Senior Report 6.25

Case Presentation by Dr. John Wilburn

CC: Chest pain

HPI:

24 year-old male presents to the emergency with complaints of chest pain, he points to the left upper sternal border and left upper chest. He reports it began about a month ago.  He describes it as a constant, dull pressure. He reports the intensity of the pain has significantly increased over the past 5 days and is now radiating to the right side of his chest.  Patient has not tried anything to alleviate this pain.  He reports taking a deep breath exacerbates his pain. He denies any fevers. He reports a dry cough that is non productive, which he attributes to smoking. He denies any trauma or dyspnea.

ROS:

Constitutional: Denies night sweats, fatigue or weight loss.

Cardiovascular: Denies syncope

Respiratory: Denies hemoptysis

Gastrointestinal: Denies Abdominal pain

Genitourinary: Denies scrotal masses

Musculoskeletal: Denies extremity pain or swelling

PMH: Denies hypertension, pneumothorax, or diabetes

PSH: None

Allergies: None

Medications: None

FHx: Reports Hypertension denies CAD

Social Hx: Patient smokes cigarettes daily, and marijuana occasionally. Denies IVDU or Cocaine. Reports to socially drinking less than 3 times per month.

Physical Examination:

General/Psychiatric: WNWD non-toxic appearing male sitting upright in the stretcher in no acute respiratory distress, speaking in full sentences. A&Ox3.

Vital signs: 122/65 HR: 58 RR 14 Temperature 37 C Pulse oximetry 96% RA

HEENT: NC/AT PERRL EOMI. No nasal discharge, or nasal flaring.. Mucous membranes of the mouth are moist. No tonsil enlargement no erythema.

Neck: Supple, No JVD Trachea Midline. Full Range of Motion, No lymphadenopathy.

Back: No Tenderness to palpation

Chest: Left sided chest wall tenderness to palpation – front back level?.

Respiratory: CTAB no wheezes rhonchi or rales.

Cardiovascular: S1S2 present no M/R/G.

Abdomen: Thin Soft ND/NT no rigidity or rebound tenderness.

Musculoskeletal: Strength 5/5 in the upper and lower ext. Palpable and symmetric radial and dorsalis pedis pulses. No edema or asymmetry. No tenderness to palpation.

Neuro: Normal speech and gait..

Medical Decision Making/Course in the ED:

Patient Received Motrin and Maalox, ECG and CXR obtained

ECG:

6.25-1

CXR:

6.25-2

6.25-3

 Questions:

1) Where is the abnormality located in this patients chest radiograph?

a) Anterior Mediastinum

b) Ascending Aorta

c) Carina

d) Right Atrium

e) Posterior Mediastinum

2) Which of the following statements is correct?

a) The anterior mediastinum extends from the sternum anteriorly to the esophagus posteriorly.

b) The anterior mediastinum contains the thymus gland.

c) The anterior mediastinum contains the transverse arches of the aorta.

d) The middle mediastinum contains the esophagus.

e) All of the above are correct.

3) Which is the most appropriate next step in this patient’s management?

a) Obtain blood cultures, start antibiotics and consult cardiothoracic surgery.

b) Obtain a CT-Thorax with contrast.

c) Obtain a Transthoracic Echocardiogram.

d) Perform a Color Doppler Ultrasound Guided Thoracentesis.

e) Start the patient on Heparin and admit to the hospital.

4) Which of the following is the most common tumor of the anterior mediastinum?

a) Bronchogenic Cysts

b) Germ Cell Tumors

c) Lymphoma Hodgkin’s disease

d) Non-Hodgkin Lymphoma

e) Thymoma

5) What is the initial diagnostic study of choice?

6) Bonus Question: What was this patient’s final diagnosis?

a) Empyema

b) Germ Cell Tumor

c) Lymphoma Hodgkin’s Disease

d) Thymoma

 

Answers & Discussion:

1) Answer: a. Anterior Mediastinum

Brief review of radiographic anatomy eliminates b, c, d.

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Patient’s Radiograph:  The radiograph does demonstrate two findings helpful in identifying the location of the mass. See below.

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3 3b

 

The Hilum overlay sign is a useful tool to help identify probable location of a mediastinal mass

Another way to evaluate for mass in either the middle or posterior mediastinum is look for the azygoesophageal recess reflection. (below)

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2)Answer: b. the thymus is located in the anterior mediastinum

The mediastinum is divided into 4 compartments

  1. The Anterior Mediastinum– extends from the sternum anteriorly to the pericardium and brachiocephalic vessels posteriorly

Structures

  • Thymus and residue of thymus
  • Fat
  • Lymph glands

The Middle Mediastinum– lies between the anterior and posterior mediastina.

