Mediastinal Granuloma is an uncommon cause of a mediastinal mass. It is thought to be due to Histoplasma infection. Surgical resection is advocated to prevent the possible progression of mediastinal granuloma to fibrosing mediastinitis. Antifungals are also thought to be helpful. We evaluated the role of itraconazole in treatment of patients with mediastinal granuloma.
We evaluated five patients with mediastinal granuloma who were seen in the pulmonary clinic at the University of Missouri-Columbia Hospital over the last three years. The patients were 30.6 ± 9.9 years of age, and 3 of them were females. The diagnosis of mediastinal granuloma was confirmed by biopsy in all patients. Three patients were treated with Itraconazole (200 mg once a day). One patient had surgical resection only, and another patient had resection followed by treatment with Itraconazole. Patients were followed up for at least four months. Fungal stains and cultures were negative for all patients. Two patients had positive Histoplasma antibodies.
Four months after starting therapy, patients receiving itraconazole alone were asymptomatic and they had almost total resolution of the mediastinal mass. The patient who had surgical resection did not have any recurrence on follow up. The patient who had resection followed by Itraconazole treatment had partial improvement. None of the patients treated with Itraconazole had liver function derangements. The most common side effect was diarrhea.
Despite lack of evidence for active Histoplasma infection, patients with mediastinal granuloma responded well to treatment with Itraconazole. The medication was effective, safe and well-tolerated. Itraconazole should be considered as the first line of treatment for mediastinal granuloma.
Patients hwo have Mediastinal Gransuloma, whether diagnosed by biopsy or clinically, may have no evidence of a previous Histoplasma infection. Such patients would still respond to Itraconazole treatment, without the need for surgical resection of the mass.
Talaat Al Shuqairat, None.