Tracheomediastinal fistula induced by concurrent chemoradiotherapy in small cell lung cancer: A case report and literature review

Tracheomediastinal fistula is a rare but life-threatening complication of cancer. We report a case of tracheomediastinal fistula induced by concurrent chemoradiotherapy in limited stage small cell lung cancer. Despite the treatment response, the metastatic paratracheal lymph node increased gradually during concurrent chemoradiotherapy, resulting in the occurrence of tracheomediastinal fistula and mediastinitis. Without any surgical intervention, the patient achieved successful recovery from mediastinitis through antibiotic treatment, although the tracheomediastinal fistula remained open. In this report, we also review previous studies of tracheomediastinal and bronchomediastinal fistulas and summarize the clinical features.

Cyanoacrylate injection treatment for postoperative leakage of Boerhaave's syndrome: A case report

RATIONALE

Surgical treatment remains the most effective option for treating Boerhaave's syndrome. However, in cases of postoperative anastomotic leakage of Boerhaave's syndrome, endoscopic interventions such as over-the-scope clip, stenting, or cyanoacrylate injection have emerged over reoperation.

PATIENT CONCERNS

We report the case of a 50-year-old male patient who presented with vomiting and abdominal pain after alcohol consumption. Laparoscopic surgery was performed for primary closure of a laceration at the lower esophagus, and for the closure of a Boerhaave's syndrome, which was detected by abdominal computed tomography. However, postoperative anastomotic leakage was confirmed through esophagography after the operation. In our case, endoscopic treatment with an over-the-scope clip and stenting were not effective for the repair of the anastomotic leakage, but cyanoacrylate injection successfully healed the anastomotic leakage.

DIAGNOSES

Boerhaave's syndrome was initially detected by abdominal computed tomography, but postoperative anastomotic leakage after the operation was confirmed with esophagography.

INTERVENTIONS

A total of 2.0 cc of N-butyl-2-cyanoacrylate and lipiodol mixture (at 1:1) was injected into the leakage tract through the perforation entrance.

OUTCOMES

Complete healing of the anastomotic leakage was confirmed with a follow-up esophagoscopy.

LESSONS

N-butyl-2-cyanocrylate injection treatment can be used as a rescue option for postoperative leakage when over-the-scope clips and stenting fail for this indication.

Nocardia beijingensis lung mass in an immunocompetent adult

A 47-year-old man was referred for ongoing workup of an enlarging lung mass. Extensive workup of the mass had been unrevealing for several months until cultures grew Nocardia beijingensis He was successfully treated with trimethoprim/sulfamethoxazole and then doxycycline with near-complete resolution of the mass on follow-up. This case presents a rare species of N. beijingensis It highlights the importance of considering nocardiosis in immunocompetent adults and the challenge in initiating targeted treatment due to delayed culture results.

Fatal vascular complications during transradial percutaneous coronary intervention: A case report

RATIONALE

Vascular complications of transradial percutaneous coronary intervention (PCI) are rare and usually occur at the access site below the elbow. However, vessels along the tract of the wire or catheter can be injured at any point, causing various types of bleeding complications.

PATIENT CONCERNS

A 57-year-old man visited due to chest discomfort. Coronary angiography showed significant stenosis at the distal right coronary artery (RCA). Immediately after the coronary guidewire was passed through the distal RCA, he started a vigorous cough. The voice changed, dyspnea occurred within minutes, and lip cyanosis and stridor were observed. After endotracheal intubation, successful stenting of the distal RCA was achieved. He was extubated at 30 minutes after coronary stenting, but 1-hour post-extubation, his blood pressure suddenly decreased to 70/50 mmHg.

DIAGNOSIS

Mediastinal widening was newly noted on chest X-ray, and blood hemoglobin was decreased. Contrast-enhanced chest computed tomography showed mediastinal hematoma, tracheal compression, and hemothorax. Contrast extravasation was noted in the terminal branches of the inferior thyroid artery on brachiocephalic angiography.

INTERVENTIONS

Successful hemostasis was achieved with endovascular embolization therapy using a Tornado embolization microcoil, Gelfoam gelatin sponge, and Histoacryl glue. The next day, the mediastinal hemorrhage was drained by mediastinoscopy. The endotracheal intubation and ventilator care were maintained for 2 days, and 6 units of packed red blood cells were transfused. Antithrombotics were used to prevent stent thrombosis, and antibiotics to control infection, respectively.