Structures

  • Heart
  • Pericardium
  • Ascending aorta
  • Trachea
  • Main bronchi
  • Lymph nodes
  • Pulmonary artery
  • Pulmonary veins
  • Phrenic nerve

Posterior Mediastinum– bounded by the pericardium/trachea anteriorly and the vertebral column posteriorly.

Structures

  • Descending aorta
  • Esophagus
  • Azygous vein
  • Hemiazygous veins
  • Lymph glands
  • Thoracic duct
  • Autonomic nerves
  • Vagus nerve

Superior Mediastinum– bounded superiorly by the thoracic inlet and inferiorly by and arbitrary plane passing horizontally and posteriorly from the manubriosternal joint to the junction of T4/T5 vertebra.  Anteriorly bounded by the sternum and posteriorly by the upper thoracic vertebra.

Structures

  • Trachea
  • Esophagus
  • Great vessels
  1. Arch of aorta
  2. Thoracic portions of left common carotid and left subclavian arteries
  • Veins
  1. Innominate veins
  2.  Upper ½ superior vena cava
  • Thymus
  • Phrenic and vagus nerves
  • Thoracic duct
  • Lymph glands

5j

3) Answer: b. CT Thorax w/ contrast should be ordered next. (Explanation below).

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 4) Answer: e. Thymoma

The most common causes of anterior mediastinal masses: Thymoma (20%) Germ Cell Tumors (seminoma, teratoma, etc(15%)); thyroid disease (15%); and lymphoma HD and non-HD (10%). Masses of the middle mediastinum are typically congenital cysts. Neurogenic tumors are the most common cause of posterior mediastinal masses.  Overall, two thirds of mediastinal tumors are benign, however masses in the anterior compartment are more likely to be malignant.

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The clinical sequelae can range from asymptomatic to symptoms of cough, chest pain, dyspnea, and fevers/chills. The likelihood of malignancy is influenced by mass location, patient age, and the degree of symptoms. Age is a strong predictor of malignancy, lymphomas and germ cell tumors (GCTs) occur mostly during the second and fourth decades. Symptomatic patients are more likely to have a malignancy. Symptoms may be delineated between localizing symptoms (mass effect) and systemic symptoms (hormonal/antibody effect). In Davis et al,7 85% of patients with a malignancy were symptomatic at presentation, compared to 46% of patients with benign neoplasms.

The initial workup of a suspected mediastinal mass involves obtaining posteroanterior and lateral chest radiographs. CT scanning is used to further characterize mediastinal masses (cystic, vascular, and soft-tissue structures) and their relationship to surrounding structures.

Other more rare imaging modalities include, fluoroscopy, and barium swallow. MRI may be used in evaluating a neurogenic tumor, and identifies vascular invasion and cardiac involvement.

Tissue diagnosis is almost always required. Biopsy may be obtained via, transthoracic or transbronchial needle aspiration, mediastinoscopy, anterior mediastinotomy, or video-assisted thoracic surgery. Modality of choice is sometimes case dependent.  Fluoroscopic or CT guided transthoracic needle biopsy, has been shown to be faster, cheaper, and better tolerated by patients. It has been shown to have good diagnostic accuracy, although sometimes specimens are inconclusive requiring further investigation.

5) Answer: CT Guided Transthoracic Needle Biopsy, however some evidence suggests Thoracoscopic biopsy is just as safe and slightly more accurate.

 6) Answer: b. Germ Cell Tumor (Seminoma)

References:

1) http://radiographics.rsna.org

A Diagnostic Approach to Mediastinal Abnormalities

Camilla R. Whitten, MRCS, FRCR, Sameer Khan, MRCP, FRCR, Graham J. Munneke, MRCP, FRCR and Sisa Grubnic, MRCP, FRCR

2)Tumors of the Mediastinum

Beau V. Duwe, MD; Daniel H. Sterman, MD. FCCP; Ali I. Musani, MD, FCCP

Chest. 2005; 128(4):2893-2909.

3)www.google.com/images

4)Harrison’s Principles of Internal Medicine 16th edition

5) Anterior mediastinal masses: utility of transthoracic needle biopsy.

S J HermanR V HolubG L Weisbrod and D W Chamberlain

Department of Radiology, Toronto General Hospital, Ont, Canada.

6)http://ats.ctsnetjournals.org

Thoracoscopic diagnosis and treatment of mediastinal masses

Ann Thorac Surg 1993;56;92-96

7)Davis, RD, Jr, Newland Oldham, H, Jr, Sabiston, DC, Jr Primary cysts and neoplasms of the mediastinum: recent changes in clinical presentation, methods of diagnosis, management and results. Ann Thorac Surg 1987; 44, 229-237 [CrossRef] [PubMed]

8)http://radiology.rsna.org/content/169/3/593.full.pdf

Percutaneous Transthoracic Needle Biopsy

Jack L. Westcott, MD

Department of Radiology, Hospital of Saint Raphael, New Haven, CT.

