1
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Boulu X, Perrin H, Schmidt J, Renard C. Superior vena cava syndrome of unusual cause. Rev Med Interne 2024; 45:174-175. [PMID: 38395715 DOI: 10.1016/j.revmed.2023.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 10/04/2023] [Accepted: 11/04/2023] [Indexed: 02/25/2024]
Affiliation(s)
- X Boulu
- Service de médecine interne, CHU Amiens-Picardie, 80054 Amiens, France; RECIF Amiens, CHU Amiens-Picardie, 80054 Amiens, France.
| | - H Perrin
- Service de médecine interne, CHU Amiens-Picardie, 80054 Amiens, France; RECIF Amiens, CHU Amiens-Picardie, 80054 Amiens, France
| | - J Schmidt
- Service de médecine interne, CHU Amiens-Picardie, 80054 Amiens, France; RECIF Amiens, CHU Amiens-Picardie, 80054 Amiens, France
| | - C Renard
- Service de radiologie et imagerie médicale, CHU Amiens-Picardie, 80054 Amiens, France
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2
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Mitrovic-Jovanovic M, Skrobic O, Odalovic S, Djikic Rom A, Plavsic A, Jankovic A, Kostadinovic M, Ivanovic N, Simic A, Djuric-Stefanovic A, Kovac JD. CT and 18FDG-PET/CT findings in progressive mediastinal idiopathic fibrosis as a benign mimicker of esophageal carcinoma: a case report. J Int Med Res 2023; 51:3000605231213212. [PMID: 38041832 PMCID: PMC10693803 DOI: 10.1177/03000605231213212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 10/23/2023] [Indexed: 12/04/2023] Open
Abstract
Idiopathic mediastinal fibrosis, also called sclerosing or fibrosing mediastinitis, is a very rare and aggressive fibroinflammatory process characterized by fibrous tissue proliferation in the mediastinal region. Herein, we present a rare case of idiopathic mediastinal fibrosis presenting with esophageal obstruction, most likely associated with immunoglobulin G (IgG4)-related disease, affecting the posterior mediastinum with intrapulmonary infiltration. Computed tomography revealed a narrowed lumen and thickened wall of the distal esophagus surrounded by a necrotic mass with infiltration into the nearby structures, suggesting a locally advanced malignant process. Positron emission tomography revealed intense accumulation of 18F-fluorodeoxyglucose, indicating an active inflammatory component, which complicates further differential diagnosis of mediastinal masses. Thoracoscopic biopsy and immunohistochemical analysis confirmed a fibroinflammatory process with perivascular lymphoid cell infiltration that was cluster of differentiation (CD)3 (++) and CD20 (++), with massive numbers of IgG4-immunoreactive plasma cells. Although a benign condition, sclerosing mediastinitis is a close mimicker of esophageal carcinoma, which cannot be differentiated by computed tomography or positron emission tomography and must be considered in a differential diagnosis.
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Affiliation(s)
- Milica Mitrovic-Jovanovic
- Department of Digestive Radiology, Clinic for Digestive Surgery, University Clinical Centre of Serbia, No. 6 Dr. Koste Todorovica Street, Belgrade, Serbia
- Department of Radiology, Faculty of Medicine, University of Belgrade, No. 8 Dr. Subotica Street, Belgrade, Serbia
| | - Ognjan Skrobic
- Department of Esophageal and Gastric Surgery, Clinic for Digestive Surgery, University Clinical Centre of Serbia, No. 6 Koste Todorovica Street, Belgrade, Serbia
- Department of Surgery and Anesthesiology, Faculty of Medicine, University of Belgrade, No. 8 Dr. Subotica Street, Belgrade, Serbia
| | - Strahinja Odalovic
- Department of Radiology, Faculty of Medicine, University of Belgrade, No. 8 Dr. Subotica Street, Belgrade, Serbia
- Center for Nuclear Medicine, University Clinical Centre of Serbia, No. 26 Višegradska street, Belgrade, Serbia
| | - Aleksandra Djikic Rom
- Department of Pathology, Clinic for Digestive Surgery, University Clinical Centre of Serbia, No. 6 Dr. Koste Todorovica Street, Belgrade, Serbia
| | - Aleksandra Plavsic
- Clinic of Allergy and Immunology, University Clinical Centre of Serbia, No. 2 Dr. Koste Todorovica Street, Belgrade, Serbia
- Department of Internal medicine, Faculty of Medicine, University of Belgrade, No. 8 Dr. Subotica street, Belgrade, Serbia
| | - Aleksandra Jankovic
- Department of Digestive Radiology, Clinic for Digestive Surgery, University Clinical Centre of Serbia, No. 6 Dr. Koste Todorovica Street, Belgrade, Serbia
- Department of Radiology, Faculty of Medicine, University of Belgrade, No. 8 Dr. Subotica Street, Belgrade, Serbia
| | - Milena Kostadinovic
- Center for Physical Medicine and Rehabilitation, University Clinical Centre of Serbia, No. 2 Pasterova Street, Belgrade, Serbia
| | - Nenad Ivanovic
- Department of Esophageal and Gastric Surgery, Clinic for Digestive Surgery, University Clinical Centre of Serbia, No. 6 Koste Todorovica Street, Belgrade, Serbia
