Surgical implications of sclerosing mediastinitis. A report of six cases and review of the literature

Mediastinal fibrosis as a late and fatal complication of treated tuberculosis mimicking a neoplastic process in a 34-year-old man

Fibrosing mediastinitis, also known as sclerosing mediastinitis, is an uncommon condition marked by abnormal proliferation of fibrous tissue in the mediastinum. This condition may accrue either as an idiopathic condition or as a complication of an underlying disease process. Its pathogenesis remains unknown. However, most reported cases are incriminating abnormal immune-mediated hypersensitivity responses to Histoplasma infection. Other rare causes include tuberculosis, blastomycosis, and an idiopathic form that may be associated with other miscellaneous conditions. CT and MR imaging play a vital role in the diagnosis and management of this disease. We present a rare case of fibrosing mediastinitis as a late complication of tuberculosis in a 34-year-old man with a prior history of mediastinal tuberculosis, mimicking initially a neoplastic mediastinal process. We will describe this clinical case in the light of the literature and point out the contribution of radiological imaging in the diagnosis of this rare pathology.

Fibrosing Mediastinitis Presenting With Superior Vena Cava Syndrome

Fibrosing mediastinitis (FM) is an uncommon diagnosis that involves the proliferation of extensive, dense fibrous tissue in the mediastinum. FM accounts for less than 1% of people with prior infection by Histoplasma capsulatum that develop hypersensitivity immune responses to antigens released during the initial exposure. Other causes include tuberculosis, blastomycosis, sarcoidosis, radiation, and idiopathic.  We describe FM presenting with superior vena cava (SVC) syndrome. A 66-year-old Caucasian male presented with a one-week history of progressively worsening facial swelling associated with dysphonia, bilateral ptosis, dyspnea on exertion, and unintentional weight loss of 30 pounds within the past three months. He had a 40-pack-year smoking history and a past medical history of essential hypertension, peripheral vascular disease, and bilateral internal carotid artery stenosis. The CT chest demonstrated non-specific soft tissue extending throughout the mediastinum and towards the right hilar region, complicated by severe attenuation of the superior vena cava and a 2.4 cm × 1.6 cm necrotic lymph node. The mediastinum had hyperemic and desmoplastic changes heavily encased in venous collaterals. L4 lymph node pathological evaluation demonstrated sinus histiocytosis and reactive lymphoid hyperplasia without signs of malignancy or atypia. The patient was treated with corticosteroid and diuretic therapy to achieve intermittent symptomatic relief, but continued to decline clinically, ultimately leading to his demise. The diagnosis of FM is best obtained through CT chest with intravenous contrast to demonstrate abnormal mediastinal tissue and possible structural compromise. A biopsy of the mediastinal tissue may also help rule out malignancy. Only a few case reports have demonstrated mixed symptomatic and radiologic responses to anti-inflammatory and/or antifungal treatment. Even non-surgical and surgical interventions have shown inconsistent efficacy, with frequent restenosis warranting re-exploration.

Pneumonectomy for Idiopathic Fibrosing Mediastinitis Mimicking Neoplasm in a Child

The unique case of a child with idiopathic fibrosing mediastinitis mimicking neoplasm is presented. A 5-year-old boy presented with pneumonia and was found to have a complex, heterogeneous, and calcified mediastinal mass along the left hilum. Percutaneous and surgical biopsies, while suggesting a potential epithelial malignancy, were non-conclusive. Due to worsening symptoms of airway obstruction and chest wall invasion, resection was performed for therapeutic and diagnostic purposes. This ultimately required pneumonectomy on cardiopulmonary bypass. Pathology revealed fibrosing mediastinitis with infiltration of lung parenchyma, and subsequent workup for infectious, neoplastic, granulomatous, and autoimmune etiologies was negative.

