Acute mediastinitis, mediastinal granuloma, and chronic fibrosing mediastinitis: A review

Nonsurgical Management of a Caudal Mediastinal Granuloma

A 3 yr old female springer spaniel presented with a 3-day history of pyrexia, lethargy, and a mild cough. A year prior, the dog had undergone surgical removal of a grass seed from her sublumbar muscles. Computed tomography of the thorax revealed the presence of a caudal mediastinal mass closely associated with the esophagus and diaphragm. A median sternotomy was performed, but the mass proved nonresectable. Biopsy results confirmed a chronic granuloma, and the culture isolated Escherichia coli spp. The patient was treated with long-term antibiotics and the response was followed with computed tomography, with the mass completely resolved in 6 mo. Caudal mediastinal masses are a rare entity in veterinary medicine. Most of the masses are abscesses or granulomas caused by migrating foreign bodies. Surgical excision or debridement is considered the preferred treatment. This case report describes the successful long-term management of a nonresectable mediastinal granuloma through medical intervention. Medical management can have successful outcomes when surgical excision is not feasible.

Changes in Antibiotic Redemption Related to Hungarian Dental Care During COVID-19

INTRODUCTION AND AIMS

Antibiotic resistance is a global health problem that can affect individuals, health systems, and the economy. Our aim was to investigate how the redemption of antibiotics and the associated dental care changed during COVID-19 in Hungary.

METHODS

The ICD codes for the infections for which antibiotics should be prescribed in dental care were identified based on the professional recommendation. The database was provided by the National Health Insurance Fund Manager of Hungary. Pearson's chi-squared test with Bonferroni correction was used to compare both the redemption of antibiotics and the associated dental care based on the recommendations in the year 2020 of the COVID-19 and the 2 preceding years.

RESULTS

There were fewer antibiotic redemptions and associated dental care in 2020 than in 2018 and 2019. The ratio of professionally relevant and nonrelevant antibiotics redeemed did not change significantly between 2018 and 2019, but the proportion of antibiotics redeemed following recommendations increased significantly during the COVID-19 year of 2020 compared to the previous 2 years. The proportion of all dental care involving antibiotic redemptions increased significantly from 2018 to 2019, and then showed a further increase in 2020. The sex and age of the patient did not affect these findings, while the type of dental care did alter the trends in some cases.

CONCLUSIONS

Antibiotics in dentistry are required only for very low proportion of cases, due to the nature of dental care where most infections such as caries and periodontal disease could be managed without resorting to antibiotics. Antibiotic redemptions during COVID-19 pandemic period increased compared to the pre-pandemic period in Hungary. Therefore, Hungarian policy makers need to develop control systems to promote the correct use of antibiotics in dental care.

CLINICAL RELEVANCE

It is important to reduce unjustified use of antibiotics so as to curb the emergence of antibiotic resistance organisms.

Bronchial artery embolization combined with left pulmonary resection in the treatment of fibrosing mediastinitis complicated with massive hemoptysis: a case report

Fibrosing mediastinitis (FM) is a rare and benign fibroproliferative disease that presents with the proliferation of extensive, dense fibrous tissue in the mediastinum. Hemoptysis is a common clinical manifestation of FM. Clinically, most patients exhibit mild to moderate hemoptysis. We report a case of FM complicated with life-threatening massive hemoptysis. The patient was successfully rescued through a combination of bronchoscopic balloon closure, bronchial artery embolization (BAE), and surgical interventions. Although FM is frequently benign, vascular involvement can progress to life-threatening massive hemoptysis and must be treated appropriately.

Non-IgG4-Related Fibrosing Mediastinitis Diagnosed on Core Needle Biopsy and Treated with Steroids: A Case Study and Review of the Differential Diagnoses

OBJECTIVES

This study aimed to investigate the histological characteristics and treatment efficacy of non-immunoglobulin G4-related fibrosing mediastinitis and discuss differential diagnoses for this rare entity.

METHODS

We present a case study of non-immunoglobulin G4-related fibrosing mediastinitis diagnosed on core biopsy and treated with steroids. A total of four 18-gauge core needle biopsy specimens were obtained for surgical pathology. Analysis of the patient's medical history, radiological characteristics of fibrosing mediastinitis, histological features, immunohistochemistry results, the differential diagnosis and treatment efficacy of different types of fibrosing mediastinitis was performed.