- Department of Surgery and Anesthesiology, Faculty of Medicine, University of Belgrade, No. 8 Dr. Subotica Street, Belgrade, Serbia
| | - Aleksandar Simic
- Department of Esophageal and Gastric Surgery, Clinic for Digestive Surgery, University Clinical Centre of Serbia, No. 6 Koste Todorovica Street, Belgrade, Serbia
- Department of Surgery and Anesthesiology, Faculty of Medicine, University of Belgrade, No. 8 Dr. Subotica Street, Belgrade, Serbia
| | - Aleksandra Djuric-Stefanovic
- Department of Digestive Radiology, Clinic for Digestive Surgery, University Clinical Centre of Serbia, No. 6 Dr. Koste Todorovica Street, Belgrade, Serbia
- Department of Radiology, Faculty of Medicine, University of Belgrade, No. 8 Dr. Subotica Street, Belgrade, Serbia
| | - Jelena Djokic Kovac
- Department of Digestive Radiology, Clinic for Digestive Surgery, University Clinical Centre of Serbia, No. 6 Dr. Koste Todorovica Street, Belgrade, Serbia
- Department of Radiology, Faculty of Medicine, University of Belgrade, No. 8 Dr. Subotica Street, Belgrade, Serbia
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3
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Wang X, Zuo X, Wang F, Wang Y. Unexpected fibrous mediastinitis in a patient with myasthenia gravis - a case report. J Cardiothorac Surg 2023; 18:322. [PMID: 37964310 PMCID: PMC10647180 DOI: 10.1186/s13019-023-02417-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Accepted: 11/03/2023] [Indexed: 11/16/2023] Open
Abstract
BACKGROUND Fibrous mediastinitis (FM) is a rare mediastinal lesion characterized by proliferation of fibrous tissue within the mediastinum. Previous reports have shown that this lesion can be caused by histoplasmosis and tuberculosis. In extremely rare cases, FM can also be caused by autoimmune diseases such as antineutrophil cytoplasmic antibody-associated vasculitis and large-vessel arteritis. CASE PRESENTATION In our case, we report unexpected fibrous mediastinitis found after robotic thymectomy in a patient with myasthenia gravis (MG). The preoperative imaging indicated no obvious lesion in the mediastinum and the patient denied histories of both histoplasmosis and tuberculosis. After the operation, both proliferation of fibrous tissue and ectopic germinal centres (GCs) could be found in the thymus. CONCLUSION This rare case might enrich our knowledge of the relationship between FM and autoimmune diseases.
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Affiliation(s)
- Xuyang Wang
- Department of Thoracic Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu, Sichuan, 610041, China
| | - Xiaoping Zuo
- Department of Thoracic Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu, Sichuan, 610041, China
- Department of Thoracic Surgery, Guang'an People's Hospital, Guangan, Sichuan, 638000, China
| | - Fuqiang Wang
- Department of Thoracic Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu, Sichuan, 610041, China
| | - Yun Wang
- Department of Thoracic Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu, Sichuan, 610041, China.
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4
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Sadiq AM, Raza FM, Abdulrahimu YR, Mwacha CP, Sadiq AM, Lyamuya FS. Idiopathic fibrosing mediastinitis with esophageal varices: A case report. Heliyon 2023; 9:e15780. [PMID: 37144209 PMCID: PMC10151416 DOI: 10.1016/j.heliyon.2023.e15780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 04/20/2023] [Accepted: 04/20/2023] [Indexed: 05/06/2023] Open
Abstract
Fibrosing mediastinitis (FM) is a rare cause of lung fibrosis with multiple etiologies ranging from infectious to autoimmune to idiopathic. Common causes of FM include histoplasmosis and a relatively new cause of IgG4-related disease. We present a 55-year-old male with symptoms of esophageal varices, intractable hiccups, and progressive difficulty in breathing. A chest X-ray showed right lung fibrosis with pleural effusion and loss of lung volume, which was originally thought to be the sequelae of SARS-CoV-2 or metastasis, but computed tomography of the chest revealed FM. His variceal bleeding was controlled, and he was discharged home. However, treatment for FM was not pursued because the cause was not identified. Using corticosteroids may not cease the progression of the disease, and surgical options are available when symptoms persist. Idiopathic FM requires laboratory and radiological findings to exclude relevant differential diagnoses.
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Affiliation(s)
- Abid M. Sadiq
- Department of Internal Medicine, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
- Kilimanjaro Christian Medical University College, Moshi, Tanzania
- Corresponding author. Department of Internal Medicine, Kilimanjaro Christian Medical Centre, Moshi, Tanzania.
