INTRODUCTION: Acute mediastinitis is an uncommon and potentially lethal clinical condition. Although introduction of highly active antiretroviral therapy (HAART) in patients with HIV has resulted in cases of immune reconstitution inflammatory syndrome (IRIS) presenting as mediastinitis (usually as a result of histoplasmosis or tuberculosis), mediastinitis in HIV negative patients, especially cryptococcal mediastinitis, is rare. We describe a case of crytococcal mediastinitis leading to pulmonary arterial hypertension in a HIV negative patient.
CASE PRESENTATION: A 26 year old male with ESRD on HD presented with fever and a tender right supra clavicular mass. Initial laboratory analysis revealed mild anemia, leucocytosis, and elevated creatinine. CT neck showed enlarged right and left cervical lymph nodes with a right paratracheal mass. Chest x-ray showed mediastinal enlargement and focal opacity in the right middle lobe. Transthoracic ECHO done to evaluate for valvular vegetations revealed moderately dilated right atrium and ventricle with paradoxical septal motion with tricuspid regurgitation and estimated pulmonary artery systolic pressure of 49 mmHg. CT chest showed diffuse soft tissue density with varying attenuation with narrowing of right main pulmonary artery and consolidation in the right middle lobe and right pleural effusion. Fine needle aspirate of supra clavicular LN showed budding yeasts with a narrow base suggestive of cryptococci. Tissue cultures grew Cryptococcus neoformans and serum cryptococcal antigen tested positive. HIV test was negative. Patient was treated with intravenous fluconazole with good clinical response.
DISCUSSIONS: Acute mediastinitis, an infection involving the mediastinum, may begin primarily from the structures in mediastinum or it may be the result of a downward extension of oral or cervical infections extending into the mediastinum. Development of cervical infection manifests initially with signs and symptoms of sepsis, swelling and pain in the neck. The involvement of mediastinum may occur as soon as 12 hours to 2 weeks, but most commonly is seen within 48 hours of onset of deep cervical infection. Pleural or pericardial involvement may occur. Compression of pulmonary arteries leading to pulmonary arterial hypertension has been described. Once the symptoms are recognized appropriate antibiotics should be promptly initiated. Extensive surgical debridement may also be necessary.
CONCLUSION: Atypical presentations of many fungal and granulomatous diseases are being increasingly recognized among patients receiving HAART. Impairment of cell mediated immunity in our patient from end stage renal disease may have predisposed him to cryptococcal infection. Cryptococcal mediastinitis is rare and is "rarer" in HIV negative patients. Our patient's case is unique in that the infecting organism was Cryptococcus which was complicated by compressive pulmonary arterial hypertension.
DISCLOSURE: Sandeep Gupta, No Financial Disclosure Information; No Product/Research Disclosure Information