Case 5.7

Case Presentation by Dr. Tim Scott

CC: Fatigue

HPI:  19yo W M with no PMH presents to the ED with complaint of fatigue.  He states that over approximately the last 6 months he has noticed that he has decreased energy that has gotten progressively worse.  He is single, lives with a room-mate and is employed.  He has no history or family history of depression.  He denies drug/alcohol abuse.  He denies any hematuria, dark or bloody stools and any other complaints.

ROS:  Positive for fatigue

PMH: Denies

PSH: Denies

Social: Denies smoking or drug use.  Drinks occasionally with friends

PE:  Pulse 86, Respirations 16, Temp 37.1, PaSO2  97% RA

Const: W/D, W/N Appears stated age, NAD

HEENT:  membranes moist, left side painless cervical lymphadenopathy, trachea midline

CV: RRR, S1 S2

Lungs: CTAB

Abd: Soft, NT/ND, BS +

Extr: normal pulses, strength and ROM

At this point you do a CBC with lytes which comes back as follows

CBC:  Hgb 12.1 and WBC 31.1  – the rest was WNL

Lytes: WNL

You go back and press this patient for more information…he says he has felt “the lump” in his neck for a few months now but he denies any cough, fever, vomiting, diarrhea and the only other info you get out of him is that he sometimes feels itchy all over.

You order a CXR because he has an elevated white count

Questions:

1) What is the likely Diagnosis in this patient?

  1. Hodgkins Lymphoma
  2. Acute Myelogenous Leukemia
  3. Acute Lymphoblastic Leukemia
  4. Pneumonia

2) What current infection (or previous history of infection) would increase the patient’s risk for this disease 5-25 times?

  1. Varicella Zoster
  2. Herpes Zoster
  3. Pertussis
  4. HIV

3) Which one of the following is NOT a common presenting symptom/sign for this disease?

  1. Painless lymphadenopathy of cervical region, axilla or groin
  2. Fever, weight loss and or night sweats
  3. Mediastinal mass causing mass effect symptoms like pain, pleural effusion or superior vena cava syndrome
  4. Pruritis and fatigue

Answers:

  1. A.  This patient likely has Hodgkins Lymphoma.  HL arises from germinal center or post-germinal center B cells and has a unique cellular composition, containing a minority of neoplastic cells (Reed-Sternberg cells and their variants) in an inflammatory background and can cause anemia and elevated white counts. HL has a bimodal age distribution curve. In the US and other economically advantaged countries, there is one peak in young adults (approximately age 20 years) and one in older age (approximately age 65 years); the majority of patients are young adults and there is a slight male predominance.  AML and ALL are close second options here due to similar early presentations, however, with AML, the median age at diagnosis is 65 years old and with ALL the vast majority of cases present between 2-5 years of age.  Bleeding disorders are more likely to be present and the cause of an initial presentation with these patients.
  1. D.  The incidence of HL is increased in a number of settings associated with immunodeficiency and infection. Among patients infected with HIV, the relative risk of HL is increased in various studies from fivefold to 25-fold. There also appears to be an increased risk of HL in patients with a history of infectious mononucleosis caused by Epstein Barr virus.  Interestingly, other childhood infectious illnesses including chickenpox, measles, mumps, rubella, and pertussis are negatively associated with the risk of HL.
  1. C.  A, B and D are all true.  Though a mediastinal mass discovered on routine chest x ray is a common presentation in an HL patient, it is NOT common to have any symptoms associated with it. The mass may be fairly large without producing local symptoms. Less commonly, the mass produces nonspecific symptoms such as retrosternal chest pain, cough, or shortness of breath. Small pericardial or pleural effusions are rare except in patients with bulky mediastinal disease. Superior vena caval obstruction is also rare.  Painless lymphadenopathy is present in as much as 80% of patients with HL.  Fever, weight loss and night sweats (the classic B symptoms), though not specific to HL, are present in less than 20 percent of patients with stage I/II Hodgkin lymphoma and up to 50 percent of patients with advanced disease.  Pruritus and fatigue, though not specific, can be early symptoms of the disease.  Pruritus specifically may be an important early symptom, preceding the diagnosis of HL by months or even a year or more. Pruritus occurs early in approximately 10 to 15 percent of patients, but the great majority of patients experience pruritus at some time during the course of illness. It is usually generalized and occasionally severe enough to cause intense scratching and excoriations.