| | - Faryal M. Raza
- Department of Internal Medicine, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
- Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Yazid R. Abdulrahimu
- Department of Internal Medicine, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Christian P. Mwacha
- Department of Internal Medicine, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Adnan M. Sadiq
- Kilimanjaro Christian Medical University College, Moshi, Tanzania
- Department of Radiology, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Furaha S. Lyamuya
- Department of Internal Medicine, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
- Kilimanjaro Christian Medical University College, Moshi, Tanzania
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5
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Wang A, Su H, Duan Y, Jiang K, Li Y, Deng M, Long X, Wang H, Zhang M, Zhang Y, Cao Y. Pulmonary Hypertension Caused by Fibrosing Mediastinitis. JACC: ASIA 2022; 2:218-234. [PMID: 36338410 PMCID: PMC9627819 DOI: 10.1016/j.jacasi.2021.11.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 11/24/2021] [Accepted: 11/25/2021] [Indexed: 12/02/2022]
Abstract
Pulmonary hypertension (PH) is a progressive and severe disorder in pulmonary hemodynamics. PH can be fatal if not well managed. Fibrosing mediastinitis (FM) is a rare and benign fibroproliferative disease in the mediastinum, which may lead to pulmonary vessel compression and PH. PH caused by FM (PH-FM) is a pathologic condition belonging to group 5 in the World Health Organization PH classification. PH-FM has a poor prognosis because of a lack of effective therapeutic modalities and inappropriate diagnosis. With the development of percutaneous pulmonary vascular interventional therapy, the prognosis of PH-FM has been greatly improved in recent years. This article provides a comprehensive review on the epidemiology, pathophysiologic characteristics, clinical manifestations, diagnostic approaches, and treatment modalities of PH-FM based on data from published reports and our medical center with the goal of facilitating the diagnosis and treatment of this fatal disease. PH-FM, as a type of rare condition in group 5 PH, has a poor prognosis because of a lack of effective therapeutic modalities and frequent misdiagnosis and underdiagnosis. The most prevalent trigger of FM is H-FM in the United States and TB-FM in China. Imaging findings, including mismatched perfusion defects in the V/Q scan, FM dyad, and FM triad are important diagnostic clues, and clinical classification facilitates decision making in diagnosis and therapeutics. Because of the limited efficacy of drug therapy as well as the uncertain effectiveness and high risk of surgical treatment, endovascular interventional modality is currently the preferred therapeutic option, although procedure-related complications and intrastent restenosis after PV intervention need to be addressed.
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6
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Hirai Y, Iwamoto R, Iguchi H, Fusamoto A, Yata Y, Ohashi T, Nishimura Y. IgG4
‐associated fibrosing mediastinitis requiring differentiation from posterior mediastinal tumour: A case report. Respirol Case Rep 2022; 10:e0958. [PMID: 35582341 PMCID: PMC9085914 DOI: 10.1002/rcr2.958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 04/12/2022] [Indexed: 11/09/2022] Open
Abstract
A 71‐year‐old man, who was found to have a posterior mediastinal tumour, was referred to our hospital. Contrast‐enhanced computed tomography (CT) showed a 15‐cm soft tissue shadow in the posterior mediastinum, with many affected areas and a gradually increasing pattern. We also detected oligemic areas with poor contrast‐filling. There was no invasion into the adjacent vertebral body and the blood vessels penetrating the interior were intact. Positron emission tomography–CT revealed a high maximum standardized uptake level of 4.53 in the mediastinal masses. We performed thoracoscopic surgery for the biopsy. Histological findings showed lymphoplasmacytic infiltration in the fibrous stroma as well as storiform fibrosis. Immunohistochemical examination revealed abundant infiltration of immunoglobulin G4 (IgG4)‐positive plasma cells and 40% IgG4/IgG‐positive plasma cells. Postoperative serum examinations showed a high serum IgG4 level (570 mg/dl). Accordingly, we diagnosed the patient with IgG4‐related fibrosing mediastinitis, a rare manifestation of IgG4‐related disease.
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Affiliation(s)
- Yoshimitsu Hirai
- Department of Thoracic and Cardiovascular Surgery Wakayama Medical University Wakayama Japan
| | - Ryuta Iwamoto
- Department of Human Pathology Wakayama Medical University Wakayama Japan
| | - Hideto Iguchi
- Department of Thoracic and Cardiovascular Surgery Wakayama Medical University Wakayama Japan
| | - Aya Fusamoto
- Department of Thoracic and Cardiovascular Surgery Wakayama Medical University Wakayama Japan
| | - Yumi Yata
- Department of Thoracic and Cardiovascular Surgery Wakayama Medical University Wakayama Japan
| | - Takuya Ohashi
- Department of Thoracic and Cardiovascular Surgery Wakayama Medical University Wakayama Japan
| | - Yoshiharu Nishimura
- Department of Thoracic and Cardiovascular Surgery Wakayama Medical University Wakayama Japan
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7
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Kobayashi Y, Ishiguro T, Takaku Y, Kagiyama N, Shimizu Y, Takayanagi N. Clinical Features of Fibrosing Mediastinitis in Japanese Patients: Two Case Reports and a Literature Review. Intern Med 2021; 60:3765-3772. [PMID: 34024847 PMCID: PMC8710366 DOI: 10.2169/internalmedicine.5737-20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 12/01/2020] [Indexed: 12/02/2022] Open
Abstract
Fibrosing mediastinitis (FM) is a rare fibroinflammatory disease of the mediastinum with an etiology and clinical features that vary by world region. The characteristics of FM in Japan are still unknown. We herein report two Japanese patients with FM who were treated with corticosteroids and responded well. We also reviewed the Japanese literature on PubMed® and summarized the characteristics of 27 Japanese FM patients, including our two patients. In Japan, the predominant cases were those without a specific cause, were diffusely distributed, and responded well to corticosteroid therapy.