Balloon angioplasty or stent implantation for pulmonary vein stenosis caused by fibrosing mediastinitis: a systematic review

Fibrosing mediastinitis (FM) is a very rare disease, often caused by histoplasmosis capsulatum, tuberculosis, sarcoidosis, autoimmunity and other diseases, such as IgG 4-related diseases. Fibrous structures in the mediastinum compress the pulmonary artery, pulmonary vein, superior vena cava, esophagus, trachea and cardiac vessels, leading to clinical symptoms. Drug therapeutic modality for pulmonary vein stenosis (PVS) caused by FM is palliative in essence and with limited efficacy, whereas surgical treatment causes high mortality. In recent years, catheter-based treatment to FM-caused PVS has emerged as a promising therapeutic modality, however, the safety and effectiveness of this modality remain unclear. Therefore, a systematic review on the safety and efficacy of the catheter-based treatment for PVS caused by FM was performed, in the hope to shed lights on the alternative therapeutic strategy to this fatal disease.

Multimodality Imaging of Focal and Diffuse Fibrosing Mediastinitis

Fibrosing mediastinitis is a rare benign but potentially life-threatening process that occurs because of proliferation of fibrotic tissue in the mediastinum. The focal subtype is more common and typically is associated with an abnormal immunologic response to Histoplasma capsulatum infection. Affected patients are typically young at presentation, but a wide age range has been reported, without a predilection for either sex. The diffuse form may be idiopathic or associated with autoimmunity, usually affects middle-aged and/or elderly patients, and is more common in men. For both subtypes, patients present with signs and symptoms related to obstruction or compression of vital mediastinal structures. The most common presenting signs and symptoms are cough, dyspnea, recurrent pneumonia, hemoptysis, and pleuritic chest pain. Patients with the diffuse subtype may have additional extrathoracic symptoms depending on the other organ systems involved. Because symptom severity is variable, treatment should be individualized with therapies tailored to alleviate compression of the affected mediastinal structures. Characteristic imaging features of fibrosing mediastinitis include infiltrative mediastinal soft tissue (with or without calcification) with compression or obstruction of mediastinal vascular structures and/or the aerodigestive tract. When identified in the appropriate clinical setting, these characteristic features allow the radiologist to suggest the diagnosis of fibrosing mediastinitis. Careful assessment is crucial at initial and follow-up imaging for exclusion of underlying malignancy, assessment of disease progression, identification of complications, and evaluation of treatment response. Online supplemental material is available for this article. ^©RSNA, 2019.

Sclerosing Mediastinitis Causing Unilateral Pulmonary Edema Due to Left Atrial and Pulmonary Venous Compression. A Case Report and Literature Review

Sclerosing mediastinitis (SM), previously named chronic fibrosing mediastinitis, is an inflammatory process that in its end-stage results to sclerosis around the mediastinal structures. SM is quite rare and has been correlated with inflammatory and autoimmune diseases, as well as malignancy. SM may either present in a mild form, with minor symptoms and a benign course or in a more aggressive form with severe pulmonary hypertension and subsequent higher morbidity and mortality. The diagnosis of SM may be difficult and quite challenging, as symptoms depend on the mediastinal structure that is mainly involved; quite often the superior vena cava. However, practically any mediastinal structure may be involved by the fibrotic process, such as the central airways, as well as the pulmonary arteries and veins, leading to obstruction or total occlusion. The latter may be impossible to undergo proper surgical excision of the lesion, and is considered to be a real challenge to the surgeon. We herein report a case of SM that presented with arterial and venous compression. The imaging appearance was that of unilateral pulmonary edema, associated with lung collapse. The case is supplemented by a non-systematic review of the relevant literature.

Aggressive and progressive fibrosing mediastinitis involving the thoracic spine mimicking malignancy: A case report

Fibrosing mediastinitis is an uncommon benign disorder in which a chronic inflammatory reaction results in diffuse fibrosis of the mediastinum, potentially compromising the airways, great vessels and other mediastinal structures. Herein we describe a progressive course of fibrosing mediastinitis in a 72-year-old man. Computed tomography images depicted a diffuse, infiltrative, soft tissue mass involving the esophagus and superior vena cava in the mediastinum. Magnetic resonance imaging revealed destruction of the adjacent thoracic spine. Positron emission tomography-computed tomography also revealed increased metabolism in the periphery of the mass.

