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EBUS-TBNA Diagnosis of Mediastinal Amyloid Lymphadenopathy Presenting as a Solitary, Calcified Paratracheal Mass FREE TO VIEW

Sachin Patel, MD; Matthew Barrett, DO; Edward Pickering, MD; Janaki Deepak, MD
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University of Maryland School of Medicine Division of Pulmonary and Critical Care Medicine, Baltimore, MD

Chest. 2013;144(4_MeetingAbstracts):22A. doi:10.1378/chest.1702297
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SESSION TITLE: Bronchology Case Report Posters II

SESSION TYPE: Affiliate Case Report Poster

PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM

INTRODUCTION: Amyloidosis is an unusual cause of mediastinal lymphadenopathy. Systemic amyloidosis can manifest as either mediastinal or hilar lymph node enlargement. Localized amyloidosis presenting as intrathoracic lymphadenopathy is extremely rare . Our case illustrates the first known case report of solitary, inthrathoracic, amyloidosis diagnosed by EBUS-TBNA.

CASE PRESENTATION: 64 year-old male with a 30 pack-year smoking history who presented with an incidental finding of a large calcified, heterogenous right paratracheal mass on noncontrast CT. He denied any constitutional symptoms. There were no abnormalities found on physical exam. PET CT scan showed a 3.2 x 2.5 cm right paratracheal mass (SUVmax = 4.0) with central calcifications and areas of low density. Bronchoscopy with TBNA revealed a bloody specimen with normal flow cytometry and negative AFB cultures. EBUS-TBNA was performed with five passes to the right paratracheal mass at the 4R location. Final cytopathology revealed acellular material consistent with amyloid, which was confirmed on Congo Red stain. He subsequently underwent serum and urine electrophoresis as well as a bone marrow biopsy which were both unrevealing.

DISCUSSION: Amyloidosis is a heterogeneous group of disorders characterized by extracellular deposition of abnormal protein and protein derivatives in a β -pleated configuration that makes the proteins resistant to proteolysis . Chest radiography shows characteristic lymphadenopathy with homogeneous low attenuation and stippled or faint calcification is a characteristic finding of amyloidosis. Some enlarged lymph nodes have been reported to show coarse, patchy or punctate calcification.

CONCLUSIONS: Case reports of intrathoracic amyloid have been diagnosed with percutaneous needle aspiration, mediastinaoscopy, open surgical biopsy, or post-mortem examination. With the advent of EBUS-TBNA patients with such a rare finding can be diagnosed without surgical intervention.

Reference #1: Urschel JD, Urschel DM. Mediastinal amyloidosis. Ann Thorac Surg 2000;69:944-6

Reference #2: Pickford HA, Swensen SJ, Utz JP. Thoracic cross-sectional imaging of amyloidosis. AJR Am J Roentgenol 1997;168:351-5

Reference #3: Borge MA, Parker LA, Mauro MA. Amyloidosis: CT appearance of calcified, enlarged periaortic lymph nodes.J Comput Assist Tomogr 1991;15:855-7

DISCLOSURE: The following authors have nothing to disclose: Sachin Patel, Matthew Barrett, Edward Pickering, Janaki Deepak

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