTS

From 2732 screening CXRs, 183 had one or more abnormalities and were scored using CRRS, with 42% having infiltrates (36% upper lobes), 35% parenchymal fibrosis and 32% adenopathy. TB disease status was determined in 129 (70%) PLWH, of whom 22 (17%) had TB disease. TB disease was associated with upper lobe infiltrates (relative risk [RR] 3.0, 95%CI 1.5-6.2) and mediastinal adenopathy (RR 3.9, 95%CI 1.8-8.4). The sensitivity and specificity of either upper lobe infiltrates or mediastinal lymphadenopathy for TB disease were respectively 64% and 82%.

CONCLUSION

A combination of CXR features was useful for predicting TB disease in asymptomatic PLWH. CRRS should be used more frequently in similar studies.

Giant mid-esophageal diverticulum. Conservative treatment of postoperative leakage

Mid-esophageal diverticula are rare entities. Only symptomatic patients usually receive surgical treatment. Esophageal leakage is one of the most common complications after these procedures. Though in literature, operative management is the preferred treatment for esophageal fistula, conservative approach is described in case of small leaks. We report a case of an operated giant mid-esophageal diverticulum complicated with an esophageal fistula. The patient underwent a surgical treatment and recovered completely.

[A case of ruptured bronchial artery aneurysm with hemothorax and mediastinal hematoma]

We encountered a case of ruptured bronchial artery aneurysm, which presented with hemothorax and mediastinal hematoma. The patient was a 65-year-old man. He was admitted because of a sudden onset of right chest pain. The chest X-ray film revealed a right pleural effusion and a pleural tap was reported to be bloody. Chest contrast CT revealed a subcarinal mass and several nodes, about 10 mm in diameter, in the thyroid. Because fine needle aspiration of the thyroid was positive, we suspected that the mediastinal lesion was a metastatic lymph node, and that the ruptured metastasis and carcinomatous pleurisy might have caused the hemothorax. However, mediastinoscopy confirmed no tumor but only mediastinal hematoma. This made us strongly suspect ruptured bronchial artery aneurysm. We next performed selective angiography of the bronchial artery, revealing an aneurysm, 10 mm in diameter. On this basis, a definitive diagnosis of ruptured bronchial artery aneurysm was made. Since the feeding vessel was too narrow to cannulate for embolization, we performed video-assisted thoracic surgery to dissect the hematoma. Although it was too organized to identify the aneurysm, it was assumed to be have been removed, and no recurrence was observed after the operation. Since a rupture of the bronchial artery could be life-threatening, a ruptured bronchial artery aneurysm should be considered as one of the differential diagnoses of hemothorax.

A case of nasogastric tube perforation of the nasopharynx causing a fatal mediastinal complication

Iatrogenic nasopharyngeal perforations secondary to improper nasogastric tube insertion probably occur more frequently than has been reported. Our review of the literature found very few cases. We report the case of a 79-year-old woman who died of mediastinal complications following the improper insertion of a nasogastric tube that resulted in a nasopharyngeal perforation. We also review the proper technique for inserting these tubes.

[Human adjuvant disease which developed after silicone augumentation mammoplasty]

A 73-year-old woman was admitted to our hospital to evaluate mediastinal lymphadenopathy found on a chest CT scan. She had undergone mammoplasty with silicone augmentation 50 years previously and had the implants removed 5 years previously. Biopsied specimens of a mediastinal lymph node under video-assisted thoracic surgery (VATS) revealed multiple hyalinized non-caseating epithelioid cell granulomas and multinucleated giant cells and foamy macrophages containing some vacuoles. According to these clinicopathological findings, we diagnosed human adjuvant disease which developed after mammoplasty with silicone augmentation. In cases of mammoplasty, we should pay attention to the complication of chronic thoracic disorder as a human adjuvant disease.

Two cases of mediastinal hematoma after cardiac catheterization: A rare but real complication of the transradial approach

Mediastinal hematoma is a very rare complication of cardiac catheterization, and is usually not considered in the differential diagnosis of chest pain after cardiac catheterization. However, we present two cases of mediastinal hematoma that developed after cardiac catheterization using the transradial approach.

[Case of Wegener's granulomatosis associated with mediastinal lymphadenopathy]

A 54-year-old asymptomatic man was admitted to our hospital because his abnormal chest radiograph finding became worse. A chest radiograph and a chest computed tomography showed a mass in the right upper lobe and mediastinal lymphadenopathy. Thoracoscopic partial lung resection was performed. The specimens showed vasculitis and geographic basophilic necrosis palisading histiocytes and neutrophils. Wegener's granulomatosis was diagnosed. After resection, mediastinal lympahdenopathy was gradually improved in spite of no drug therapy. We report a rare case of Wegener's granulomatosis associated with lymphadenopathy.