OUTCOMES

After successful hemostasis, thrombocytosis and high on-treatment platelet reactivity that disappeared at 2 weeks post-discharge were noted. Follow-up chest imaging showed the normalized mediastinal widening. At 14 months post-discharge, the patient remains healthy.

LESSONS

As life-threating vascular complications, such as brachiocephalic, subclavian vessel dissection, and vessel perforation in the internal mammary, costocervical, and thyrocervical arteries, can occur anytime during transradial PCI, the intervention cardiologist should be well aware of it and have the appropriate countermeasures implemented in the routine procedure.

Esophageal perforation in eosinophilic esophagitis: A systematic review on clinical presentation, management and outcomes

There is evidence of an increased fragility in the inflamed esophagus of patients with eosinophilic esophagitis (EoE). We performed a systematic review on presentation, management and outcomes of and surgical interventions for esophageal perforation in these patients, by searching in the MEDLINE, Embase and Scopus databases. Of the 599 references identified, 41 full-papers and 9 abstract met the inclusion criteria. Overall, 76 esophageal perforation episodes in 70 individual patients aged between 9 and 65 years were reported. 51 patients had not been diagnosed with EoE at the time of perforation; 14 patients had an untreated disease and the remaining were non responsive to therapy. Acute or progressive pain after long-lasting dysphagia and food impaction was the most common symptom leading to diagnosis in 42 patients who presented with Boerhaave syndrome. Pushing impacted food into the stomach led to perforation in 5 cases. Eight episodes appeared after dilation. CT scans demonstrated perforation in 82.4% of patients. Conservative management (including esophageal stenting) was used in 67.1% patients. The 25 remaining patients underwent surgery. Recovery was uneventful in the vast majority of patients. No death was reported. Active inflammation due to undiagnosed or untreated EoE was present in most cases of esophageal perforation. Conservative treatment of perforation should always be considered in EoE.

Tuberculous esophagomediastinal fistula with concomitant mediastinal bronchial artery aneurysm-acute upper gastrointestinal bleeding: A case report

BACKGROUND

Esophagomediastinal fistula is a very rare complication of tuberculosis in otherwise healthy adults, and mediastinal bronchial artery aneurysm is even rarer. In this case report, we describe a rare case of tuberculosis complication that presented with acute upper gastrointestinal (GI) bleeding. It also highlights the benefits of chest computed tomography (CT) as an excellent adjunct diagnostic tool to endoscopy and bronchoscopy and the role of trans-arterial embolization as a minimal invasive therapy alternative to surgery.

CASE SUMMARY

A 19-year-old medically free male patient presented with acute multiple episodes of hematemesis for 1 d. Upper GI endoscopy, bronchoscopy, and chest CT with IV contrast confirmed esophagomediastinal fistula with mediastinal bronchial artery aneurysm. After resuscitating patient with IV fluid and blood product transfusion, trans catheter embolization was performed for mediastinal bronchial artery aneurysm.

CONCLUSION

We successfully treated a patient with acute upper GI bleeding due to tuberculous esophagomediastinal fistula and mediastinal bronchial artery aneurysm using transcatheter coil embolization.

Salvage therapy for subclavian artery perforation resulting in mediastinal hematoma during percutaneous coronary intervention: A case report

RATIONALE

Transradial access (TRA) is a widely used technique during percutaneous coronary intervention (PCI). However, mediastinal and cervical hematomas, the rare and severe complications of transradial approach, have extremely high mortality rates. To the best of our knowledge, there were no medical literatures about the successful anticoagulation reversal procedure of mediastinal hematoma in PCI till now.

PATIENT CONCERNS

We here present a 54-year-old male Han patient who underwent PCI. Immediately after PCI, he reported an episode of neck and chest discomfort, dyspnea, cough recurrence, and cold sweats. Emergency chest computed tomography (CT) revealed a perforation of the subclavian artery resulting in a large mediastinal hematoma with potentially lethal tracheal compression.

DIAGNOSIS

A diagnosis of the large mediastinal hematoma was made based on the enhanced computed tomography.

INTERVENTIONS

The patient was successfully managed with palliative therapy of anticoagulation reversal instead of a covered stent graft and surgical operation.

OUTCOMES

Angiography confirmed the absence of leakage after anticoagulation reversal. The patient had an apparent remission of clinical dyspnea. Follow-up CT confirmed an almost entire absorption of the mediastinal hematoma 35 days postdischarge.

