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A Rare Cause of Cervico-Mediastinal Mass FREE TO VIEW

Paramjyothi Gongati, MD; Shantveer Uppin, MD; Sundaram Challa, MD; Manmadha rao Talluri, MD; Narender kumar Narahari, MD; Vinathi Paritala, MD; Bhaskar Kakarla, MD
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Nizams Institute of Medical Sciences, Hyderabad, Andhra Pradesh, India

Chest. 2014;146(4_MeetingAbstracts):151A. doi:10.1378/chest.1989214
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SESSION TITLE: Infectious Disease Global Case Reports

SESSION TYPE: Global Case Report

PRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PM

INTRODUCTION: A variety of neoplastic and non-neoplastic conditions can present as cervico-mediastinal masses. However invasive Aspergillosis presenting as cervico-medisatinal mass especillay in an immunocommpetant host is extremely uncommon. There were very few published cases in the english literature. we present clinical, radiological and pathological findings of one such rare case which was appropriately managed at our institution

CASE PRESENTATION: A 27 year old male presented with complaints of on and of cough of 3 years. This was followed by breathlessness and swelling in front of the neck of four month duration. Swelling was gradually increasing in size, firm in consistentcy, non-tender and moving with deglutation. Breathlessnes was insidious in onset and gradually worsening and more in supine position. He had loss of weight and appetite over past 1 year. He was non-smoker, non-alcoholic and garment store worker by occupation. There was no history of promiscuity. Routine laboratory investigations were within normal limits except for an elevated ESR (65 mm 1st Hour). Chest X-ray (CXR) showed mediastinal widening. CECT chest and neck showed a soft tissue density involving bilateral paratracheal region (R>L) at lower neck, pre vertebral region, pre tracheal, pre carina, subcarinal and at aortopulmonary window.Trachea was compressed and esophagus was displaced to left. The mass was encasing right main pulmonary artery, SVC, brachiocephalic trunk & its branches. Bronchoscopy showedexternal compression of trachea and carina.Bronchial washings were negative for malignant cells, AFB, and fungi. CT guided trucut biopsy of the mass revealed granulomas with extensive fibrosis. Silver mithenamine stain showed narrow septate hyphae branching at acute angle. Stains for acid fast bacilli were negative. A daignosis of mediastinal aspergillosis was made and patient was administered oral Voriconazole (200 mg twice a day for 3 months) with regular follow-up. Follow-up CT and CXR showed regression of mass. Patient also had relief of symptoms.

DISCUSSION: Differential diagnosis of cervico mediastinal masses include congenital malformations/ cysts, infections (myobacterial, fungal etc), and tumors. Medisatinal granulomas with fibrosis can result from low grade infection due to mycobacteria and fungi like histoplasma, coccidioidomycosis, blastomycosis. Aspergillus is a ubiquitous mold and common commensal of the human airways. It causes a broad spectrum of diseases, ranging from hypersensitivity reactions to direct angioinvasion. Invasive aspergillosis is usually an apportunistic infecton affecting immunecompromised host.Primary mediastinal aspergillosis in immunocomptenet is a unusual form of invasive Aspergillosis. It is a diagnostic challenge as it can mimic tumors and diagnosis of such case requires high index of suspicion with aggressive diagnostic procedures including biopsy. Management includes early diagnosis and institution of antifungal therapy, with voriconazole or amphotericin B.

CONCLUSIONS: Aspergillosis needs to be included in the differential diagnosis of cervico-mediastinal granulomatous inflammation especially in countries like India where most cases are treated as tuberculosis. Biopsy and appropriate fungal stains are mandatory for proper diagnosis and management of such cases.

Reference #1: Wightman SC, Kim AW, Proia LA, Faber LP, Gattuso P, Warren WH, Liptay MJ.An unusual case of Aspergillus fibrosing mediastinitis.Ann Thorac Surg. 2009 Oct;88(4):1352-4.

Reference #2: Ahmad M, Weinstein AJ, Hughes JA, Cosgrove DE. Granulomatous mediastinitis due to Aspergillus flavus in a nonimmunosuppressed patient. Am. J. Med. 1981 Apr;70(4):887-890.Sumita Gupta et al 2004 ;Vol. 6 No. 2

Reference #3: Kumar J, Seith A, Kumar A, Madan K, Guleria R.Chest wall and mediastinal nodal aspergillosis in an immunocompetent host. Diagn Interv Radiol. 2009 Sep;15(3):176-8.

DISCLOSURE: The following authors have nothing to disclose: Paramjyothi Gongati, Shantveer Uppin, Sundaram Challa, Manmadha rao Talluri, Narender kumar Narahari, Vinathi Paritala, Bhaskar Kakarla

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