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Affiliation(s)
- Yoichi Kobayashi
- Department of Respiratory Medicine, Saitama Cardiovascular and Respiratory Center, Japan
| | - Takashi Ishiguro
- Department of Respiratory Medicine, Saitama Cardiovascular and Respiratory Center, Japan
| | - Yotaro Takaku
- Department of Respiratory Medicine, Saitama Cardiovascular and Respiratory Center, Japan
| | - Naho Kagiyama
- Department of Respiratory Medicine, Saitama Cardiovascular and Respiratory Center, Japan
| | - Yoshihiko Shimizu
- Department of Pathology, Saitama Cardiovascular and Respiratory Center, Japan
| | - Noboru Takayanagi
- Department of Respiratory Medicine, Saitama Cardiovascular and Respiratory Center, Japan
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8
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Hajsadeghi S, Pakbaz M, Sadeghipour A, Ahari AA, Marzban M. A Case of IgG4-Related Constrictive Pericarditis With Literature Review. J Clin Rheumatol 2021; 27:S331-S334. [PMID: 35073632 DOI: 10.1097/rhu.0000000000001711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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9
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Abstract
Fibrosing mediastinitis is rare in settings where histoplasmosis is not endemic. An idiopathic form of the disease may present with
indistinguishable features and requires methodical exclusion of competing differential diagnoses. We report the case of a 30-year old female
patient who presented with intermittent haemoptysis for the past 2 years with no constitutional symptoms. Computed tomography of the
chest revealed a prominent right bronchial arterial circulation with a mass-like lesion, which encased and attenuated the right pulmonary
trunk and adjacent structures. Endobronchial ultrasonography with transbronchial fine-needle aspiration showed a paucicellular aspirate
with no evidence of malignancy or granulomas. Fungal infection, tuberculosis, sarcoidosis, IgG4-disease, and connective tissue disease were
ruled out by appropriate serological, molecular, and microbiological tests. A diagnosis of idiopathic fibrosing mediastinitis was therefore
made by exclusion and the patient was successfully treated with oral corticosteroids.
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10
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SOHAIL AA, ASIF N, INAM H, PERVEZ MB, FATIMI SH. Aspergillus fibrosing mediastinitis presenting as anterior mediastinal mass and massive pericardial effusion. Chirurgia (Bucur) 2021. [DOI: 10.23736/s0394-9508.20.05108-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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11
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Mittal S, Chattopadhyay A, Nada R, Basher R, Jain S, Sharma A. Paraparesis and gangrene: an unknown manifestation of IgG4 disease. Rheumatology (Oxford) 2021; 59:e105-e106. [PMID: 32594152 DOI: 10.1093/rheumatology/keaa276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 04/16/2020] [Accepted: 04/27/2020] [Indexed: 11/13/2022] Open
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12
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Zhang Z, Guan W, Lin Q, Yu W. Thoracic paravertebral involvement in patients with IgG4-related disease: CT and MR imaging findings. Rheumatology (Oxford) 2021; 59:3878-3885. [PMID: 32556185 DOI: 10.1093/rheumatology/keaa254] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Revised: 03/19/2020] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES To retrospectively evaluate CT and magnetic resonance (MR) imaging thoracic paravertebral findings at baseline and follow-up in patients with IgG4-related disease. METHODS The study consisted of 36 patients with IgG4-related disease involving thoracic paravertebral regions (32 men and four women; mean age, 58 years; range, 25-78 years). A total of 36 patients underwent CT or MR imaging at baseline; 20 patients underwent follow-up. CT and MR images were reviewed and analysed in consensus by two radiologists for the various features of thoracic paravertebral lesions. RESULTS All lesions were located around two or more thoracic vertebrae, particularly the lower thoracic vertebrae (n = 36). The right side of vertebrae was predominantly affected in all cases (n = 36). Radiologically, IgG4-related thoracic paravertebral lesions were categorized into three types: solitary or multiple saddle-like masses type (32 patients); multiple nodules type (three patients); and invasively irregular mass type (three patients). All the types showed soft-tissue density on CT images, isointense on T1- and T2-weighted images, and homogeneous enhancement with penetration of small arteries in the lesions on contrast-enhanced CT and MR images. Steroid therapy administered to 20 patients dramatically diminished the mean maximum thickness in 18 patients. One patient with T7-12 vertebrae involved improved after steroid therapy. CONCLUSION IgG4-related paravertebral lesions occur mainly around the right side of the lower thoracic vertebrae and manifest as three major patterns of CT and MR imaging findings. Recognition of these diagnostic features will assist in the diagnosis and treatment of IgG4-related disease.
