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Unruptured Mediastinal Teratoma Presenting as Pericardial Effusion With Tamponade Symptoms FREE TO VIEW

Jenny Phan, DO; Amy Bellinghausen Stewart, BS; Andrew Son, MD; Afshin Molkara, MD; Roger Garrison, MD
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Riverside County Regional Medical Center, Moreno Valley, CA

Chest. 2014;146(4_MeetingAbstracts):201A. doi:10.1378/chest.1984303
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SESSION TITLE: Miscellaneous Student/Resident Cases

SESSION TYPE: Medical Student/Resident Case Report

PRESENTED ON: Tuesday, October 28, 2014 at 04:30 PM - 05:30 PM

INTRODUCTION: Mediastinal teratomas are the most common extra-gonadal germ cell tumors; approximately 15% of anterior mediastinal masses in adults. Most affected individuals are asymptomatic and the mass is detected incidentally. Prior publications have discussed teratoma rupture mimicking pneumonia secondary to spillage of necrotic material into bronchi1. Rupture into the pericardium, causing cardiac tamponade, has also been reported2. However, to our knowledge, unruptured tumors producing symptoms mimicking post-viral pericarditis with pericardial tamponade have not previously been described.

CASE PRESENTATION: A previously healthy, 28-year-old female presented with pleuritic, 10/10, left-sided chest pain, and dyspnea of four days duration. She described an episode 10 days prior of rhinorrhea, dry cough and fever of 102° F. On physical exam she was tachycardic and intermittently hypotensive with dullness to percussion and decreased breath sounds over the left lower posterior lung field. Chest x-ray demonstrated what appeared to be either a massive pericardial effusion or left lower lobe pneumonia. After admission for suspected pericarditis with possible tamponade, CT demonstrated a heterogeneous mediastinal mass with fat, solid, and cystic components. The patient's serum was negative for lactate dehydrogenase, β-human chorionic gonadotropin, and α fetoprotein. Given these findings, a decision was made to proceed to surgery without a tissue diagnosis3. The mass was excised via median sternotomy and pathological examination revealed a well-encapsulated, mature teratoma. The patient recovered well from the operation and was discharged home on post-operative day 5.

DISCUSSION: Although benign teratomas do not metastasize, they can cause respiratory and cardiovascular symptoms, either by rupture into the bronchial tree or pericardium, or in this case, by direct compression of the mediastinum. Previously, cases of unruptured mediastinal teratomas mimicking pericarditis have not been described. In this case, although the mass was unruptured and well-encapsulated, central necrosis may have contributed to generation of symptoms. Had a pericardiocentesis been attempted, it is possible that the mass would have perforated and caused significant deterioration of the patient’s condition.

CONCLUSIONS: This case highlights the importance of appropriate clinical decision making and diagnostic imaging prior to performing invasive procedures for suspected pericardial effusions and mediastinal masses.

Reference #1: Sasaka K, Kurihara Y, Nakajima Y, et al. Spontaneous rupture: a complication of benign mature teratomas of the mediastinum. Am J Roentgenol. 1998;170(2):323-328.

Reference #2: Oomman A, Rajan S, Vijayakumar C, Jayaraman S, Ramachandran P, Kumar S. Anterior mediastinal teratoma presenting as cardiac tamponade. Indian Heart J. 2004; 56(1):64-6.

Reference #3: Choi S, Lee JS, Song KS, Lim TH. Mediastinal teratoma: CT differentiation of ruptured and unruptured tumors. Am J Roentgenol. 1998;171(3): 591-4.

DISCLOSURE: The following authors have nothing to disclose: Jenny Phan, Amy Bellinghausen Stewart, Andrew Son, Afshin Molkara, Roger Garrison

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