LESSONS

The current case highlights the importance of anticoagulation reversal as well as careful guidewire and guide catheter manipulation by the radial approach. Early evaluation, prompt identification, appropriate treatment, and close monitoring are all essential for invasive cardiology.

Parathyroid adenoma presenting with spontaneous cervical and anterior mediastinal hemorrhage: A case report

RATIONALE

Spontaneous anterior cervical or mediastinal hemorrhage is a rare presentation of parathyroid adenoma.

PATIENT CONCERNS

A 69-year-old woman presented with neck hematoma and dysphagia and was found to have a soft tissue mass adjacent to her thyroid gland as seen on MRI and neck ultrasound.

DIAGNOSIS

Laboratory testing demonstrated elevated calcium and parathyroid hormone supporting diagnosis of parathyroid adenoma.

INTERVENTIONS

She underwent right inferior parathyroidectomy and en bloc right hemithyroidectomy due to significant fibrosis.

OUTCOMES

Pathology confirmed hypercellular parathyroid and normal thyroid tissue. Postoperatively, patient's calcium and parathyroid hormone levels had normalized.

LESSONS

In conclusion, imaging may not always be specific in identifying the source of neck hematoma and so laboratory studies should be done to rule out parathyroid adenoma as the underlying etiology.

Transition of a Mallory-Weiss syndrome to a Boerhaave syndrome confirmed by anamnestic, necroscopic, and autopsy data: A case report

RATIONALE

Spontaneous esophageal rupture (Boerhaave syndrome) is a rare, though frequently fatal, event. It is generally caused by a sudden increase in pressure inside the esophagus. In some cases, full-thickness perforations of the esophagus may develop from previous lesions that initially involve only the esophageal mucosa (Mallory-Weiss syndrome) and which, following further triggering events, give rise to a transmural lesion.

PATIENT CONCERNS

Here, we present the case of a 45-year-old subject who suddenly died of acute cardio-respiratory failure, an autopsy was performed to identify the cause of death.

DIAGNOSIS, INTERVENTIONS, AND OUTCOMES

The autopsy examination revealed a full-thickness rupture of the esophageal wall. Through the integration of necroscopy findings, anamnestic data, and histopathological examination, it has been possible to establish that complete esophageal rupture resulted from the evolution of a previous partial lesion of the esophageal wall, and that an untreated Mallory-Weiss syndrome evolved into a rapidly fatal Boerhaave syndrome.

LESSONS

This case shows that distal esophageal tears, rather than constituting a distinct entity, may be part of a spectrum of diseases and that a partial lesion of the esophageal wall caused by barogenic injury may evolve into a full-thickness rupture following further barotraumas.

Endoscopic repair of spontaneous esophageal rupture during gastroscopy: A CARE compliant case report

RATIONALE

Most of esophageal rupture is a very serious life-threatening benign gastrointestinal tract disease with high mortality. However, there are a few cases of spontaneous esophageal rupture during gastroscopy.

PATIENT CONCERNS

A 57-year-old man who underwent a routine diagnostic gastroscopy due to food obstruction was reported. During the gastroscopy, he vomited severely, which was followed by severe left chest pain radiating into the back and upper abdomen. The diagnosis was made by computed tomography (CT) scan without delay. Enhanced CT showed extensive mediastinal emphysema, a small amount of left pleural effusion, and a 6 cm tear was confirmed in the lower esophagus posteriorly.

DIAGNOSES

The patient was diagnosed with an intrathoracic rupture type of spontaneous esophageal rupture.

INTERVENTIONS

The patient received endoscopic suturing techniques under endotracheal intubation, titanium clip clamping, and over the scope clip (OTSC) sealing.

OUTCOMES

The procedure was smooth and the patient recovered well after operation.

LESSONS

During gastroscopy, the risk of esophageal rupture should be considered due to sudden pain caused by severe nausea and vomiting. Esophageal rupture can rapidly lead to severe life-threatening infections such as empyema and mediastinitis. Therefore, awareness of this condition is important so that appropriate treatment can rapidly be implemented to increase the likelihood of a good outcome.

[Upper abdominal pain caused by oesophageal perforation]

Boerhaave's syndrome or spontaneous oesophageal perforation is associated with significant mortality de-pending on time of diagnosis and initiation of treatment. However, the diagnosis is often delayed, as the condition mimics more frequent causes of chest- and abdominal pain. This case report describes a patient with severe upper ab-dominal and back pain following ructus in an effort to loosen a piece of candy stuck in the oesophagus. The case demon-strates, that Boerhaave's syndrome should always be con-sidered in patients presenting with acute chest- or upper abdominal pain.