Posterior mediastinal abscess secondary to esophageal perforation following fish bone ingestion

Accidental swallowing of fish bone, which arrested in esophagus, is fairly common. However the incidence of esophageal perforation due to fish bone swallowing is low. Delayed posterior mediastinal abscess as a result of the esophageal perforation is a rare manifestation and may lead to fatal outcome. Two cases of delayed formation of posterior mediastinal abscess following esophageal perforation due to accidental fish bone ingestion are described here. In these cases patients presented with interscapular back pain. In one of the cases the patient died because of the presentation was misdiagnosed hence leading to delay in the intervention. Radiological findings and surgical management namely esophagoscopy and neck exploration are briefly described.

[Spontaneous mediastinal and retroperitoneal hematoma caused by trauma in an patient receiving anticoagulation treatment]

An 80-year-old man had chest and abdominal pains after he fell and twisted his body. He was taking anticoagulant drugs as a precautionary measure to prevent stroke. His chest CT and MRI was taking the presence of a sandglass-like nonenhanced shadow extending from the retromediastinum to the retroperitneum. No mediastinal tumor was detected by gastroscopy or on a chest CT 6 months later. Although the patient gradually became anemic, his vital signs remained normal throughout his hospital stay. The shadow decreased following conservative treatment by transthoracic drainage. We suspect that this tumor was a spontaneous hematoma caused by trauma in a patient receiving anticoagulation treatment.

[Mediastinal abdominal wall fistula due to ePTFE membrane]

A 78-year-old woman who had undergone double valve replacement 13 years before was referred to our department because of postoperative wound dehiscence and exudate. Although the result of exudate culture was negative, the wound was disinfected continuously for 4 weeks and showed a transient remission. However, the exudate was observed again 3 weeks later. By chest computed tomography (CT), a highly bright shadow was revealed in the mediastinum, which was suspected to be a foreign body and, therefore, the cause of the exudate. Considering the possibility of infection, the patient underwent an operation. Following incision of the epigastric region and the resection of the xiphoid process, ePTFE membrane with poor granulation tissue was found. The membrane was removed, the lesion was washed with warm saline, and then the wound was closed. The postoperative course was uneventful without recurrence. This complication was considered to be caused by biological reaction to a foreign body.

Mediastinal mass mimicking a tumor in a patient with bladder cancer after Bacillus Calmette-Guerin treatment

We describe the case of a 78-year-old male with bladder cancer who developed a mediastinal mass after intravesical immunotherapy with live Mycobacterium bovis BCG. The clinical diagnosis was mediastinal tumor suggestive for lymphoma. However, cultures of the biopsy specimens grew an acid-fast organism, which was identified as M. bovis BCG. To the best of our knowledge, this is the first reported case in which a post-instillation BCG infection induced a mediastinal mass that mimicked a tumor in a patient with bladder cancer.

Chronic illness masquerading as acute injury in pre-hospital care

Clinical diagnosis in pre-hospital care is challenging. It aims to identify life-threatening pathology that requires immediate treatment prior to evacuation to hospital. This case report present two elderly patients injured in a road traffic accident who presented with signs consistent with acute life-threatening pathology. Subsequent investigations in hospital revealed that in both patients, the underlying pathology was secondary to chronic malignancy and not as a result of any injury sustained during the accident. The importance of past medical history and the incidence of co-morbidity in relation to pre-hospital care are discussed.

Innominate venous aneurysm presenting as a rapidly expanding mediastinal mass

Thoracic venous aneurysms are extremely rare conditions. Only 14 innominate venous aneurysms have been reported in the literature. We report a case of a 13-year-old girl who presented with a mediastinal mass on chest roentgenogram, which was performed because the patient was postoperatively tachypneic after a routine appendectomy. Further investigations revealed a large left innominate venous aneurysm that was growing rapidly. The patient underwent aneurysmectomy and reconstruction of the innominate vein. The patient's postoperative course was uneventful, and her respiratory symptoms resolved.

On-pump vs. off-pump coronary artery bypass surgery at a non-academic community hospital: have biocompatibility improvements eliminated the superiority of off-pump surgery?