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Affiliation(s)
- Zaizhu Zhang
- Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Wenmin Guan
- Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Qiang Lin
- Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Wei Yu
- Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
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13
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Ahmed S, Hameed M, Thomas MM, Syed KS, Haq IU, AlAbbas A. Ptosis and Miosis Associated with Fibrosing Mediastinitis. AMERICAN JOURNAL OF CASE REPORTS 2021; 22:e927556. [PMID: 33431787 PMCID: PMC7811979 DOI: 10.12659/ajcr.927556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Fibrosing mediastinitis is a rarely seen, progressive disease. It results from an excessive fibrotic reaction in the mediastinum. We describe a presentation of fibrosing mediastinitis that, to our knowledge, has never been seen before. CASE REPORT A 30-year-old female Colombian flight attendant presented with a right eyelid droop. Examination revealed partial right-sided ptosis and miosis but no anhidrosis. An ill-defined firm swelling was palpable at the root of the neck. Chest radiography revealed a widened mediastinum, and computerized tomography (CT) showed a right paratracheal mass without calcification extending to the thoracic inlet, encasing multiple blood vessels. All basic blood tests, magnetic resonance imaging of the head, and ultrasound Doppler of the neck vessels were normal. History and work up for infections including fungal diseases, granulomatous diseases, vasculitis, and autoimmune diseases were negative. Positron emission tomography (PET) showed significant FDG uptake in the mediastinum. Mediastinal biopsy was histologically consistent with fibrosing mediastinitis. All relevant immunohistochemistry and microbiological studies were negative. Subsequently, the patient developed signs of superior vena cava compression; this was managed by balloon angioplasty, which resulted in improvement of symptoms. However, over time, her symptoms worsened progressively, resulting in a left-sided ptosis and radiological progression of the mass on CT. She received treatment with rituximab and concomitant steroids, which yielded excellent results: the treatment led to both resolution of her symptoms and regression of the mass and its metabolic activity on PET scan. CONCLUSIONS Fibrosing mediastinitis can present with an incomplete Horner's syndrome. Treatment with rituximab and steroids shows promising results in select cases of metabolically active idiopathic fibrosing mediastinitis.
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Affiliation(s)
- Shakeel Ahmed
- Department of Pulmonary Medicine, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Mansoor Hameed
- Department of Pulmonary Medicine, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar.,Department of Medicine, Weill Cornell Medicine-Qatar, Doha, Qatar
| | - Merlin M Thomas
- Department of Pulmonary Medicine, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar.,Department of Medicine, Weill Cornell Medicine-Qatar, Doha, Qatar
| | - Khezar S Syed
- Department of Pulmonary Medicine, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Irfan U Haq
- Department of Pulmonary Medicine, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Abbas AlAbbas
- Department of Pulmonary Medicine, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
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14
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Maritati F, Peyronel F, Vaglio A. IgG4-related disease: a clinical perspective. Rheumatology (Oxford) 2020; 59:iii123-iii131. [DOI: 10.1093/rheumatology/kez667] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 12/10/2019] [Indexed: 12/11/2022] Open
Abstract
AbstractIgG4-related disease (IgG4-RD) is a recently recognized fibro-inflammatory disorder that can affect almost any organ. Common presentations include major salivary and lacrimal gland enlargement, orbital disease, autoimmune pancreatitis, retroperitoneal fibrosis and tubulointerstitial nephritis. The main histopathological features are a dense, polyclonal, lymphoplasmacytic infiltrate rich in IgG4+ plasma cells, storiform fibrosis and obliterative phlebitis. The precise pathogenic mechanisms of IgG4-RD are still unclear. CD4+ T and B cells, including IgG4-expressing plasmablasts, constitute the major inflammatory cell populations and are believed to cause organ damage and tissue fibrosis. The diagnosis of the disease may be challenging and should be based on specific histopathological findings, typical laboratory and radiological aspects and an appropriate clinical context. The first-line treatment of IgG4-RD is based on glucocorticoids, which are usually efficacious. However, B cell depletion induced by rituximab has also been found to induce remission in steroid-resistant disease or has been used as steroid-sparing agent for relapsing disease. This review provides an update on clinical and therapeutic aspects of IgG4-RD.
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Affiliation(s)
- Federica Maritati
- Nephrology, Dialysis and Kidney Transplant Unit, Ospedali Riuniti, AnconaItaly
| | | | - Augusto Vaglio
- Nephrology and Dialysis Unit, Meyer Children’s University Hospital, Florence, Italy
- Department of Biomedical Clinical and Experimental Sciences, University of Firenze, Firenze, Italy
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15
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Successful management of fibrosing mediastinitis with severe vascular compromise: Report of two cases and literature review. Respir Med Case Rep 2019; 29:100987. [PMID: 31890562 PMCID: PMC6928374 DOI: 10.1016/j.rmcr.2019.100987] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Revised: 12/13/2019] [Accepted: 12/13/2019] [Indexed: 01/08/2023] Open
Abstract
Fibrosing mediastinitis is a rare disorder characterized by the invasive proliferation of fibrous tissue within the mediastinum. This fibrosis can result in compression of intrathoracic structures including the pulmonary vasculature leading to clinical symptoms and complications like pulmonary hypertension. Here, we present two cases of young patients with fibrosing mediastinitis complicated by pulmonary artery stenosis requiring medical and endovascular management with excellent results.