Fibrosing Mediastiniti: a Rare Cause of Unilateral Absent Lung Perfusion on a V/Q Scan

We report a case of a 29-year-old female with a history of asthma, post-partum ARDS, and pulmonary hypertension who presents with severe shortness of breath. The patient describes her shortness of breath as progressive over the past 10 years. Chest radiography and CT angiography of the thorax showed findings consistent with fibrosing mediastinitis with severe stenosis of the left main pulmonary artery. This resulted in appearance of unilateral absent left lung perfusion on quantitative Tc-99-MAA perfusion and Xe-133 ventilation (V/Q) scan.

Right Middle Lobe Collapse and Pleural Effusion in an 18-Year-Old Man

An 18-year-old African American male subject presented to an acute care clinic with 3 days of productive cough, chills, pleuritic right chest pain, sore throat with hoarseness, congestion, and intermittent shortness of breath. He recently relocated to Texas from Georgia to undergo basic military training. He denied any other recent travel or contact with persons with pulmonary TB or other respiratory illnesses. His medical history was significant for glucose-6-phosphate dehydrogenase deficiency and sickle cell trait.

[Treatment of chronic mediastinitis]

BACKGROUND

Chronic mediastinitis is a rare disorder characterized by the proliferation of fibrous tissue within the mediastinum resulting in compression of mediastinal structures.

OBJECTIVE

This article gives an overview of the treatment options for chronic mediastinitis.

MATERIAL AND METHODS

A literature search was carried out regarding treatment options for chronic mediastinitis

RESULTS AND CONCLUSION

Little is known about the pathogenesis of chronic mediastinitis, which has hampered the development of novel therapeutic approaches. There is no convincing evidence for the success of medicinal (antifungal or conventional anti-inflammatory) therapy and it is not recommended. In cases of clinical symptoms procedures for decompression, such as endovascular or endobronchial stents or surgical procedures, such as decompression interventions or extra-anatomic bypasses should be considered. The prognosis for unilateral involvement is better than for bilateral involvement if performed in specialized centers.

Fibrosing mediastinitis: a rare complication of histoplasmosis

We report a case of a 29-year-old man who presented with intermittent haemoptysis for about 18 months. Previously, his symptoms had been diagnosed as musculoskeletal pain and later as pneumonia. CT found a venous infarct in the right lung in addition to extensive lymphadenopathy in the mediastinum and pulmonary hila, with associated calcifications almost completely occluding the superior vena cava and azygos vein. Further questioning revealed that the patient had once worked on an organic farm in Colorado. Subsequent work up was positive for histoplasmosis yeast antibodies. The patient was diagnosed with fibrosing mediastinitis (FM) and started on itraconazole for 3 months. We note that FM is a rare complication of histoplasmosis and can present as chronic haemoptysis. Travel history is an important aspect of the clinical evaluation. Antifungal agents have shown some efficacy in treating histoplasmosis-related FM.

Fibrosing mediastinitis: an unusual cause of pulmonary symptoms

Fibrosing mediastinitis (FM), also known as granulomatous or sclerosing mediastinitis, is an uncommon but serious cause of chest symptoms. Due to an infectious or inflammatory challenge, production of collagen occurs in the confined space of the mediastinum. Collagen formation leads to compression of vital structures, resulting in cough, chest pain and dyspnea. The majority of cases of FM occur as a result of prior exposure to Histoplasma capsulatum. The following is a case of a previously healthy young woman who presented with a 3-month history of cough, chest pain and trouble breathing, and was subsequently found to have fibrosing mediastinitis. Fibrosing mediastinitis should be considered in the differential diagnosis of cough, chest pain and dyspnea, primarily when findings such as increased venous pressure are present on physical exam and hilar abnormalities are seen on chest radiograph. Clinical presentation, diagnosis and management of fibrosing mediastinitis are discussed.

Pulmonary Artery Narrowing: A Less Known Cause for Massive Hemoptysis

Chronic pulmonary artery narrowing may result from diverse causes; congenital as well as acquired. The relative hypoperfusion of the lung results in hypertrophy of multiple systemic arteries. Such patients can present with recurrent hemoptysis from hypertrophied systemic arteries, most commonly bronchial arteries. These patients remain undiagnosed for a long time because of the lack of awareness of this entity. We present three cases of chronic pulmonary artery narrowing presenting with massive hemoptysis.