RESULTS

This report describes a unique presentation of fibrosing mediastinitis (syncope and weight loss) that was concerning for malignancy. Histological, laboratory and radiographical studies confirmed the diagnosis of non-immunoglobulin G4-related fibrosing mediastinitis. The patient received corticosteroid treatment which showed marked improvement after 1 month of treatment.

CONCLUSIONS

Fibrosing mediastinitis is an extremely uncommon entity with unknown pathogenesis, and it is more important to rule out malignancy and infection than to delineate between fibrosing mediastinitis and IgG4-related disease. In doing this, we may reasonably initiate a trial of corticosteroids which may prove beneficial, as in this patient. More studies on the pathogenesis of fibrosing mediastinitis are necessary to guide better directed treatments.

A retrospective analysis of transudative pleural effusion due to fibrosing mediastinitis

BACKGROUND

Pleural effusion caused by fibrosing mediastinitis is rarely reported. This study aimed to summarize the clinical manifestations, diagnosis and treatment of transudative pleural effusion due to fibrosing mediastinitis.

METHODS

Medical records and follow-up data of 7 patients with transudative pleural effusion due to fibrosing mediastinitis in Beijing Chaoyang Hospital between May 2014 and Feb 2018 were retrospectively analyzed.

RESULTS

These patients included 4 males and 3 females, with an average age of (64 ± 9) years. There were 3 left-sided effusions, 2 right-sided effusions and 2 bilateral effusions. Previous or latent tuberculosis was found in 6 patients. Pulmonary hypertension was indicated by echocardiography in all the 7 patients. Computed tomography pulmonary angiography (CTPA) of all the 7 cases showed increased soft tissue images visible in the mediastinum and bilateral hilus, different degrees of stenosis or occlusion in the pulmonary artery and pulmonary vein. In addition, 4 cases were found of right middle lobe atelectasis with a mediastinal window setting. There was interstitial pulmonary edema on the side of pleural effusion with a lung window setting. All the 7 patients were treated with intermittent drainage of pleural effusion combined with diuretic therapy. Five patients were treated with antituberculosis therapy. Up to now, two patients died of right heart failure and respiratory failure after 2 and 16 months respectively; The remaining 5 patients were still in follow up.

CONCLUSION

Fibrosing mediastinitis can lead to pulmonary vein stenosis or occlusion, and thus cause transudative pleural effusion, which can be detected by CTPA. Pulmonary hypertension, long time of cough, and a history of tuberculosis are common in these patients. The common therapy is intermittent drainage of pleural effusion combined with diuretic therapy.

Scoping review of post-TB pulmonary vascular disease: Proceedings from the 2nd International Post-Tuberculosis Symposium

Tuberculosis (TB) may cause significant long-term cardiorespiratory complications, of which pulmonary vascular disease is most under-recognized. TB is rarely listed as a cause of pulmonary hypertension (PH) in most PH guidelines, yet PH may develop at various stages in the time course of TB, from active infection through to the post-TB period. Predisposing risk factors for the development of PH are likely multifactorial, involving active TB disease and post-TB lung disease (PTLD), host-related and environment-related factors. Moreover, post-TB PH should likely be classified in Group 3 PH, with the pathogenesis similarly complex and multifactorial as other Group 3 PH causes. Identifying risk factors that predispose to post-TB PH may aid in developing risk stratification criteria for early identification and referral for confirmatory diagnostic tests. Given that universal screening for PH in TB survivors may be impractical and unfeasible, a targeted screening approach for high-risk individuals would be sensible. In this scoping review of post-TB PH, resulting from the proceedings of the 2nd International Post-Tuberculosis Symposium, we aim to describe the epidemiology, risk factors, and pathophysiology of post-TB PH. We emphasize diagnosing PH with an alternative set of diagnostic guidelines in resource-constrained settings where right heart catheterization may not be feasible. Research to describe the burden and distribution of post-TB PH should be prioritized as there is a current gap in knowledge regarding the prevalence and incidence of post-TB PH among persons with TB.

