Spontaneous mediastinal hemorrhage in patients on chronic hemodialysis

Ruptured thymoma managed via thoracotomy

Thymomas rarely present with chest pain due to hemorrhage. This could cause shortness of breath if it ruptures into the pleural space, and is best managed surgically. We describe the case of an 83-year-old woman who presented with such symptoms. Computed tomography showed a ruptured mediastinal mass with pleural effusion. She was managed successfully by thoracotomy with excision of the mass and drainage of the effusion. Histopathology revealed a ruptured thymoma with infarction and necrosis.

Nonvascular, nontraumatic mediastinal emergencies in adults: a comprehensive review of imaging findings

Given their high frequency, mediastinal emergencies are often perceived as being a result of external trauma or vascular conditions. However, there is a group of nonvascular, nontraumatic mediastinal emergencies that are less common in clinical practice, are less recognized, and that represent an important source of morbidity and mortality in patients. Nonvascular, nontraumatic mediastinal emergencies have several causes and result from different pathophysiologic mechanisms including infection, internal trauma, malignancy, and postoperative complications, and some may be idiopathic. Some conditions that lead to nonvascular, nontraumatic mediastinal emergencies include acute mediastinitis; esophageal emergencies such as intramural hematoma of the esophagus, Boerhaave syndrome, and acquired esophagorespiratory fistulas; spontaneous mediastinal hematoma; tension pneumomediastinum; and tension pneumopericardium. Although clinical findings of nonvascular, nontraumatic mediastinal emergencies may be nonspecific, imaging findings are often definitive. Awareness of various nonvascular, nontraumatic mediastinal emergencies and their clinical manifestations and imaging findings is crucial for making an accurate and timely diagnosis to facilitate appropriate patient management.

Shock induced by spontaneous rupture of a giant thymoma

Spontaneous bleeding of thymoma is a very rare event. We report the case of a 73-year-old woman who was referred to our hospital for acute onset of chest pain followed by shock. Chest computed tomographic scanning showed a huge mediastinal tumor with abundant left pleural effusion and contralateral shift of the mediastinum. Emergency surgical treatment was carried out through a clamshell incision. At the opening of the left pleura 1,600 mL of fresh blood was found, originating from a rupture of the tumor's capsular veins. The lesion was completely resected, en-bloc with a wide pericardial excision. The postoperative course was uneventful. The pathology report classified the lesion as thymoma AB.

Suicide by severing the arterio-venous subclavian dialysis catheter

Haemodialysis access is an essential requirement for haemodialysis treatment in end-stage renal disease. The common forms are arteriovenous fistula (AVF) and arteriovenous grafts in ante-cubital fossa, forearm and upper thigh. Sometimes temporary or immediate access is created via a subclavian catheter or internal jugular catheter. This report is on a 79-year-old man who was suffering from chronic renal failure with a non-functional peripheral AVF; he was being dialysed through a permanent subclavian catheter and he became depressed due to continuing deterioration of his health. He used the easily accessible haemodialysis site as the method of suicide by cutting the tube that connected with the main vessel in his chest and bled to death. This highlights the requirement to assess carefully the patient's mental state in those on chronic haemodialysis, even though very few similar fatal cases have been previously reported.

Spontaneous thymic cyst hemorrhage causing hemothorax

The case describes a 56-year-old man who had thymic cyst hemorrhage, followed by right hemothorax. There was a high possibility that his accompanying disease, an alteration in hemostasis due to alcoholic liver cirrhosis and hypertension, would induce thymic cyst hemorrhage. Thymic cyst hemorrhage should be included in possible causes of the sudden onset of mediastinal or intrathoracic hemorrhage, in addition to the rupture of aortic aneurysm or malignant mediastinal tumor.

Ruptured thymoma causing mediastinal hemorrhage resected via partial sternotomy

A case of a ruptured thymoma causing mediastinal hemorrhage and hemothorax that was electively resected by a partial sternotomy approach is presented. This case and others previously reported illustrate that a sudden onset of dyspnea and chest pain accompanied by acute mediastinal widening on chest roentgenogram in a previously healthy patient should suggest the diagnosis of a ruptured thymoma. An upper part sternotomy approach may be as safe and effective as a less invasive surgical procedure in resection of noninvasive thymomas, even if dense tumor adhesion exists.