Fibrosing mediastinitis mimicking bronchogenic carcinoma

Fibrosing mediastinitis is a rare but benign disorder characterized by an excessive fibrotic reaction in the mediastinum which can result in compromise of airways, great vessels, and other mediastinal structures. In this paper we presented a patient with fibrosing mediastinitis mimicking bronchogenic carcinoma. The patient was a 32-year-old diabetic male admitting with cough and hemoptysis. There was a right hilar mass and multiple mediastinal conglomerated lymph nodes on chest computed tomography. Positron emission tomography with computed tomography (PET/CT) scan demonstrated increased fluorodeoxyglucose (FDG) uptake at the right hilar mass lesion and mediastinal lymph nodes. Fiberoptic bronchoscopy showed mucosal distortion of right upper lobe. Pathologic examination of the mucosal biopsy revealed inflammation. Endobronchial ultrasound guided transbronchial needle and cervical mediastinoscopic lymph node biopsies were undiagnostic. Diagnostic thoracotomy confirmed the diagnosis fibrosing mediastinitis. Administration of six months of systemic corticosteroid and antituberculous therapy was not beneficial. In conclusion, despite being a rare clinical entity, fibrosing mediastinitis should be kept in mind in the differential diagnosis of mediastinal mass lesions of unknown etiology. The diagnosis is exceptionally difficult in the presence of atypical radiological findings. The treatment is particularly challenging without any proven effective therapy.

[Acute pulmonary edema, new complication of sclerosing mediastinitis]

Sclerosing mediastinitis is a rare and benign disease, which can cause obstruction of mediastinal structures, this determines the clinical presentation and prognosis. The obstruction of pulmonary venous structures secondary to mediastinal fibrosis has been rarely reported, clinically it mimics mitral stenosis. We describe the clinical case of a young patient with idiopathic sclerosing mediastinitis. The radiologic exams found stenosis of the right pulmonary artery, the right bronchus and pulmonary veins. Through this observation, we discuss this rare entity that although benign, can also be deadly. We study the different etiologies, clinical and therapeutic possibilities.

Fibrosingmediastinitis and consequent superior vena cava syndrome - A case report

Fibrosing mediastinitis is a rare, chronic inflammatory disease that has several implicated etiologies. We describe a case of a 41-year old woman who presented with the classic signs and symptoms of superior vena cava syndrome. Imaging revealed a diffuse infiltrative mediastinal process, which on biopsy was consistent with fibrosing mediastintis.

Fibrosing mediastinitis: clinical presentation, therapeutic outcomes, and adaptive immune response

Fibrosing mediastinitis (FM) is a rare disorder characterized by the invasive proliferation of fibrous tissue within the mediastinum. FM frequently results in the compression of vital mediastinal structures and has been associated with substantial morbidity and mortality. Its pathogenesis remains unknown. However, in North America most cases are thought to represent an immune-mediated hypersensitivity response to Histoplasma capsulatum infection. To characterize the clinical disease spectrum, natural disease progression, responses to therapy, and overall survival, we retrospectively analyzed all 80 consecutive patients with a diagnosis of FM evaluated at Mayo Clinic, Rochester, MN, from 1998 to 2007. Furthermore, we characterized the adaptive immune response in 15 representative patients by immunohistochemistry. The majority of patients presented with nonspecific respiratory symptoms due to the compression of mediastinal broncho-vascular structures. Chest radiographic imaging most frequently revealed localized, invasive, and frequently calcified right-sided mediastinal masses. Most patients had radiographic or serologic evidence of previous histoplasmosis. In contrast to earlier reports summarizing previously reported FM cases, the clinical course of our patients appeared to be more benign and less progressive. The overall survival was similar to that of age-matched controls. There were only 5 deaths, 2 of which were attributed to FM. These differences may reflect publication bias associated with the preferential reporting of more severely affected FM patients in the medical literature, as well as the more inclusive case definition used in our consecutive case series. Surgical and nonsurgical interventions effectively relieved symptoms caused by the compression of mediastinal vascular structures in these carefully selected patients. In contrast, antifungal and antiinflammatory agents appeared ineffective. Histologic examination and immunostaining revealed mixed inflammatory infiltrates consistent with a fibroinflammatory tissue response in these histoplasmosis-associated FM cases. The immune cell infiltrates included large numbers of CD20-positive B lymphocytes. As B lymphocytes may contribute to the pathogenesis of the disease, therapeutic B-cell depletion should be investigated as a therapeutic strategy for FM.

