East Tennessee State University Johnson City, TN, United States
Mohammad Darweesh, MD1, Rasheed Musa, MD1, Susan Kullab, MD1, Ratib Mahfouz, MD2, Adham E. Obeidat, MD3 1East Tennessee State University, Johnson City, TN; 2Brown University, Warwick, RI; 3University of Hawaii, Honolulu, HI
Introduction: Diagnosing mediastinal masses can be challenging. Although thymoma, teratoma, thyroid goiter and lymphoma are the most common causes, sometimes, differential diagnosis has to be widened to include other less common and rare etiologies.
Case Description/Methods: A 72-year-old male patient with a past medical history significant for hypertension, GERD and nutcracker esophagus was admitted with a mediastinal mass.
The patient had a recent history of cardiac arrest post a chocking episode two months earlier. His CT Chest showed pneumomediastinum and pneumothorax along with left lobe pneumonia and pleural effusion. He underwent thoracotomy and laparotomy with repair of lower esophageal rupture and drainage of empyema in which food material was recovered from the mediastinum and pleural cavity during surgery. He was treated with multiple courses of IV antibiotics and was discharged to rehabilitation facility afterwards. He presented back to our hospital with persistent chest discomfort that was thought to be due to rib fracture sustained during resuscitation. He underwent CT chest that showed new soft tissue mass in the anterior mediastinum that was believed to be an abscess.
It was decided to treat the patient initially with antibiotics, but because there was no improvement, he then underwent CT guided aspiration of the mass. Culture grew Candida Albicans. Pathology showed extensive necrosis with chronic inflammation, giant cells, and plant foreign material with granulomatous reaction that represented food residues. The patient has for a long time received a course of Fluconazole and Amoxicillin/Clavulanic Acid with subsequent improvement.
Discussion: Anatomically, esophagus is situated in the posterior mediastinum and esophageal tumors or cysts can present as posterior mediastinal masses. In this patient’s case, the mediastinal mass, which consists of food particles most likely results from previous esophageal perforation and is peculiarly located in the anterior mediastinum. It is very unusual for food to travel to anterior part rather than stay posteriorly close to the esophagus. This is possibly thought to be due to chronic inflammation and organization leading to migration of the granuloma anteriorly. This case represents an unusual etiology of anterior mediastinal mass as well as unusual presentation of delayed complications of esophageal perforation. Physicians should always keep in mind the less common causes of mediastinal masses especially if they do not get better with treatment.
Figure: CT scan chest showing soft tissue mass in the anterior mediastinum
Disclosures: Mohammad Darweesh indicated no relevant financial relationships. Rasheed Musa indicated no relevant financial relationships. Susan Kullab indicated no relevant financial relationships. Ratib Mahfouz indicated no relevant financial relationships. Adham Obeidat indicated no relevant financial relationships.
Mohammad Darweesh, MD1, Rasheed Musa, MD1, Susan Kullab, MD1, Ratib Mahfouz, MD2, Adham E. Obeidat, MD3. P0342 - An Unusual Case of a Mediastinal Mass, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.