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16
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Deshwal H, Ghosh S, Magruder K, Bartholomew JR, Montgomery J, Mehta AC. A review of endovascular stenting for superior vena cava syndrome in fibrosing mediastinitis. Vasc Med 2019; 25:174-183. [PMID: 31804157 DOI: 10.1177/1358863x19884130] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Fibrosing mediastinitis (FM) is a rare disorder of inflammation and fibrosis involving the mediastinum. The formation of fibroinflammatory mass in the mediastinum can lead to obstruction of mediastinal structures and cause severe debilitating and life-threatening symptoms. Superior vena cava syndrome (SVCS) is a dreaded complication of FM with no medical therapy proven to be efficacious. Spiral vein grafting has long been utilized as first-line therapy for SVC syndrome due to FM. Endovascular repair with stents and angioplasty for malignant causes of SVC syndrome is well established. However, there are limited data on their utility in SVC syndrome due to FM. We present two cases of SVC syndrome due to FM treated with endovascular stenting and a detailed review of current literature on its utility in SVCS due to benign causes.
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Affiliation(s)
- Himanshu Deshwal
- Division of Pulmonary and Critical Care Medicine, New York University School of Medicine, New York, NY, USA
| | - Subha Ghosh
- Department of Radiology, Cleveland Clinic, Cleveland, OH, USA
| | - Karen Magruder
- Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
| | | | | | - Atul C Mehta
- Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
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Abstract
Fibrosing lesions of the mediastinum represent a small but challenging group of lesions that range in etiology from infectious to idiopathic to neoplastic. The diagnosis of such lesions becomes more challenging in the setting of mediastinoscopic biopsies. In addition, over the years, there has been further accumulation of knowledge of the clinical aspects of these lesions that needs to be incorporated into their evaluation. Therefore, it is essential that in the general evaluation of these fibrosing processes, one not only carefully examines the histopathologic features of the lesion, that of a fibroinflammatory process with the appropriate histochemical and immunohistochemical studies, but also carefully evaluates the clinical presentation and imaging findings. Needless to say, as will be illustrated in this review, determining a definitive unequivocal diagnosis on a small mediastinoscopic biopsy may be difficult, and often one needs to provide guidance on the perspective of the histologic features present. In some cases, mainly tumoral conditions with extensive fibrosis, a conclusive diagnosis can be made; however, it is those cases in which the extensive fibrosis is the only histopathologic feature where more appropriate guidance is required. While this review will focus more on the non-neoplastic fibroinflammatory lesions of the mediastinum, within the discussion of differential diagnoses, we will discuss some neoplastic conditions that commonly show extensive fibrosing features.
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18
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Gao WW, Zhang X, Fu ZH, Hu WY, Zhang XR, Dai GC, Zeng Y. Tuberculosis mediastinal fibrosis misdiagnosed as chronic bronchitis for 10 years: a case report. Quant Imaging Med Surg 2019; 9:1179-1183. [PMID: 31367572 DOI: 10.21037/qims.2019.06.13] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Wei-Wei Gao
- Department of Tuberculosis of Three, Nanjing Public Health Medical Center, Nanjing Second Hospital, Nanjing Hospital Affiliated to Nanjing University of Traditional Chinese Medicine, Nanjing 211132, China
| | - Xia Zhang
- Department of Tuberculosis of Three, Nanjing Public Health Medical Center, Nanjing Second Hospital, Nanjing Hospital Affiliated to Nanjing University of Traditional Chinese Medicine, Nanjing 211132, China
| | - Zhi-Hao Fu
- Department of Tuberculosis of Three, Nanjing Public Health Medical Center, Nanjing Second Hospital, Nanjing Hospital Affiliated to Nanjing University of Traditional Chinese Medicine, Nanjing 211132, China
| | - Wei-Yi Hu
- Department of Tuberculosis of Three, Nanjing Public Health Medical Center, Nanjing Second Hospital, Nanjing Hospital Affiliated to Nanjing University of Traditional Chinese Medicine, Nanjing 211132, China
| | - Xiang-Rong Zhang
- Department of Tuberculosis of Three, Nanjing Public Health Medical Center, Nanjing Second Hospital, Nanjing Hospital Affiliated to Nanjing University of Traditional Chinese Medicine, Nanjing 211132, China
| | - Guang-Chuan Dai
- Department of Tuberculosis of Three, Nanjing Public Health Medical Center, Nanjing Second Hospital, Nanjing Hospital Affiliated to Nanjing University of Traditional Chinese Medicine, Nanjing 211132, China
| | - Yi Zeng
- Department of Tuberculosis of Three, Nanjing Public Health Medical Center, Nanjing Second Hospital, Nanjing Hospital Affiliated to Nanjing University of Traditional Chinese Medicine, Nanjing 211132, China
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19
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Zhou Y, Shao L, Ruan W, Jin J, Xu H, Ying K, Wu X. Pulmonary vascular involvement of IgG4-related disease: Case series with a PRISMA-compliant systemic review. Medicine (Baltimore) 2019; 98:e14437. [PMID: 30732204 PMCID: PMC6380675 DOI: 10.1097/md.0000000000014437] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Revised: 12/29/2018] [Accepted: 01/16/2019] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Immunoglobulin G4-related disease (IgG4-RD) is a recently recognized, immune-mediated chronic fibrotic inflammation that can involve almost all organs, causing tumefaction and dysfunction. Its presence in pulmonary circulation is underestimated and has not yet been investigated. OBJECTIVES We describe a representative IgG4-RD patient with pulmonary artery stenosis and pulmonary embolism, leading to reversible pulmonary hypertension. Literature review of IgG4-RD with pulmonary circulation involvement was conducted. DATA SOURCES References for this review were identified through searches via PubMed, EBSCO, and Web of Science for published articles before November 2016. RESULTS There were 15 published cases of IgG4-RD with pulmonary vascular involvement, 3 with pulmonary arteritis, 2 with pulmonary artery aneurysm, 3 with pulmonary artery stenosis, 1 with obliterative phlebitis, and 1 with pulmonary embolism. Possible immunity and inflammation mechanisms were summarized. CONCLUSIONS IgG4-RD with pulmonary vascular involvement is rare. Echocardiogram and contrast-enhanced chest CT are helpful to screen the disease. Clinical manifestations were found from asymptomatic to dyspnea or even syncope. And nearly all cases had more than 1 organ affected, with significantly increased serum IgG4 levels. PET/CT aided in identifying affected organs and determining candidate biopsy sites. More awareness is urged to evaluate the pulmonary vascular manifestations of this disease.