Pulmonary artery stenosis secondary to fibrosing mediastinitis: management with cutting balloon angioplasty and endovascular stenting

Cutting balloon angioplasty is a common treatment modality in the pediatric population for pulmonary artery stenosis. We present an adult with histoplasmosis induced fibrosing mediastinitis resulting in pulmonary artery stenosis that was successfully treated with cutting balloon angioplasty and subsequent stent deployment. Percutaneous endovascular stent placement has be shown to effectively alleviate pulmonary artery stenosis, however in-stent restenosis does limit durability. Pharmacologic therapy is indicated with either mediastinal adenitis or mediastinal granuloma with anti-fungal agents such as amphotericin B and itraconazole. Surgical intervention for histoplasmosis induced fibrosing mediastinitis is rarely indicated and may result in fatal complications that stem from mediastinal fibrosis due to resultant destruction of surgical planes. To our knowledge, this is the first reported case of utilizing cutting balloon angioplasty and stent insertion for the treatment of histoplasmosis induced fibrosing mediastinitis complicated by pulmonary artery stenosis.

Pulmonary pseudoneoplasms

CONTEXT

Not uncommonly, a surgical pathologist will be requested to review excised material, with a clinical diagnosis of cancer, in which no malignancy can be identified. Often, sampling may be the issue. However, different nonneoplastic processes may mimic cancer clinically and not be recognized histologically. These are commonly referred to as pseudoneoplasms and can involve the lung, pleura, and mediastinum.

OBJECTIVE

To review the most commonly encountered pseudoneoplasms of the thoracic cavity in surgical pathology and discuss the main differential diagnosis.

DATA SOURCES

Literature and personal review of cases with focus on inflammatory pseudotumors of the lung, organizing pneumonia, nodular lymphoid hyperplasia, apical cap, round atelectasis, and sclerosing mediastinitis with its pulmonary counterpart, hyalinizing granuloma.

CONCLUSIONS

When reviewing specimens that appear nondiagnostic for malignancy, it is important to consider one of these pseudoneoplasms in the differential diagnosis as they may explain the clinical and radiologic information.

Sclerosing mediastinitis mimicking anterior mediastinal tumor

A 54-year-old asymptomatic man presented with an anterior mediastinal mass discovered on chest roentgenogram. Chest computed tomography revealed a noncalcified round mass in the mediastinum. A white solid mass, 5-cm in diameter, had arisen from the pericardial adipose tissue with multiple small nodular lesions mimicking mediastinal tumor with pleural dissemination. Postoperative pathologic examination confirmed a diagnosis of sclerosing mediastinitis. Details of the clinical and radiographic feature are presented.

Unusual fibrosclerotic lesion of the laryngotracheal complex presenting as subglottic stenosis

We present a case report that describes the pathology, presentation, and management complexities of an unusual, destructive fibrosclerotic lesion of the laryngotracheal complex. An otherwise healthy 21-year-old man presented with a 1-year history of progressive shortness of breath and stridor. The initial examination revealed a 3-cm, grade III subglottic stenosis. Nodular fibrosis of the strap muscles, laryngotracheal cartilages, and trachea was evident. Biopsies revealed dense peritracheal desmoplastic reaction with focal erosion of cartilage. However, features diagnostic for relapsing polychondritis, desmoid tumor, or orbital pseudotumor were absent. The disease progressed to involve severe stenosis and thickening of the trachea and main stem bronchi. Surgical and medical management of this unusual fibrosclerotic lesion did not ameliorate the disease process, but a recent encouraging response to tamoxifen citrate has been observed with improvements in vocal fold motion and activity levels. Prognosis and management experience for this unknown pathologic entity are absent in the literature. In this case, diffuse disease progression occurred despite surgical and medical management, but has been halted by tamoxifen therapy. The prospect of a durable response and disease remission is unknown.

