Clinical Manifestations of Fibrosing Mediastinitis in Chinese Patients

A retrospective analysis of transudative pleural effusion due to fibrosing mediastinitis

BACKGROUND

Pleural effusion caused by fibrosing mediastinitis is rarely reported. This study aimed to summarize the clinical manifestations, diagnosis and treatment of transudative pleural effusion due to fibrosing mediastinitis.

METHODS

Medical records and follow-up data of 7 patients with transudative pleural effusion due to fibrosing mediastinitis in Beijing Chaoyang Hospital between May 2014 and Feb 2018 were retrospectively analyzed.

RESULTS

These patients included 4 males and 3 females, with an average age of (64 ± 9) years. There were 3 left-sided effusions, 2 right-sided effusions and 2 bilateral effusions. Previous or latent tuberculosis was found in 6 patients. Pulmonary hypertension was indicated by echocardiography in all the 7 patients. Computed tomography pulmonary angiography (CTPA) of all the 7 cases showed increased soft tissue images visible in the mediastinum and bilateral hilus, different degrees of stenosis or occlusion in the pulmonary artery and pulmonary vein. In addition, 4 cases were found of right middle lobe atelectasis with a mediastinal window setting. There was interstitial pulmonary edema on the side of pleural effusion with a lung window setting. All the 7 patients were treated with intermittent drainage of pleural effusion combined with diuretic therapy. Five patients were treated with antituberculosis therapy. Up to now, two patients died of right heart failure and respiratory failure after 2 and 16 months respectively; The remaining 5 patients were still in follow up.

CONCLUSION

Fibrosing mediastinitis can lead to pulmonary vein stenosis or occlusion, and thus cause transudative pleural effusion, which can be detected by CTPA. Pulmonary hypertension, long time of cough, and a history of tuberculosis are common in these patients. The common therapy is intermittent drainage of pleural effusion combined with diuretic therapy.

Added value of spectral computed tomography quantitative parameters for differentiating tuberculosis-associated fibrosing mediastinitis from endobronchial lung cancer: initial results

OBJECTIVE

The objective of this study was to explore the added value of spectral computed tomography (CT) parameters to conventional CT features for differentiating tuberculosis-associated fibrosing mediastinitis (TB-associated FM) from endobronchial lung cancer (EBLC).

METHODS

Chest spectral CT enhancement images from 109 patients with atelectasis were analyzed retrospectively. These patients were divided into two distinct categories: the TB-associated FM group (n = 77) and the EBLC group (n = 32), based on bronchoscopy and/or pathological findings. The selection of spectrum parameters was optimized with the least absolute shrinkage and selection operator regression analysis. The relationship between the spectrum parameters and conventional parameters was explored using Pearson's correlation. Multivariate logistic regression analysis was used to build spectrum model. The spectrum parameters in the spectrum model were replaced with their corresponding conventional parameters to build the conventional model. Diagnostic performances were evaluated using receiver operating characteristic curve analyses.

RESULTS

There was a moderate correlation between the parameters ㏒(L-AEFNIC) - ㏒(L-AEFC) (r= 0.419; p< 0.0001), ㏒(O-AEF40KeV) - ㏒(O-AEFC) (r= 0.475; p< 0.0001), [L-A-hydroxyapatite {HAP}(I)] - (L-U-CT) (r= 0.604; p< 0.0001), {arterial enhancement fraction (AEF) derived from normalized iodine concentration (NIC) of lymph node (L-AEFNIC), AEF derived from CT40KeV of bronchial obstruction (O-AEF40KeV), arterial-phase Hydroxyapatite (Iodine) concentration of lymph node [L-A-HAP(I)], AEF derived from conventional CT (AEFC), unenhanced CT value (U-CT)}. Spectrum model could improve diagnostic performances compared to conventional model (area under curve: 0.965 vs 0.916, p= 0.038).

CONCLUSION

There was a moderate correlation between spectrum parameters and conventional parameters. Integrating conventional CT features with spectrum parameters could further improve the ability in differentiating TB-associated FM from EBLC.

