Disorders of the Mediastinum: Fellow Case Report Slide: Disorders of the Mediastinum |

Making Unusual Connections: Fibrosing Mediastinitis Leading to Bronchoesophageal Fistula FREE TO VIEW

Ji Yeon Lee, MD; Keriann Van Nostrand, MD; David Berkowitz, MD
Author and Funding Information

Emory University, Decatur, GA

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):544A. doi:10.1016/j.chest.2016.08.562
Text Size: A A A
Published online

SESSION TITLE: Fellow Case Report Slide: Disorders of the Mediastinum

SESSION TYPE: Affiliate Case Report Slide

PRESENTED ON: Tuesday, October 25, 2016 at 07:30 AM - 08:30 AM

INTRODUCTION: Mediastinal lymphadenopathy (LAD) can be an incidental finding on chest imaging and is often asymptomatic. When symptomatic, it is usually due to mass effect on the surrounding organs. In the rare circumstance of fibrosing mediastinitis, invasive fibrous tissue formation and inflammation may lead to bronchoesophageal (BE) fistula formation.

CASE PRESENTATION: A 72 year-old male with history of OSA, stroke, and obesity presented to pulmonary clinic for evaluation of chronic cough of 4 months with intermittent hemoptysis. He also had fatigue, shortness of breath, and 40 pound weight loss. CT showed mediastinal LAD and an esophageal diverticulum. EGD and barium swallow confirmed no fistula. He had a bronchoscopy, showing edematous airways in the right middle and lower lobe. Cultures were negative. Biopsy showed acute and chronic inflammation. PFTs showed obstruction with bronchodilator response, so he was started on Advair and given prednisone for possible asthma exacerbation. He did not improve, so repeat bronchoscopy was performed, showing worsening airway edema and friable, bleeding mucosa. Repeat CT identified a BE fistula at the bronchus intermedius (BI) and aspiration. He underwent surgery, and the esophagus, fistula, and BI were scarred down to the subcarinal lymph node (LN). The fistula was repaired. The LN histology showed fibrocalcific change. He had a complicated post-op course, including recurrence of his BE fistula, mediastinal abscess, and empyema, leading to a prolonged hospital and rehabilitation course.

DISCUSSION: Fibrosing mediastinitis is an invasive, fibrotic process resulting from chronic mediastinal granulomatous disease. It can result in a variety of pathologic findings, depending on the mediastinal structures that are compressed or eroded by this abnormal fibroproliferative response. It usually causes vascular or bronchial obstruction but rarely can lead to fistula formation. It is commonly related to Histoplasma exposure in the US. However, less than 1% of patients with Histoplasma infection will develop fibrosing mediastinitis.

CONCLUSIONS: This case illustrates a rare cause of cough and hemoptysis, as well as a rare cause of bronchoesophageal fistula.

Reference #1: Peikert T, et al. Fibrosing mediastinitis: clinical presentation, therapeutic outcomes, and adaptive immune response. Medicine (Baltimore). 2011 Nov;90(6):412-23.

Reference #2: Dunn E, et al. Surgical Implications of Sclerosing Mediastinitis. Chest. 1990 Feb;97(2):338-46.

DISCLOSURE: The following authors have nothing to disclose: Ji Yeon Lee, Keriann Van Nostrand, David Berkowitz

No Product/Research Disclosure Information




Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).

Some tools below are only available to our subscribers or users with an online account.

Related Content

Customize your page view by dragging & repositioning the boxes below.

Find Similar Articles
CHEST Journal Articles
  • CHEST Journal
    Print ISSN: 0012-3692
    Online ISSN: 1931-3543