Fibrosing Mediastinitis Caused by Histoplasmosis in an Adolescent

Fibrosing mediastinitis (FM) is a rare, potentially progressive disease resulting from an idiosyncratic immune response to a variety of stimuli that lead to fibrous infiltration of the mediastinum and possible narrowing of the bronchovascular structures. We report an unusual case of FM in a pediatric patient presenting as myopericarditis and progressing to pericardial thickening and encasement of the mediastinal vascular structures needing surgical intervention. Imaging, including transthoracic echocardiography, cardiac computed tomography, and cardiac magnetic resonance played a crucial role in the diagnosis, assessment, and follow-up. Contrast-enhanced computed tomography can be especially helpful to demonstrate potential findings associated with FM.

Benign lesions of the mediastinum

Mediastinal tumours represent a heterogeneous group of entities derived from the manifold structures located in or adjacent to the mediastinum. Due to the occurrence of some of these tumours in characteristic mediastinal compartments, an anatomical subdivision of the mediastinum in the prevascular (anterior), visceral (middle), and paravertebral (posterior) is helpful for the differential diagnosis. Benign anterior mediastinal tumours linked to an enlargement of the thymic gland mainly consist of thymic cysts and several types of thymic hyperplasia: true thymic hyperplasia, rebound hyperplasia, lymphofollicular hyperplasia, and so-called thymic hyperplasia with lymphoepithelial sialadenitis (LESA)-like features. Mature teratomas, ectopic (para)thyroid tissue, and benign thymic tumours such as thymolipoma or thymofibrolipoma represent further typical tumours of the anterior mediastinum. Pericardial, bronchogenic, or oesophageal duplication cysts predominate in the middle mediastinum, whereas neurogenic tumours and myelolipomas are characteristic findings in the posterior compartment. Vascular tumours, lipomas, adenomatoid tumours, Castleman disease, or mediastinitis are further examples of less frequent tumours or tumorous lesions affecting the mediastinum. This review focuses on benign mediastinal lesions with an emphasis on benign tumours of the thymus. Besides histology, characteristic epidemiological and clinical aspects prerequisite for the correct diagnosis and patient management are discussed.

A rare sequelae of esophageal perforation: Fibrosing mediastinitis

Fibrosing mediastinitis (FM) is a rare disease caused by different causes. If left untreated, the prognosis is poor. The common causes of FM are Tuberculosis and Histoplasma capsulatum infection. Esophageal perforation is also a rare condition that is often easily under- and mis-diagnosed due to the lack of specificity of symptoms. Here we report a case of FM caused by esophageal perforation.

[Lesions of the paravertebral mediastinum]

BACKGROUND

Lesions of the paravertebral mediastinum are rare, and knowledge of possible differential diagnoses is essential for clinical practice.

OBJECTIVE/METHODS

To review common lesions of the paravertebral mediastinum.

RESULTS

The paravertebral mediastinum mainly includes fatty tissue and neurogenic structures. Imaging is commonly performed using computed tomography (CT) and magnetic resonance imaging (MRI). Neurogenic tumors are the most common lesions of the paravertebral mediastinum. Other pathologies include extramedullary hematopoiesis, lipomatous, lymphogenic, inflammatory, and cystic lesions. Moreover, also diaphragmatic hernias, vascular and esophageal pathologies may be found in the paravertebral mediastinum.

Successful management of 72-h delay-detected blunt esophageal injury with trans-gastric primary repair; a case report and literature review

Diagnosis of blunt esophageal injury is currently a challenging issue. Early surgical interventions still play as the mainstay of treatment. There was no consensus about appropriate treatment options. However, it was potential morbidity if delayed management. We report a 33-year-old man with a history of a motorcycle accident who presented with hematemesis and epigastrium pain. He was initially diagnosed with left pneumohemothorax and low-grade gastric injury. The patient developed a high-grade fever with complex left pneumohemothorax 72-h after admission. The diagnostic studies revealed a lower esophageal rupture. He was treated with trans-gastric primary repair and recovered well with no complications. We propose the trans-gastric intraluminal repair is one of the surgical options in a blunt lower esophageal rupture.

