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Tunneling Through Fibrosing Mediastinitis
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A1562 - Tunneling Through Fibrosing Mediastinitis
Author Block: N. Raya, A. Gamino; Department of Pulmonary and Critical Care Medicine, Rush University Medical Center, Chicago, IL, United States.
This is a case of fibrosing mediastinitis that was treated with an uncommonly placed vascular stent. The patient is a 30-year man presenting with intermittent hemoptysis for the previous 4 months. This would occur daily with roughly 3-4 tablespoons of clots and blood. He has no other past medical history nor is he on any medications chronically.
He underwent a chest radiograph followed by a CT chest revealing evidence of pulmonary infiltrates in the left apex as well as a large mass seeming to impinge on the left side of his tracheobronchial tree and possibly the left main pulmonary artery. Bronchoscopy with BAL and transbronchial brushings were performed which were negative for infection and malignancy. A follow-up VATS with lymph node biopsy was also performed that was negative for infection and malignancy. The patient was initially started Levaquin and Doxycycline with some improvement but was transitioned to Bactrim DS and prednisone given persistent hemoptysis.
Repeat CT Chest with IV contrast showed persistent narrowing of the left upper lobe bronchus and complete occlusion of the left upper lobe pulmonary vein. Patient underwent EBUS with FNA which was negative for malignancy and infection, but concerning for fibrosing mediastinitis.
Subsequently the patient underwent an angioplasty and stenting of the left upper lobe pulmonary vein successfully and was discharged on Plavix and Aspirin to maintain patency of the vessel.
Fibrosing mediastinitis, also known as sclerosing mediastinitis or mediastinal fibrosis, is an uncommon benign disorder of proliferation of dense fibrous tissue within the mediastinum. Often the cause is idiopathic and while the pathogenesis is unknown, the prevailing theory is that mediastinal granules rupture into the mediastinum and cause inflammation. This can present in two varieties: local or diffuse disease. The main concern is the compression from the inflammation of the superior venous cava, pulmonary veins or arteries and other passages such as the airways and esophagus. Often diffuse disease has no good treatment but directed therapy at local disease has been shown to offer symptom improvement. Placement of vascular stents have been shown to provide anatomic obstruction relief along with improvement of pressure gradients and sustained symptomatic relief in patients. While long-term data is limited on stenting, it should be considered in the appropriate setting.
Unfortunately for our patient, his questionable medication compliance lead to the collapse of the previously placed stent. He underwent a second stenting with resolution of his symptoms.
Author Block: N. Raya, A. Gamino; Department of Pulmonary and Critical Care Medicine, Rush University Medical Center, Chicago, IL, United States.
This is a case of fibrosing mediastinitis that was treated with an uncommonly placed vascular stent. The patient is a 30-year man presenting with intermittent hemoptysis for the previous 4 months. This would occur daily with roughly 3-4 tablespoons of clots and blood. He has no other past medical history nor is he on any medications chronically.
He underwent a chest radiograph followed by a CT chest revealing evidence of pulmonary infiltrates in the left apex as well as a large mass seeming to impinge on the left side of his tracheobronchial tree and possibly the left main pulmonary artery. Bronchoscopy with BAL and transbronchial brushings were performed which were negative for infection and malignancy. A follow-up VATS with lymph node biopsy was also performed that was negative for infection and malignancy. The patient was initially started Levaquin and Doxycycline with some improvement but was transitioned to Bactrim DS and prednisone given persistent hemoptysis.
Repeat CT Chest with IV contrast showed persistent narrowing of the left upper lobe bronchus and complete occlusion of the left upper lobe pulmonary vein. Patient underwent EBUS with FNA which was negative for malignancy and infection, but concerning for fibrosing mediastinitis.
Subsequently the patient underwent an angioplasty and stenting of the left upper lobe pulmonary vein successfully and was discharged on Plavix and Aspirin to maintain patency of the vessel.
Fibrosing mediastinitis, also known as sclerosing mediastinitis or mediastinal fibrosis, is an uncommon benign disorder of proliferation of dense fibrous tissue within the mediastinum. Often the cause is idiopathic and while the pathogenesis is unknown, the prevailing theory is that mediastinal granules rupture into the mediastinum and cause inflammation. This can present in two varieties: local or diffuse disease. The main concern is the compression from the inflammation of the superior venous cava, pulmonary veins or arteries and other passages such as the airways and esophagus. Often diffuse disease has no good treatment but directed therapy at local disease has been shown to offer symptom improvement. Placement of vascular stents have been shown to provide anatomic obstruction relief along with improvement of pressure gradients and sustained symptomatic relief in patients. While long-term data is limited on stenting, it should be considered in the appropriate setting.
Unfortunately for our patient, his questionable medication compliance lead to the collapse of the previously placed stent. He underwent a second stenting with resolution of his symptoms.
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