Successful Treatment of Blunt Musculophrenic Artery Injury by Transcatheter Arterial Embolization: A Case Report

An 86-year-old woman was transported by ambulance after jumping from the second floor of a building. Upon arrival, the blood pressure was stable; however, computed tomography indicated the presence of an anterior mediastinal hematoma. Eight hours after arrival, the patient exhibited shock. The blood pressure increased with rapid infusion. Emergency angiography was performed. Extravasation from the musculophrenic artery, which branches off from the left internal mammary artery, was observed. Transcatheter arterial embolization was performed and bleeding was controlled. This is the first report of musculophrenic artery injury caused by blunt trauma to the best of our knowledge. Findings suggested that if an anterior mediastinal hematoma develops, bleeding must be rapidly controlled. If the patient responds to rapid infusion and injury of the internal mammary artery or one of its branches is suspected, transcatheter arterial embolization is considered appropriate.

An unusual cause of Boerhaave´s syndrome in a young patient

An 18-year-old male patient with a history of atopy and intermittent dysphagia for solids, presented to the emergency department with sudden onset total dysphagia followed by hematemesis, after ingesting an ibuprofen tablet. Urgent upper gastrointestinal endoscopy revealed a deep laceration just above the tablet impacted in the distal esophagus. Abdominal CT-scan confirmed the suspicion of an esophageal perforation. The impacted tablet was broken up with biopsy forceps, and a covered metallic stent (Hanarostent® 60/100x20/26mm) was placed across the cardia effectively excluding the fistula. Recovery was uneventful and the stent was easily removed 6 weeks later. Follow-up biopsies showed marked mucosal infiltration by eosinophils confirming the diagnosis of eosinophilic esophagitis (EE). The patient was treated with oral budesonide and remains asymptomatic.

[Large bowel obstruction with effects on the mediastinum]

Large bowel obstruction with effects on the mediastinum We present a patient in which the colon and left kidney herniated through a left-sided diaphragmatic hernia. The cause of the hernia was unknown, although most likely it emanated from an earlier diaphragmatic rupture caused by trauma. Due to a diverticular stenosis of the sigmoid colon, the patient developed large bowel obstruction, causing displacement of mediastinal structures. Emergency laparotomy and anterolateral thoracotomy was performed.

[Mediastinal abscesses caused by a fish bone]

A 72-year-old man presented with left-sided neck pain after eating fish. A flexible fiberolaryngoscopy showed no signs of fish bone or wounds. At the follow-up two days later the patient had developed fever. Direct laryngoscopy and oesophagoscopy revealed no abnormalities. A computed tomography of the neck and thorax showed subcutaneous emphysema and abscesses in the neck and mediastinum originating from the oesophagus. Treatment included incision of the neck, drainage tubes and broad-spectrum IV antibiotics. Although not found, the cause of perforation is strongly believed to have been a fish bone.

Closure of a Traumatic Esophagomediastinal Fistula in a Child by Endoscopic Fulguration and Fibrin Injection

Posttraumatic esophagomediastinal fistula is an uncommon clinical entity that warrants surgical awareness due to its life-threatening potential. Its management, especially in previously operated field, is controversial and several endoscopic methods are being proposed as alternatives. Ours is the first report of endoscopic fulguration and fibrin injection in successful closure of such fistula. A 9-year-old female sustained complete tracheoesophageal transection from a gunshot wound to the neck and underwent immediate primary repair. She presented nine months later with fevers and swelling over anterior neck. CT revealed air tracking posteriorly to the dorsal neck and inferiorly to the mediastinum. Considering difficulty of open surgical approach, endoscopic intervention was attempted. Posterior wall fistula was identified via microlaryngoscopy above the esophageal anastomosis. The fistula tract was de-epithelialized via a Bugbee fulgurating electrode and then sealed with fibrin glue. Consequent imaging studies demonstrated complete occlusion of the fistula. Posterior posttraumatic esophagomediastinal fistula presents a challenging scenario from a surgical standpoint, as it combines difficulty of safe approach, high rate of injury to surrounding structures, and significant postoperative recurrence rate. Endoscopic Bugbee fulguration and fibrin glue injection are a safe and effective alternative to the traditional approach.