Pemphigoid of the pulmonary system (POPS): A review of a less recognized feature

This review of Pemphigoid of the Pulmonary System (POPS) is a comprehensive description of pulmonary involvement in patients with mucous membrane pemphigoid (MMP), which is an orphan autoimmune blistering disease. The objective of the review was to analyze clinical features of pulmonary involvement in MMP. This POPS review is a case series in which multiple search engines were utilized from inception to June 2022 for cases of MMP with biopsy and immunopathology proven tracheal and bronchial pemphigoid. Clinical profiles prior to pulmonary involvement, bronchoscopy findings, clinical course and therapy were recorded and cause of death was analyzed. Patients with documented MMP who developed tracheal, bronchial and pulmonary involvement were included in the POPS review. Histology and immunopathology documentation were essential diagnostic criteria. Comparison groups were not possible. Patients were treated with immunosuppressive therapy. Some required surgical interventions. Six of the 11 patients attained complete or partial remission on or off therapy. Five patients died from pulmonary complications. The POPS review had six females and five males. The mean age at onset was 20 years (range 4-76), while 80% of the patients were under 40 years. All had severe widespread MMP involving three to five mucosal tissues. 100% had oral, 82% had ocular and cutaneous involvement. Pulmonary involvement occurred at 24 mo (range 2-372) after the onset of MMP. Bronchoscopy revealed acute inflammation during active disease and scarring of the trachea and bronchi in the later stages. Systemic infections occurred in 45%, while pulmonary infection occurred in 36%. Mortality due to respiratory failure, at the median age of 20 years (range 18-76), occurred in 45% of the patients, and was considered disease related. In spite of the young age, while there are some similarities in the clinical profile and response to systemic therapy, there are definitive differences from other patients with MMP. Early diagnosis with appropriate management could produce better clinical outcomes and prevent mortality in this orphan disease. Consequently, there is a critical need for early identification and diagnosis of POPS.

Extensive fibrotic wrapping of the heart: a rare echocardiographic diagnosis

BACKGROUND

Fibrosing mediastinitis (FM) is considered a benign disease, but it can be fatal if progression leads to compression of the hilum of the lungs or invasion of the heart. Echocardiographic reports of this disease are very rare.

CASE PRESENTATION

We present a 14-year-old male patient whose non-enhanced chest computed tomography showed unclear soft-tissue dense lesions in the anterior superior mediastinum. Echocardiography showed the heart was extensively wrapped by soft tissue lesions. The histology confirmed FM.

CONCLUSIONS

When FM affects the heart, echocardiography can help to characterize the disease and aid in the diagnosis. Echocardiography should be considered an important tool to follow the progression of this disease and guide the therapeutic approach.

Pulmonary Hypertension Caused by Fibrosing Mediastinitis

Pulmonary hypertension (PH) is a progressive and severe disorder in pulmonary hemodynamics. PH can be fatal if not well managed. Fibrosing mediastinitis (FM) is a rare and benign fibroproliferative disease in the mediastinum, which may lead to pulmonary vessel compression and PH. PH caused by FM (PH-FM) is a pathologic condition belonging to group 5 in the World Health Organization PH classification. PH-FM has a poor prognosis because of a lack of effective therapeutic modalities and inappropriate diagnosis. With the development of percutaneous pulmonary vascular interventional therapy, the prognosis of PH-FM has been greatly improved in recent years. This article provides a comprehensive review on the epidemiology, pathophysiologic characteristics, clinical manifestations, diagnostic approaches, and treatment modalities of PH-FM based on data from published reports and our medical center with the goal of facilitating the diagnosis and treatment of this fatal disease.

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PH-FM, as a type of rare condition in group 5 PH, has a poor prognosis because of a lack of effective therapeutic modalities and frequent misdiagnosis and underdiagnosis.

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The most prevalent trigger of FM is H-FM in the United States and TB-FM in China.

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Imaging findings, including mismatched perfusion defects in the V/Q scan, FM dyad, and FM triad are important diagnostic clues, and clinical classification facilitates decision making in diagnosis and therapeutics.

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Because of the limited efficacy of drug therapy as well as the uncertain effectiveness and high risk of surgical treatment, endovascular interventional modality is currently the preferred therapeutic option, although procedure-related complications and intrastent restenosis after PV intervention need to be addressed.