A case with multifocal masses

A 70-year-old man presented with progressive dyspnea, chest and back pain, fatigue of 5 years' duration, and dysphagia and weight loss of 1 year's duration. Despite multiple diagnostic work-ups performed previously, no eventual diagnosis could have been made. His personal past history was remarkable for impaired vision and recurrent "pneumonias" over the last 3 years. Computed tomography revealed mediastinal, right pulmonary, and retroperitoneal masses. The mediastinal mass compressed and obstructed the airways, superior vena cava, right main pulmonary artery, and esophagus, whereas the retroperitoneal mass encased inferior vena cava, abdominal aorta, and ureters. Transbronchial needle aspiration and endobronchial biopsy by rigid bronchoscopy and surgical biopsies of the mediastinal and pulmonary masses all showed inflammatory fibrous tissue. Ophthalmologic examination revealed a right orbital pseudotumor. A diagnosis of multifocal fibrosclerosis was made and corticosteroid treatment started. However, the patient died 2 weeks after establishing the diagnosis.

A case of idiopathic sclerosing mediastinitis in a 7-year-old Japanese boy

Sclerosing mediastinitis is a very rare benign disorder characterised by the development of dense fibrous tissue within the mediastinum. Affected patients are typically young adults with infant cases being uncommon especially in areas without endemic histoplasmosis. We report a Japanese boy with markedly elevated serum inflammatory markers for more than 1 year in the absence of any clinical manifestations. 67Ga-scintigraphy demonstrated an accumulation in the mediastinal region and an open biopsy revealed a hard fibrous mass in the anteriosuperior mediastinum. Thus, a diagnosis of idiopathic sclerosing mediastinitis was made.

CONCLUSION

To the best of our knowledge, this case is the youngest patient reported with this disorder. In patients with mediastinal mass lesions the diagnosis of sclerosing mediastinitis should be considered as well as infectious, autoimmune or neoplastic disease even in children.

Fibrosing Mediastinitis

Fibrosing mediastinitis is a rare benign disorder caused by proliferation of acellular collagen and fibrous tissue within the mediastinum. Although many cases are idiopathic, many (and perhaps most) cases in the United States are thought to be caused by an abnormal immunologic response to Histoplasma capsulatum infection. Affected patients are typically young and present with signs and symptoms of obstruction or compression of the superior vena cava, pulmonary veins or arteries, central airways, or esophagus. There may be two types of fibrosing mediastinitis: focal and diffuse. The focal type usually manifests on computed tomographic (CT) or magnetic resonance (MR) images as a localized, calcified mass in the paratracheal or subcarinal regions of the mediastinum or in the pulmonary hila. The diffuse type manifests on CT or MR images as a diffusely infiltrating, often noncalcified mass that affects multiple mediastinal compartments. CT and MR imaging play a vital role in the diagnosis and management of fibrosing mediastinitis.

Relief of sleep apnea after intravascular stenting for superior vena cava syndrome

A rarely reported association of sleep apnea and superior vena cava stenosis from mediastinal fibrosis is described. A case is presented where substantial improvement in the sleep parameters and the symptoms of sleep apnea occurred subsequent to superior vena cava thrombolysis and stent angioplasty.