Intraoperative hypotension associated with massive deep space neck abscesses in a 9-month old: A case report

The neck is divided into multiple compartments by cervical fasciae. The deep space compartments, which all have a potential for becoming infected, are interconnected, providing a mechanism for the spread of infections. Thus, infections of the deep spaces can lead to devastating consequences, especially when there is extension to the mediastinum. Here we report a case of intraoperative hypotension in a 9-month-old child with extensive bilateral parapharyngeal and retropharyngeal abscesses with mediastinal extension with a focus on when hemodynamic monitoring should be considered.

Minimally invasive drainage of a posterior mediastinal abscess through the retropharyngeal space: a report of 2 cases

Foreign-body ingestion is a common cause of esophageal perforation, which can lead to a fatal posterior mediastinal abscess. Routine treatments include the drainage of pus through the esophageal perforation, thoracotomy, and videothoracoscopic drainage. We present 2 cases of posterior mediastinal abscess caused by esophageal perforation. Both patients-a 44-year-old woman and an 80-year-old man-were successfully treated with a novel, minimally invasive approach that involved draining pus through the retropharyngeal space; drainage was supplemented by the administration of broad-spectrum antibiotics and nasal feeding.

A patient with refractory shock induced by several factors, including obstruction because of a posterior mediastinal hematoma

A 44-year-old man who drove a motorcycle experienced a collision with the side of another motorcycle. Because he had sustained a high-energy injury to the spinal cord, he was transferred to our hospital. His circulation was unstable, and received tracheal intubation in addition to thoracostomy for the hemothorax. Whole-body computed tomography (CT) revealed multiple fractures, right hemopneumothorax with pulmonary contusion, and minor liver injury. After infusing 5000 mL of lactated Ringer's solution and 10 units of blood, his circulation remained unstable. On a repeat CT examination, the left atrium was found to be compressed by a posterior mediastinal hematoma induced by the fracture of the thoracic spine, and a diagnosis of shock induced by multiple factors, including hemorrhagic, neurogenic, and obstructive mechanisms, was made. After obtaining stable circulation and respirations, internal fixation of the extremities and extubation were performed on the 12th hospital day. Chest CT performed on the 27th day showed the disappearance of compression of the left atrium by the hematoma.

Tracheomediastinal fistula in a patient with lung adenocarcinoma and its treatment with argon plasma coagulation: a case report

Tracheomediastinal fistula is a rare complication that occurs during the course of lung cancer. The fistula connects the airways to the mediastinum and is often associated with lymphoma. Clinical data on tracheomediastinal fistulas are limited to case reports. Tracheal stenting, pericardial and omental patch closure, and muscle flap closure can be performed to repair such fistulas. We herein report a case of tracheomediastinal fistula in a 47-year-old man.The main symptoms were shortness of breath and a feeling of fullness in the neck. Thoracic magnetic resonance imaging revealed an approximately 57  ×  16  ×  20 mm multiloculated cystic lesion with air density located in the upper mediastinum of the right paratracheal region and a fine fistula tract at this level. The main diagnosis was primary lung adenocarcinoma-related mediastinal lymphadenomegaly with a tracheomediastinal fistula.The patient underwent fistula opening on the trachea, which was then coagulated and sealed using argon plasma coagulation.The patient is currently asymptomatic and doing well 8 months after the intervention.

Successful surgical strategy in a late case of Boerhaave’s syndrome

Boerhaave’s syndrome refers to the spontaneous transmural rupture of the esophagus. Primary repair may be performed in patients who present within 24 h of perforation, and such cases have the best outcomes as most complications have not yet developed. However, the treatment of late perforations remains controversial. Various approaches and strategies to repair late perforations have been described in the literature, but there is no uniform approach. We present a case of Boerhaave’s syndrome in which the patient underwent surgical repair 48 h after the acute event and was subsequently treated successfully. The initial approach included direct esophageal repair, a drainage series, and nutritional support via a feeding jejunostomy. Although the repair site was subsequently disrupted, the patient showed complete healing of the perforation after three weeks. We consider that our surgical treatment strategy is safe and technically feasible, and appears to be a promising alternative approach for the treatment of patients with late Boerhaave’s perforation.

[Clinical features and outcome of eight patients with mediastinal and neck hematoma after transradial cardiac catheterization approach]

OBJECTIVE

The clinical features of patients with mediastinal and/or neck hematoma after transradial cardiac catheterization were reviewed and analyzed to help the clinicians to recognize this complication, and try their best to avoid the complication and treat the complication properly.