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Affiliation(s)
- Yong Zhou
- Respiratory and Critical Care Medicine, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
- Thoracic Oncology Program, Department of Surgery, Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, CA
| | - Lingyan Shao
- Respiratory and Critical Care Medicine, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Wenjing Ruan
- Respiratory and Critical Care Medicine, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Joy Jin
- Thoracic Oncology Program, Department of Surgery, Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, CA
| | - Hangdi Xu
- Respiratory and Critical Care Medicine, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Kejing Ying
- Respiratory and Critical Care Medicine, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Xiaohong Wu
- Respiratory and Critical Care Medicine, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
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20
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Kavurmacı Ö, Akçam Tİ, Ergönül AG, Turhan K. İdiyopatik mediastinal fibrozis. EGE TIP DERGISI 2018. [DOI: 10.19161/etd.414700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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21
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Takanashi S, Akiyama M, Suzuki K, Otomo K, Takeuchi T. IgG4-related fibrosing mediastinitis diagnosed with computed tomography-guided percutaneous needle biopsy: Two case reports and a review of the literature. Medicine (Baltimore) 2018; 97:e10935. [PMID: 29851832 PMCID: PMC6393095 DOI: 10.1097/md.0000000000010935] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
RATIONALE Immunoglobulin G4-related disease (IgG4-RD) is a fibroinflammatory disease characterized by elevated serum IgG4 levels with infiltration of IgG4+ plasma cells and severe fibrosis in affected tissues. Recently, idiopathic fibrosing mediastinitis (FM), an extremely rare fibroinflammatory disorder, has been recognized as a form of IgG4-RD. As IgG4-RD can be treated by glucocorticoids, identification of the etiology of FM by surgical biopsy is essential; however, mediastinal biopsy is often difficult. We report 2 cases of IgG4-related FM successfully diagnosed with computed tomography (CT)-guided percutaneous needle biopsy. PATIENT CONCERNS Case 1 was a 66-year-old woman with elevated serum C-reactive protein without any symptoms and case 2 was 78-year-old woman with abnormal mediastinal contour on chest x-ray. By further work-up, both cases were found to have mediastinitis accompanied by elevated serum IgG4. CT-guided percutaneous needle biopsy revealed massive infiltration of IgG4+plasma cells along with storiform fibrosis. DIAGNOSIS IgG4-related FM. INTERVENTIONS Glucocorticoid therapy. OUTCOME The treatment resulted in significant improvement of the lesions after 3 months. LESSONS Early recognition and diagnosis of IgG4-related FM is essential because a delay in appropriate treatment initiation leads to progressive fibrosis with irreversible organ damage and poor prognosis. Our cases highlight CT-guided percutaneous needle biopsy as a promising option for histological examination in patients with IgG4-related FM.