Venous retrograde approach for endovascular angioplasty in chronic total pulmonary vein occlusion -a case report

INTRODUCTION

Fibrosing mediastinitis (FM) is a rare disease characterized by excessive proliferation of fibrous tissue in the mediastinum and can cause bronchial stenosis, superior vena cava obstruction, pulmonary artery and vein stenosis, etc. CASE PRESENTATION: An aging patient with intermittent chest tightness and shortness of breath was diagnosed with FM associated pulmonary hypertension (FM-PH) by echocardiography and enhanced CT of the chest, and CT pulmonary artery (PA)/ pulmonary vein (PV) imaging revealed PA and PV stenosis. Selective angiography revealed complete occlusion of the right upper PV, and we performed endovascular intervention of the total occluded PV. After failure of the antegrade approach, the angiogram revealed well-developed collaterals of the occluded RSPV-V2b, so we chose to proceed via the retrograde approach. We successfully opened the occluded right upper PV and implanted a stent.

CONCLUSIONS

This report may provide new management ideas for the interventional treatment of PV occlusion.

A 46-year-old woman presenting with anterior mediastinal mass and superior vena cava obstruction syndrome

Mucormycosis can rarely lead to an anterior mediastinal mass and a high index of suspicion is necessary so that intervention can be carried out at an early stage. https://bit.ly/4aUuqvc.

Endobronchial ultrasound-guided cautery-assisted transbronchial mediastinal cryobiopsy in the diagnosis of fibrosing mediastinitis secondary to atypical sarcoidosis: a case report

Background

Fibrosing mediastinitis (FM) secondary to atypical sarcoidosis (atypical presentation of sarcoidosis) is rarely reported at home and abroad. Its clinical manifestations represent a lack of specificity, and the initial diagnosis is frequently difficult. In particular, this case has multiple pulmonary nodules with mediastinal lymph node enlargement and bilateral pleural effusion, and pulmonary fibrosis still exists after treatment, which is inconsistent with any clinical stage of pulmonary sarcoidosis, further increasing the diagnostic difficulty. We retrospectively analyzed the clinical data of a case of FM secondary to atypical sarcoidosis diagnosed by endobronchial ultrasound-guided cautery-assisted transbronchial mediastinal cryobiopsy (EBUS-CA-TBMCB) in Chongqing University Fuling Hospital, to improve clinicians' attention to FM and understand that EBUS-CA-TBMCB remains an effective way of etiological diagnosis.

Case Description

A 70-year-old man was hospitalized with cough and dyspnea for two months. After admission, through chest computed tomography (CT), ultrasound guided bilateral lung biopsy, left parietal pleural biopsy, and EBUS-CA-TBMCB, the final diagnosis was atypical sarcoidosis secondary FM. After taking glucocorticoid orally, the patient's condition improved significantly, and was discharged from the hospital. We continued following up outside the hospital, and the patient's condition was further improved.

Conclusions

The diagnosis of FM is mainly based on typical imaging manifestations. When the contrast-enhanced chest CT finds localized or diffuse soft tissue density shadows around the mediastinum and pulmonary hilum with an irregular shape, with or without calcification, particular attention should be paid to exclude FM. EBUS-CA-TBMCB, as an improved minimally invasive method, can obtain enough tissue samples for pathological diagnosis, which may be the effective biopsy method for the etiology of FM to avoid missed diagnosis and misdiagnosis in the future.

Pulmonary vascular stenosis scoring in fibrosing mediastinitis

Aims

This study aims to develop a scoring system for evaluating the degree of pulmonary vascular stenosis in fibrosing mediastinitis (FM).

Methods and results

A retrospective single-centre study was conducted on 56 patients with FM in China between April 2014 and August 2021. The involvement of pulmonary vessels in patients with FM was assessed using dual-phase computed tomography pulmonary angiography, and we found that 85.7% of the patients had both pulmonary artery (PA) and vein (PV) involvement. PA involvement was mainly located proximal to both the upper PA and the bilateral basal trunk levels in the lower lungs. The involvement of the superior PV was more common than that of the inferior PV, and the right inferior PV was the least involved. Most of these lesions exhibited moderate or severe stenosis. Additionally, a scoring system for evaluating the degree of pulmonary vascular stenosis was developed. A correlation analysis revealed a negative correlation between the final pulmonary vascular score and the pulmonary arterial pressure, pulmonary vascular resistance, and maximum tricuspid regurgitation velocity. The calculated score of 17.1 was the best cut-off value for the diagnosis of mild and severe pulmonary hypertension (PH).