METHODS

A total of 8 patients with mediastinal and/or neck hematoma after right transradial cardiac catheterization in Fuwai hospital from January 1, 2005 to the end of 2012 were included in this study. Among these 8 patients, 1 patient underwent coronary angiography, 7 patients underwent percutaneous coronary intervention and drug eluting stents were successfully implanted in 6 patients. The clinical data of these patients were analyzed retrospectively.

RESULTS

Super slide hydrophilic guild-wire was used in all patients. These patients felt chest pain, dyspnea and neck pain and neck or throat tightness after the procedure. CT scan was performed in all 8 patients and reviewed mediastinal hematoma, 4 patients complicated with neck hematoma, and suspicious laceration on the right subclavian artery or branch of innominate artery were found in 2 patients. Post procedure hemoglobin decrease was evidenced in all 8 patients. Anti-platelet therapy was discontinued until discharge in 2 patients, dual anti-platelet drugs were transiently discontinued or underwent dosage reduction in 4 patients, protamine was administered in 2 patients to neutralize heparin. Blood transfusion was not required, there was no stent thrombosis, and surgery was not indicated for all 8 patients. No complication was reported during follow up.

CONCLUSIONS

Mediastinal and/or neck hematoma is a rare complication post transradial catheterization approach. This complication is caused by super slide guild-wire or catheter's injury of small vessels near the aortic arch or subclavian artery, especially with rough manipulation. Neck and mediastinal CT scan should be performed as early as possible for patients with suspect hematoma and prognosis is usually fine with suitable therapy.

Esophagomediastinal fistula secondary to multidrug-resistant tuberculous mediastinal lymphadenitis

Esophagomediastinal fistula secondary to mediastinal tuberculosis (TB) lymphadenitis is a rare and unusual complication. A 32-year-old woman visited our clinic because of chest pain. Computed tomography (CT) demonstrated an esophagomediastinal fistula with subcarinal lymphadenopathy and no remarkable parenchymal lung lesions. The esophagomediastinal fistula was confirmed by esophagoscopy; however, the patient's bronchoscopy findings were unremarkable. The endobronchial ultrasound-guided lymph node aspiration did not confirm a diagnosis of TB. Finally, the patient was diagnosed via a lymph node biopsy. A drug-sensitivity test revealed the presence of a multidrug-resistant pathogen. To the best of our knowledge, this is the first case of esophagomediastinal fistula secondary to multidrug-resistant (MDR-) TB mediastinal lymphadenitis.

A case of acute traumatic aortic injury of a right-sided aortic arch with rupture of an aberrant left subclavian artery

Acute traumatic aortic injury is a potentially lethal condition with most patients die at the scene of the accidents. Rapid deceleration due to motor vehicle accidents is the commonest mechanism of injury. These injuries can be successfully repaired in the few patients who survive the initial trauma if proper diagnosis and rapid treatment are provided. The occurrence of acute traumatic aortic injury in patients with congenital abnormality of the aortic arch has been rarely reported; however, it renders the diagnosis and treatment more difficult. In this paper, we describe an extremely rare case of aortic injury in a young patient who had a right sided aortic arch with rupture of an aberrant left subclavian artery. The patient was suspected to have a Kommerell's diverticulum in the aberrant subclavian artery origin. This injury resulted in an unusually huge pseudoaneurysm involving part of the mediastinum and extending into the neck. Unfortunately; patient succumbed in spite of surgical intervention.

Extracranial head and neck infections

This article outlines infections in the submandibular, lateral pharyngeal, retropharyngeal, danger, and prevertebral spaces, in conjunction with infections of the sinuses and mediastinum. By understanding the anatomy and pathophysiology, the reader will gain insight into the rationale for various therapeutic options.

Differentiation of lymphoma versus sarcoidosis in the setting of mediastinal-hilar lymphadenopathy: assessment with diffusion-weighted MR imaging

OBJECTIVES

To determine the performance of diffusion-weighted magnetic resonance imaging in differentiating lymphoma from sarcoidosis in mediastinal-hilar lymphadenopathy.

MATERIALS AND METHODS

Forty-four mediastinal-hilar lymphadenopathy were examined in 27 patients with T1- and T2-weighted conventional images. Then, two diffusion-weighted images were obtained with b = 0 and 1000 s/mm2 values and apparent diffusion coefficients (ADCs) were calculated. The statistical significance of differences between measurements was tested using the Student-t test.