OBJECTIVES

Standard coronary artery bypass grafting (CABG) surgery involves cardiopulmonary bypass (CPB) but given concerns over neurological and inflammatory complications related to CPB, many patients receive so-called off-pump procedures (OPCABG). Our objective is to determine if the recent improvements in the biocompatibility of CPB circuitry have improved post-operative outcomes at the community hospital level, particularly in terms of hospital length of stay (LOS), stroke and post-operative infection.

METHODS

We analyzed hospital LOS, incidence of stroke, infection, and mortality along with several clinical variables in 209 patients (38% underwent OPCABG) at a single, non academic community hospital. We constructed a series of forward, stepwise, multiple-variable regression models using mediastinal infection, hospital LOS, and stroke as dependant variables.

RESULTS

OPCABG was associated with a shorter median hospital LOS (3 days vs. 4 days; p=0.0001) and a reduced occurrence of stroke (0% vs. 7.6%; p=0.03). However, mediastinal infections occurred more commonly in OPCABG cases (10% vs. 2.2%; p=0.02). CABG and pre-existing renal disease were predictors of increased hospital LOS (p< 0.0001) whereas CABG was the only factor associated with decreased risk of mediastinal infection (OR=0.21 (0.05-0.80); p=0.02).

CONCLUSIONS

At the community level, OPCABG appears to be superior in terms of LOS and incidence of stroke. Paradoxically, CABG surgery demonstrates a reduced rate of mediastinal infection.

Esophagectomy for complications of esophageal intramural pseudodiverticulosis

This report describes the clinical course of a patient with complications of esophageal intramural pseudodiverticulosis. The condition led to fistulization and abscess formation in the mediastinum. The initial presentation was for the septic process and appropriate antibiotic therapy led to infection control while the abscess drained spontaneously back into the esophageal lumen. A long stricture affecting the distal half of the esophagus became evident after a few months and could not be managed by repeat dilatations. After appropriate preparation, subtotal esophagectomy was offered to the patient with an initial right thoracic approach followed by laparotomy and left cervical reconstruction. A total gastric tube was used for reconstruction and placed in a substernal position. An uneventful postoperative evolution led to normal swallowing comfort.

Anterior mediastinal herniation of the transverse colon after an omental flap transposition

Poststernotomy mediastinitis continues to be an infrequent but serious complication after cardiac surgery. We present a case of a 59-year-old man who developed a deep sternal wound infection after an emergency cardiac surgery. Omental transposition flap was used to cover the sternal defect. Several days later, the patient developed a transverse colon herniation into the anterior mediastinum that required emergency exploration and colon resection. The patient survived after a difficult hospital course. Indications, technical points, and possible complications of using omental flap transposition are discussed.

Value of sonography for follow-up of mediastinal lymphadenopathy in children with tuberculosis

PURPOSE

To assess the clinical value of sonography for the follow-up of mediastinal lymphadenopathy in children diagnosed with pulmonary tuberculosis (TB).

METHODS

We conducted a retrospective review of the medical records of 21 children (9 boys, 12 girls) with a mean age of 6 years (range, 7.4 months to 18 years) who had a positive intradermal tuberculin skin test. All patients underwent thorough history-taking, physical examination, frontal and lateral chest radiographs, and sonographic study of the mediastinum. The mediastinum was accessed through the suprasternal and left parasternal approaches. The presence of 1 or more masses with an ovoid or round shape and hypoechoic appearance in the anterior or middle mediastinum was recorded. A comparison was made between the results of the sonographic examination of the mediastinum before administration of anti-TB agents and after 3 months of treatment.

RESULTS

Pulmonary radiographic findings were suggestive of TB in 17 patients and were uncertain in 4 patients. Sonographic examination, however, detected mediastinal lymphadenopathy in all patients. A comparison of pretreatment mediastinal sonograms with those obtained after 3 months of anti-TB treatment showed a marked reduction of lymph node involvement in 17 patients (80.9%). In the remaining 4 patients, mediastinal lymphadenopathy was still present.

CONCLUSION

Mediastinal sonography appears to be a valuable tool for the diagnosis of TB and in the monitoring of response to treatment in children.

Mediastinal shift secondary to a diaphragmatic hernia: a life-threatening combination

An 85-year-old man was referred to our department, with a three-day history of increasing shortness of breath. Following clinical and radiological assessment, diaphragmatic herniation of bowel was identified to be causing mediastinal shift and respiratory distress. An emergency laparotomy identified a massive diaphragmatic defect which was not amenable to primary closure. A colopexy procedure was performed to comparmentalise the abdomen and obliterate the diaphragmatic defect. Despite aggressive treatment in the intensive care unit he died from multi-organ failure. This case highlights an extremely rare and life-threatening cause of mediastinal shift and respiratory distress.