Constrictive pericarditis

The diagnosis of constrictive pericarditis remains a challenge because its physical findings and hemodynamics mimic restrictive cardiomyopathy. Various diagnostic advances over the years enable us to differentiate between these two conditions. This review begins with a case report of constrictive pericarditis, followed by a brief history and discussions of etiologies. Clinical features, radiologic, electrocardiographic, angiographic findings, and hemodynamics of constrictive pericarditis are reviewed. The echocardiographic findings are detailed and the recent advances in Doppler flow velocity patterns of pulmonary, mitral, tricuspid valves and hepatic veins are reported. Nuclear ventriculograms depict rapid ventricular filling in constrictive pericarditis and differentiate it from restrictive cardiomyopathy. Endomyocardial biopsy helps further in recognizing the various types of restrictive cardiomyopathies. Computed tomography and magnetic resonance imaging delineate abnormal pericardial thickness in constrictive pericarditis. Association of characteristic hemodynamic changes and abnormal pericardial thickness > 3 mm usually confirms the diagnosis of constrictive pericarditis. Effusive and occult varieties of constrictive pericarditis are briefly described. This review concludes with emphasizing the importance of pericardial resection.

Chronic active mediastinitis in a 7-year-old boy: MRI findings

A 7-year-old child with a right mediastinal mass was found to have chronic active mediastinitis. The mass spontaneously involuted after biopsy. MRI showed the infiltrative nature of the mass.

Constrictive pericarditis: its history and current status

The diagnosis of constrictive pericarditis remains a challenge because it is often mimicked by restrictive cardiomyopathy. The last few years have seen numerous advances in our ability to differentiate between these two conditions which often have similar physical findings and hemodynamics. This review begins with a brief history of constrictive pericarditis; this is followed by an extensive discussion of newer etiologies, and then the classical clinical history and physical examination findings are described. Radiologic, electrocardiographic, and angiographic findings are discussed. The hemodynamics of constrictive pericarditis are reviewed. Recent results of echocardiographic and echo-Doppler investigations are presented. Emphasis is placed upon the limitations of M-mode echocardiography in the diagnosis of constrictive pericarditis. The value of echocardiographic Doppler studies of mitral and tricuspid flow velocity patterns, as well as of those in the pulmonary veins and hepatic veins, is described. Nuclear ventriculograms and angiocardiograms tend to show more rapid ventricular filling in constrictive pericarditis than in restrictive cardiomyopathy. Although only a small number of patients has been studied, these evaluations seem to have merit in separating restrictive cardiomyopathy from constrictive pericarditis. The role of computed tomography scanning and magnetic resonance imaging studies of pericardial thickness in confirming the presence of constrictive pericarditis is discussed. Abnormal pericardial thickening (> 3 mm) confirms the diagnosis of constrictive pericarditis, but only if the characteristic hemodynamic pattern is present. The usefulness of endomyocardial biopsy in recognizing specific varieties of restrictive cardiomyopathy is presented.(ABSTRACT TRUNCATED AT 250 WORDS)

Idiopathic pulmonary hilar fibrosis: an unusual cause of pulmonary hypertension

A 37-year-old man with progressive exertional dyspnea had pulmonary hypertension associated with pulmonary arterial and venous obstruction. An autopsy revealed that the cause of death was idiopathic pulmonary hilar fibrosis, a variant of mediastinal fibrosis. Pulmonary hilar fibrosis can mimic thromboembolic pulmonary hypertension, pulmonary veno-occlusive disease, and pulmonary venous hypertension.

Chronic fibrosing mediastinitis and superior vena caval obstruction from blastomycosis

Chronic fibrosing mediastinitis is most commonly a complication of granulomatous disease caused by histoplasmosis. We report a case of Blastomyces dermatitidis causing superior vena caval obstruction from fibrosing mediastinitis.

Recurrent massive pleural effusion due to pleural, pericardial, and epicardial fibrosis in histoplasmosis

Acute histoplasmosis is generally a benign, self-limited pulmonary infection. Although Histoplasma capsulatum pneumonitis is common, pleural effusions associated with histoplasmosis are quite rare, and massive pleural effusions have not been reported. There have been several reports of pericardial fibrosis secondary to histoplasmosis, but epicardial fibrosis has not been described. We report a biopsy-proven case of histoplasmosis initially associated with recurrent massive pleural effusions and excessive pleural fibrosis causing a trapped lung. The patient later developed constrictive pericarditis. Despite pericardiectomy, severe cor pulmonale occurred, and the patient died. Necropsy demonstrated fibrosis of the epicardium.