RESULTS

The ADC value in the lymphoma group was lower than in the sarcoidosis group, and the difference was statistically significant (p < 0.001). By using the cut-off value of 1.266 x 10(-3) mm2/s, ADC had a sensitivity of 100%, specificity of 81%, positive predictive value of 100%, and negative predictive value of 77% for the differentiation of lymphoma and sarcoidosis. With the cut-off value of 1,97 x 10(-3) mm2/s, ADC had a sensitivity of 50%, specificity of 99.4%, positive predictive value of 68%, and negative predictive value of 91%.

CONCLUSIONS

Diffusion-weighted imaging may be useful besides other modalities in differentiating lymphoma from sarcoidosis in mediastinal-hilar lymphadenopathy.

Boerhaave's syndrome: a differential diagnosis of acute chest pain following a vomiting illness

Spontaneous oesophageal rupture (Boerhaave's syndrome) is extremely rare in children. Presentation is usually in middle aged men as a result of vomiting following heavy food or alcohol consumption. We describe an unusual case of a 12-year old boy without significant past medical history presenting with acute chest pain following gastroenteritis.

Sternal osteomyelitis with a mediastinal abscess caused by Gemella morbillorum following blunt force trauma

Infections caused by Gemella morbillorum are uncommon. This organism is primarily associated with endocarditis and bacteremia and rarely with spondylodiscitis, arthritis, hepatic abscesses and meningitis. Sternal osteomyelitis caused by G. morbillorum has not yet been reported. We herein present a case of sternal osteomyelitis with a mediastinal abscess caused by G. morbillorum that occurred in a 74-year-old diabetic patient following blunt force trauma to the anterior chest wall. The patient was treated successfully with surgical excision and prolonged antibiotic treatment. Early recognition and timely intervention are important for managing life-threatening osteomyelitis of the sternum.

An unusual case of hypotension after fibrinolysis resulting from mediastinal hemorrhage

BACKGROUND

Although bleeding complications may occur after fibrinolysis, mediastinal hemorrhage is extremely rare.

CASE REPORT

We encountered mediastinal hemorrhage in a case of anterior wall myocardial infarction (MI); the patient developed sudden-onset chest pain with hypotension after fibrinolysis. The differential diagnosis and approach to management of such a case is discussed.

CONCLUSION

As fibrinolysis remains a common means of establishing reperfusion in patients with acute MI, emergency physicians should be aware of such unusual complications secondary to fibrinolysis. An orderly clinical approach with an individualized management protocol is essential in such situations so that undue instrumentation and invasive procedures with their attendant risks in a thrombolysed patient are avoided.

Utility of cardiac magnetic resonance imaging to differentiate cardiac sarcoidosis from arrhythmogenic right ventricular cardiomyopathy

Some patients diagnosed with arrhythmogenic right ventricular cardiomyopathy (ARVC) are eventually found to have cardiac sarcoidosis (CS). Accurate differentiation between these 2 conditions has implications for immunosuppressive therapy and familial screening. We sought to determine whether cardiac magnetic resonance imaging (MRI) could be used to identify the characteristic findings to accurately differentiate between CS and ARVC. Consecutive patients with a diagnostic MRI scan indicating CS and/or ARVC constituted the cohort. All patients diagnosed with CS had histologic confirmation of sarcoidosis, and all patients with ARVC met the diagnostic task force criteria. The cardiac MRI data were retrospectively analyzed to identify possible differentiating characteristics. Of the patients, 40 had CS and 21 had ARVC. Those with CS were older and had more left ventricular scar. The presence of mediastinal lymphadenopathy or left ventricular septal involvement was seen exclusively in the patients with CS (p <0.001). A family history of sudden cardiac death was seen only in the ARVC group (p = 0.012). The right ventricular ejection fraction and ventricular volumes were also significantly different between the 2 groups. In conclusion, patients with CS have significantly different cardiac MRI characteristics than patients with ARVC. The cardiac volume, in addition to the degree and location of cardiac involvement, can be used to distinguish between these 2 disease entities. The presence of mediastinal lymphadenopathy and left ventricular septal scar favors a diagnosis of CS and not ARVC. Consideration of CS should be given if these MRI findings are observed during the evaluation for possible ARVC.