Emergencies in continuous dialysis patients: diagnosis and management

The number of patients undergoing long-term hemodialysis and peritoneal dialysis is growing in the United States. To provide adequate emergent care to these patients emergency physicians must understand the alterations in normal physiologies present in these patients and how this may affect care. Cardiovascular disease and infection (especially Staphylococcus aureus sepsis) are the leading causes of death among dialysis patients. These patients are also subject to a significantly higher incidence of life-threatening electrolyte disturbances, particularly hyperkalemia and hypercalcemia, than the general population. Suicide, cardiac tamponade, intracranial hemorrhage, bleeding disorders, and bowel infarction are also much more frequent. The inability of dialysis patients to excrete drugs, metabolites, toxins, and fluids significantly alters their responses to common emergencies and should directly influence their care. Failure to recognize these differences in physiology may result in the use of standard forms of emergency therapy that may compound, rather than treat, the underlying disorder. Although most dialysis patients who come into an emergency department have conditions that can, and should, be managed by their nephrologist, the presence of a life threatening emergency requires prompt, appropriate therapy by the emergency physician.

Epoprostenol (PGI2, prostacyclin) during high-risk hemodialysis: preventing further bleeding complications

The frequency of hemodialysis-associated hemorrhage was studied prospectively in two successive, parallel, heparin-controlled studies using epoprostenol (PGI2; average dose, 4.1 ng/kg.min) as the sole antithrombotic agent. Sixty-three patients with active or recently active bleeding underwent 163 hemodialysis treatments in each of which prospective bleeding risk was assessed. PGI2 was associated with up to 50% overall reduction in the frequency of bleeding, particularly in the highest risk circumstances. PGI2 also allowed successful completion of the full, prospectively prescribed hemodialysis time in the most treatments (82% versus 93% with heparin). Furthermore, the efficiency of hemodialysis using PGI2, as indicated by the reduction in concentration of blood urea nitrogen and serum creatinine, was equal to that using heparin, even though there was a tendency toward modest reduction in residual volume of the hollow fiber dialyzer and slightly more frequent early termination of treatment from dialyzer clotting with PGI2. No severe vasodilatory side effects of PGI2 were observed during these studies. Hypotension was equally frequent during hemodialysis with heparin as with PGI2. The current results suggest that PGI2 should be considered as a substitute for heparin during high-risk hemodialysis because PGI2 may reduce the incidence of dialysis-associated bleeding without severe adverse side effects.

Mediastinal tumors presenting as spontaneous hemothorax, simulating aortic dissection

The usual causes of hemomediastinum and hemothorax include chest trauma, rupture of an aortic aneurysm or aortic dissection. We report two patients who presented with a clinical picture of aortic dissection. In both patients, the chest radiograph revealed anterior mediastinal masses. Aortic dissection could not be excluded on the basis of the chest radiograph, and additional investigation by thoracic aortography was performed. The tumors had undergone spontaneous bleeding into the mediastinum and the pleural space, presumably causing the patients pain. The interesting and unusual causes of spontaneous hemomediastinum and hemothorax are reviewed.

Alterations in hemostatic parameters during hemodialysis with dialyzers of different membrane composition and flow design. Platelet activation and factor VIII-related von Willebrand factor during hemodialysis

The effect of dialyzer membrane and design on hemostatic parameters during hemodialysis were evaluated in a prospective controlled study. This study demonstrated that hemodialysis is associated with significant platelet activation and loss, which are influenced by both dialyzer configuration and membrane composition. In addition, use of the cuprophan membrane is associated with greater perturbations of the vascular endothelium, as reflected in changes in factor VIII-related von Willebrand factor and 6-keto-prostaglandin F1 alpha concentrations not seen with the polyacrylonitrile membrane. Of the dialyzers studied, the polyacrylonitrile membrane in a hollow-fiber configuration appears to minimize platelet loss and activation, and to minimize increases in factor VIII-related von Willebrand factor and 6-keto-prostaglandin F1 alpha.

Deamino-8-D-arginine vasopressin shortens the bleeding time in uremia

In a randomized double-blind cross-over trial we gave either 1-deamino-8-D-arginine vasopressin or placebo to 12 patients with uremia, hemorrhagic tendencies, and prolonged bleeding times. After vasopressin infusion, all patients had shortened bleeding times, with the effect lasting for at least four hours in most cases. Platelet count, platelet cyclic AMP levels, platelet retention on glass beads, plasma fibronectin, serum thromboxane B2 and residual prothrombin, hematocrit, and plasma osmolarity were unchanged after vasopressin. A consistent post-infusion increase in factor VIII coagulant activity and, to a lesser extent, in factor VIII-related antigen and ristocetin cofactor accompanied the shortening of bleeding time. In addition, vasopressin induced the appearance in plasma of larger von Willebrand-factor multimers than those present in the resting state. The compound was given to nine additional patients with acute or chronic renal failure and prolonged bleeding times, before major surgery or renal biopsy. In these patients, shortening of the bleeding time was associated with normal hemostasis. Our findings indicate that 1-deamino-8-D-arginine vasopressin can be used for temporary correction of bleeding time and may prevent surgical bleeding in patients with uremia.