Conclusion

We successfully developed a scoring system for pulmonary vascular stenosis that can be used to evaluate the severity of pulmonary vessel involvement and PH. This scoring system may be relevant in the future development of target-based strategies for percutaneous interventions.

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.

Chest X-ray features facilitate screening for pulmonary hypertension caused by fibrosing mediastinitis

Background

Misdiagnosis and underdiagnosis of pulmonary hypertension caused by fibrosing mediastinitis (PH-FM) are considerably prevalent due to unspecific symptoms and as well as the lack of awareness of this fatal disease.

Objectives

The aim of this study was to evaluate the diagnostic accuracy of the chest X-ray (CXR) for screening the patients with PH-FM from those with pulmonary hypertension (PH).

Design

This was a retrospective observational cohort study.

Methods

The patients with suspected PH were recruited between October 2014 and October 2020. All the clinical data and CXR findings were collected. The sensitivity, specificity, and likelihood ratio of the CXR features were calculated. Logistic regression was used to identify the factors associated with the CXR characteristics and FM and to generate a prediction model. Finally, the diagnostic efficiency of the prediction model was evaluated using nomogram and internal validation.

Results

The patients with PH-FM (n = 36) and PH caused by the diseases other than FM (PH-non-FM, n = 62) were enrolled. The CXR features, including atelectasis, pleural effusion, consolidation, nodules, calcification, interlobular septal thickening, and interstitial reticulation, were more prevalent in patients with PH-FM than in those with PH-non-FM (all p < 0.05). Atelectasis had a specificity of 97%, a sensitivity of 50%, and a greater accuracy for diagnosing of PH-FM [area under the curve (AUC) = 0.720; 95% CI: 0.634-0.806] than the other factors did. The combination of tuberculosis, natural logarithmic NT-proBNP (lnBNP), atelectasis, pleural effusion, and prominent right heart border constituted a prediction model to distinguish the PH-FM from the PH-non-FM, with a sensitivity of 91.7% and a specificity of 83.9%. The model demonstrated good prediction performance by showing an AUC of 0.922 (95% CI: 0.861-0.983) in the internal validation.

Conclusion

In this study, atelectasis was the most specific and accurate CXR characteristic for identifying PH-FM in the PH patients. The combination of atelectasis, pleural effusion, prominent right heart border, tuberculosis, and lnBNP constituted a prediction model that distinguished the PH-FM patients from the PH-non-FM ones with good performance.

Pulmonary Hypertension Caused by Fibrosing Mediastinitis

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.

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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.

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The most prevalent trigger of FM is H-FM in the United States and TB-FM in China.

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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.

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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.

Comparison of fibrosing mediastinitis patients with vs. without markedly increased systolic pulmonary arterial pressure: a single-center retrospective study

INTRODUCTION

Fibrosing mediastinitis (FM) complicated with pulmonary hypertension (PH) has been considered as an important cause of morbidity and mortality. This study was designed to observe the possible effects of abnormal hemodynamics on patients by conducting a between-group comparison according to the presence of markedly increased systolic pulmonary arterial pressure (SPAP), so as to provide more information for clinical management.

MATERIALS AND METHODS

Fifty-one patients with clinically diagnosed FM were divided in two groups (SPAP < 50 mmHg group; SPAP ≥ 50 mmHg group) and retrospectively included in the study. Data mainly including demographic factors, echocardiographic data, results of right heart catheter and computed tomography (CT) examination were retrieved from the medical database. Echocardiographic parameters pre- and post- balloon pulmonary angioplasty (BPA) treatment were also collected in 8 patients.