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22
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Unexpected Fibrosing Mediastinitis Shown on FDG PET/CT in a Patient With IgG4-Related Disease. Clin Nucl Med 2017; 42:818-819. [DOI: 10.1097/rlu.0000000000001783] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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23
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Su J, Simonsen U, Carlsen J, Mellemkjaer S. Pulmonary Artery Occlusion and Mediastinal Fibrosis in a Patient on Dopamine Agonist Treatment for Hyperprolactinemia. Front Pharmacol 2017; 8:492. [PMID: 28775691 PMCID: PMC5517450 DOI: 10.3389/fphar.2017.00492] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Accepted: 07/10/2017] [Indexed: 11/30/2022] Open
Abstract
Unusual forms of pulmonary hypertension include pulmonary hypertension related to mediastinal fibrosis and the use of serotonergic drugs. Here, we describe a patient with diffuse mediastinal fibrosis and pulmonary hypertension while she was on dopamine agonist therapy. A young woman, who was treated with cabergoline and bromocriptine for hyperprolactinemia, presented with progressive dyspnea over several months. Based on the clinical investigation results, in particular, elevated pulmonary arterial pressures and significant perfusion defects on computed tomography (CT) pulmonary angiography and ventilation/perfusion (V/Q) scintigraphy, chronic thromboembolic pulmonary hypertension (CTEPH) was initially considered the most plausible diagnosis. However, during an attempted pulmonary endarterectomy, loose fibrous tissues were observed in the mediastinum and cryosection of the right pulmonary artery showed fibrosis and chronic inflammation. Subsequent investigations revealed that diffuse mediastinal fibrosis with concurrent pulmonary hypertension, and not CTEPH, was the most likely diagnosis and cabergoline and bromocriptine may have triggered the fibrotic changes. Both drugs are ergot-derived dopamine agonists, which are known to cause cardiac valve fibrosis and less frequently, non-cardiac fibrotic changes. The underlying mechanism is attributed to their interactions with serotonin receptors. There is much evidence that serotonin, a potent vasoconstrictor and mitogen, is involved in the pathogenesis of pulmonary hypertension. In conclusion, as CT and V/Q scintigraphy findings can occasionally be deceptive, physicians should be particularly aware of differential diagnoses in patients without obvious history of venous thromboembolism that are suspected of having chronic thromboembolic pulmonary hypertension.
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Affiliation(s)
- Junjing Su
- Department of Biomedicine and Pharmacology, Aarhus UniversityAarhus, Denmark
| | - Ulf Simonsen
- Department of Biomedicine and Pharmacology, Aarhus UniversityAarhus, Denmark
| | - Jørn Carlsen
- Department of Cardiology, RigshospitaletCopenhagen, Denmark
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24
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Bharadwaj R, Madakshira MG, Bharadwaj P, Sidhu HS. Sclerosing Mediastinitis Presenting as Complete Heart Block. J Clin Diagn Res 2017; 11:ED12-ED14. [PMID: 28658779 DOI: 10.7860/jcdr/2017/26349.9786] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2016] [Accepted: 02/23/2017] [Indexed: 12/24/2022]
Abstract
Sclerosing Mediastinitis (SM) is a rare condition which is characterized by the presence of dense fibrosis which infiltrates and encroaches upon various structures in the mediastinal cavity. Depending on the extent and the predominant organ of involvement, the patient presents with symptomatology of dysphagia, superior vena cava compression syndrome or dyspnoea. However, the involvement of the heart is rarely seen. Aetiologies of SM are several, with infections being the most common. We discuss a case of SM involving the oesophagus, descending aorta, hilum of lungs and the heart secondary to mucormycosis in an immunocompetent male.
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Affiliation(s)
- Reena Bharadwaj
- Professor and Head, Department of Pathology, Armed Forces Medical College, Pune, Maharashtra, India
| | - Manoj Gopal Madakshira
- Assistant Professor, Department of Pathology, Armed Forces Medical College, Pune, Maharashtra, India
| | - Prashant Bharadwaj
- Professor and Head, Department of Cardiology, Military Hospital, Cardio Thoraic Center, Pune, Maharashtra, India
| | - Hardeep Singh Sidhu
- Classified Specialist, Department of Pathology, Military Hospital, Cardio Thoraic Center, Pune, Maharashtra, India
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25
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Rossi GM, Rocco R, Accorsi Buttini E, Marvisi C, Vaglio A. Idiopathic retroperitoneal fibrosis and its overlap with IgG4-related disease. Intern Emerg Med 2017; 12:287-299. [PMID: 28070877 DOI: 10.1007/s11739-016-1599-z] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Accepted: 12/27/2016] [Indexed: 02/07/2023]
Abstract
Retroperitoneal fibrosis (RPF) is a rare disease characterised by fibrous tissue proliferation in the retroperitoneum, with encasement of the ureters and large vessels of the abdomen as the most destructive of potentially severe complications. It can either be idiopathic, or secondary to infections, malignancies, or the use of certain drugs. The idiopathic form accounts for approximately 75% of the cases, and is usually responsive to immunosuppressive therapy. In recent years, the emergence of a new clinical entity, IgG4-related disease (IgG4-RD), shed light on many fibro-inflammatory disorders once thought to be separate clinical entities, although frequently associated in the so-called multifocal fibrosclerosis. Among these, together with sclerosing pancreatitis and cholangitis, pseudotumour of the orbit, idiopathic mediastinal fibrosis and other conditions, is idiopathic retroperitoneal fibrosis (IRF). Both IRF and IgG4-RD can be associated with a wide variety of disorders, usually governed by immune-mediated (and particularly auto-immune) mechanisms. In our review, we discuss the clinical and therapeutic challenges IRF presents to the internist, as well as the meaning of its recent inclusion in the IgG4-RD spectrum from a clinical practice standpoint.
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Affiliation(s)
| | - Rossana Rocco
- Nephrology Unit, Parma University Hospital, Via Gramsci 14, 43126, Parma, Italy
| | | | - Chiara Marvisi
- Nephrology Unit, Parma University Hospital, Via Gramsci 14, 43126, Parma, Italy
| | - Augusto Vaglio
- Nephrology Unit, Parma University Hospital, Via Gramsci 14, 43126, Parma, Italy.
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