Cardiovascular calcifications after radiation therapy for Hodgkin lymphoma: computed tomography detection and clinical correlation

OBJECTIVE

To study cardiovascular calcifications, detected by computed tomography, in patients following mediastinal radiation for Hodgkin lymphoma, and correlate them with clinical findings.

MATERIALS AND METHODS

Fifteen patients, <or=55 years, with computed tomography detected cardiovascular calcifications after mediastinal radiotherapy for Hodgkin lymphoma were identified during a 10-year period. Calcifications were evaluated for site and extent and were correlated with clinical data including symptoms and signs of heart disease, angiographic and surgical findings.

RESULTS

Accelerated calcifications were detected in the coronary arteries (n=11), in the aorta (n=11), and in the aortic valve and the mitral apparatus (n=8). Calcifications were more extensive when radiation was given at a young age. Clinical evidence of cardiovascular disease included coronary events in three patients, valvular dysfunction in two, pericarditis in two and complete atrioventricular block in one. Seven patients had no cardiac symptoms.

CONCLUSION

Early cardiovascular calcifications can be radiation associated. Such calcifications may represent radiation-induced atherosclerosis and can be detected by computed tomography even in asymptomatic patients. The implication of our findings is that spiral computed tomography may serve as a non-invasive modality to detect accelerated cardiovascular calcifications in high-risk asymptomatic patients who survived Hodgkin lymphoma.

Incidence of sarcoidosis in head and neck cancer

Sarcoidosis and sarcoid-like reactions have been reported to be associated with malignancies, particularly testicular cancer and lymphoma. They occur either synchronously or metachronously, and may also occur after chemotherapy. We know of only two other case reports of granulomatous reactions in head and neck cancer. The present case highlights the association of sarcoidosis with head and neck cancer, and the importance of considering the diagnosis in patients who may have metastatic disease.

[Mediastinal recurrence of breast cancer suspecting mediastinal fibrosis]

A 63-year-old female, who had undergone a modified radical mastectomy for breast cancer at the age of 45, was suffered from trachyphonia due to left recurrent nerve paralysis at the age of 53. She presented left phrenic nerve paralysis and dysphagia at the age of 61. Computed tomography (CT) revealed mediastinal fibrosis, stenosis of esophagus and superior vena cava, and slight lymph nodes swelling. Video-assisted thoracoscopic mediastinal biopsy was performed and the mediastinal fibrosis was diagnosed as recurrence of breast cancer 17 years after the breast cancer operation. She underwent mediastinal radiation and chemotherapy for mediastinal recurrence and stenting for esophageal stenosis.

Ruptured left gastric artery aneurysm: unique presentation with hemothorax and hemomediastinum

Although splanchnic artery aneurysms are uncommon and remain mostly asymptomatic, they are associated with a high mortality rate when they rupture. We discuss the case of a 66-year-old woman who had successful embolization of a left gastric artery aneurysm after presenting with acute chest pain and the unusual computed tomography findings of hemothorax and hemomediastinum. To our knowledge, only one other similar case has been published in the literature.

Chronic encapsulated mediastinal abscess presenting with remote cutaneous fistulization 12 years after redo aortic valve replacement for prosthetic valve endocarditis

Chronic encapsulated mediastinal abscess is an unusual complication of previous open heart surgery. We report on the case of a 79 year old male who presented with epigastric fistulization of an encapsulated anterior mediastinal abscess 12 years after a redo aortic valve replacement for prosthetic valve endocarditis. The encapsulated abscess and its complex branching tracts and the cutaneous fistula were excised completely except the thin longitudinal strip of the ascending aorta which formed part of the posterior wall of the infected tract. This was covered with transposed greater omentum based on right gastroepiploic artery pedicle. Patient remains fit and well 2 years after his operation.

This report is unusual on account of the length of the interval between previous heart surgery and the infective complication, the presumed dormancy of the abscess for as long as 12 years, the complex course, branching tracts and the contents of the abscess, the remote fistulization of the abscess at a distant anatomical site and, finally, the principle of successfully covering an infected tract which formed the adventia of the ascending aorta with pedicled omentum in the hope of avoiding an ascending aortic replacement in a frail 79 year old man.

In the entire English language literature, this report represents the longest interval between a heart operation and a sternal or mediastinal abscess