RESULTS

Significant changes in cardiac structure, hemodynamics and cardiac function were detected in patients complicated with markedly increased SPAP. Patients in the SPAP ≥ 50 mmHg group had increased right heart diameter, right heart ratio and velocity of tricuspid regurgitation (VTR) (p < 0.05). Deteriorated right heart function was also observed. There was no significant difference in CT findings between the two groups, except that more patients in the SPAP ≥ 50 mmHg group had pleural effusion (p < 0.05). After primary BPA in 8 patients, improvement in the right atrium proportion was observed.

CONCLUSIONS

Changes due to significantly increased SPAP in patients with FM include adverse structure and function of the right heart, but differences in CT findings were not significant. Echocardiography has advantages as a noninvasive tool for the evaluation of cardiac structure, function and hemodynamics in patients with FM.

Clinical Features of Fibrosing Mediastinitis in Japanese Patients: Two Case Reports and a Literature Review

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.

Refractory pleural effusion as a rare complication of pulmonary vascular stenosis induced by fibrosing mediastinitis: a case report and literature review

Fibrosing mediastinitis (FM) is a progressive, life-threatening disease characterized by extrinsic compression of mediastinal bronchovascular structures, and the clinical manifestations largely depend upon the affected structures. Pleural effusion is rarely reported in patients with FM. We herein describe a 70-year-old man who presented with recurrent breathlessness and refractory left pleural effusion. He was misdiagnosed with and treated for tuberculous pleurisy for several months. Thoracentesis revealed a transudative pleural effusion, and a contrast-enhanced computed tomography scan of the thorax showed an extensive mediastinal soft tissue mass consistent with FM. Pulmonary angiography demonstrated pulmonary artery stenosis on the right side and pulmonary vein stenosis mainly on the left side. After measurement of the pulmonary arterial pressure by right heart catheterization, the patient was diagnosed with pulmonary hypertension associated with FM. He underwent balloon angioplasty and stent implantation of the stenosed pulmonary vessels, which led to long-term improvement in his breathlessness and pleural effusion. Our systematic review of the literature highlights that pleural effusion can be an uncommon complication of FM and requires careful etiological differentiation.

Thoracic Cardiovascular Complications of Tuberculosis

ABSTRACT

Mycobacterium infection remains a leading cause of morbidity and mortality worldwide. Although rare, thoracic cardiovascular complications are associated with devastating consequences if not promptly diagnosed using computed tomography. Intrapulmonary complications include tuberculous aortitis, Rasmussen aneurysms, involvement of bronchial and nonbronchial systemic arteries, and thromboembolic events. Extrapulmonary complications include pericarditis, myocarditis, endocarditis, involvement of coronary arteries, annular-subvalvular left ventricle aneurysms and mediastinal fibrosis. This article will review these complications and their computed tomography features.

Fungal fibrosing mediastinitis in pregnancy - Case report with review of literature

Fibrosing mediastinitis (FM) is characterized by extensive and invasive fibro-inflammatory proliferation, triggered by a delayed hypersensitivity reaction to variety of infective or noninfective stimuli. The infective agents often have a geographic distribution such as Histoplasma capsulatum in North America and Mycobacterium tuberculosis in Asian regions. In few reports, the mediastinitis is caused by fungi, particularly Aspergillus species. We report the first case of possible aspergillous FM in a young pregnant woman.

Mimickers of chronic thromboembolic pulmonary hypertension on imaging tests: a review

Chronic thromboembolic pulmonary hypertension (CTEPH) is caused by mechanical obstruction of large pulmonary arteries secondary to one or more episodes of pulmonary embolism. Ventilation perfusion scan is the recommended initial screening test for this condition and typically shows multiple large mismatched perfusion defects. However, not all patients with an abnormal ventilation perfusion scan have CTEPH since there are other conditions that be associated with a positive ventilation perfusion scan. These conditions include in situ thrombosis, pulmonary artery sarcoma, fibrosing mediastinitis, pulmonary vasculitis and sarcoidosis, among others. Although these conditions cannot be distinguished from CTEPH using a ventilation perfusion scan, they have certain characteristic radiological features that can be demonstrated on other imaging techniques such as computed tomography scan and can help in differentiation of these conditions. In this review, we have summarized some key clinical and radiological features that can help differentiate CTEPH from the CTEPH mimics.