Cervical necrotizing fasciitis and a descending mediastinal abscess caused by acute epiglottitis with diabetes mellitus: a life-threatening complication

Cervical necrotizing fasciitis and a descending mediastinal abscess of the neck following acute epiglottitis, life-threatening complications, is reported in a 43-year-old man with DM. The bacterial culture showed Peptostreptococcus anaerobius. The patient recovered after surgical debridement and broad-spectrum antibiotics therapy.

Mediastinal haematoma: a rare complication following insertion of central venous catheter

Mediastinal haematoma is a rare complication following insertion of central venous catheter, with few cases reported in the literature. We report a case of mediastinal haematoma in a 33-year-old male patient with end-stage renal disease. In this patient central venous catheter insertion through the right subclavian vein was attempted on the operation table for renal transplantation but the procedure was abandoned as the attempt was unsuccessful. Post-procedure chest radiograph showed a large mediastinal haematoma occupying right hemithorax that developed as a result of injury to the subclavian vein. Patient was managed conservatively and haematoma completely resolved in four weeks time. This case is being reported to signify the importance of routine obtaining a post-procedure chest radiograph and to state that even large mediastinal haematoma can be managed conservatively in asymptomatic patients.

[Case of large vein perforation caused by pumping using central venous catheter revealed by postoperative CT]

A 72-year-old woman, 157 cm in height and weighing 45 kg, was scheduled for emergency surgery for acute abdomen suggestive of gastrointestinal perforation. During the procedure, a triluminal central venous catheter (CVC) was inserted via the left internal jugular vein; venous blood could be aspirated separately through its lumens. On attempting blood transfusion, we noticed that the opening of one the CVC lumen tips was blocked and blood pumping was thus performed to achieve rapid transfusion. Colostomy was then performed and the transverse colon resection surgery was completed. Postoperative CT revealed right-sided hemothorax, a mediastinal hematoma located in the anterior region, and extravascular findings of CVC. The CT findings suggested a perforation of the left internal jugular vein due to the catheter tip. In the present case, the intraoperative pumping performed to enable rapid blood transfusion was believed to have caused blood vessel perforation. After the intraoperative blood vessel perforation, the condition may have been aggravated by steroid use, amyloidosis, and blood vessel fragility, ultimately presenting the extravascular findings observed on CT. We thus believe that in cases where CVC is inserted via the left internal jugular vein, blood pumping in particular is believed to be dangerous. Although the risks of blood vessel perforation when using CVC are relatively low, the possibility of unexpected complications should be borne in mind.

[Case of miliary tuberculosis with esophageal perforation and a tracheal inflammatory polyp secondary to mediastinal lymphadenitis causing massive hematemesis and hemosputum]

A 62-year-old man with a history of left nephrectomy due to tuberculosis was referred to our hospital, because chest radiography showed diffuse miliary shadows in the bilateral lung fields, and acid-fast bacilli were detected from his hemosputum after steroid therapy for fever of unknown origin. Chest computed tomography showed mediastinal lymph node enlargement with partial calcification of these lymph nodes together with the presence of air. He was diagnosed with miliary tuberculosis and tuberculous mediastinal lymphadenitis and anti-tuberculosis drug therapy was started. Massive hematemesis occurred 11 days after the start of the treatment. Although gastroendoscopy was performed, the bleeding point could not be identified. The patient's symptoms improved after conservative therapy. Repeat gastroendoscopy showed a submucosal nodule with laceration of the esophageal mucosa, 30 days after admission for the examination of melena and progression of anemia. The episodes occurred because of esophageal perforation secondary to tuberculous mediastinal lymphadenitis. Bronchoscopic examination for hemosputum showed an inflammatory polypoid lesion in the left tracheal wall. These symptoms improved with anti-tuberculosis drug therapy. In our case, mediastinal lymphadenitis progressed to miliary tuberculosis because of endogenous reactivation. We report a rare case of esophageal perforation with a tracheal inflammatory polyp secondary to tuberculous mediastinal lymphadenitis. In cases of tuberculous mediastinal lymphadenitis, if hematemesis or hemosputum is observed, an endoscopic examination should be performed.

Not just another sore throat

Case study A man, 26 years of age, presented to a hospital emergency department complaining of a sudden onset of a sore throat 6 hours previously while consuming a carbonated drink at work. The pain commenced about lunchtime, after he had been mixing concrete powder, and since then had been intermittent and was becoming more severe.