Indian Journal of Radiology and Imaging Indian Journal of Radiology and Imaging

QUIZ
Year
: 2004  |  Volume : 14  |  Issue : 2  |  Page : 223--224

Radiological diagnosis quiz - chest


R Goyal, R Azad, V Kalia 
 Dept of Radiodiagnosis Dyanand Medical College & Hospital, Ludhiana-141 001, India

Correspondence Address:
R Azad
1877-A, Maharaj Nagar, Ludhiana-141 001
India




How to cite this article:
Goyal R, Azad R, Kalia V. Radiological diagnosis quiz - chest.Indian J Radiol Imaging 2004;14:223-224


How to cite this URL:
Goyal R, Azad R, Kalia V. Radiological diagnosis quiz - chest. Indian J Radiol Imaging [serial online] 2004 [cited 2019 Nov 18 ];14:223-224
Available from: http://www.ijri.org/text.asp?2004/14/2/223/30475


Full Text

An 18 year old woman presented with fever and breathlessness since one and a half month and recurrent hemoptysis since one month. Clinical examination did not reveal any significant abnormality. Routine investigations revealed an erythrocyte sedimentation rate of 104 millimeters at the end of one hour, haemoglobin of 10 grams per deciliter and total leucocyte count within normal limits. A chest radiograph (done on day one of admission) and CT scan (done on day four of admission) were obtained.

 View Answer

 Radiological Diagnosis



 Fibrosing Mediastinitis with Pulmonary Hypertension and intrapulmonary Hemorrhage



The chest radiograph shows widening of the right paratracheal stripe with septal thickening, increased interstitial markings in both parahilar and para-cardiac regions and haziness in the left lower zone. Spiral CT shows infiltrating soft tissue attenuation mass in the mediastinum encasing the right and left pulmonary branches, mainstem bronchi, SVC, pulmonary veins and esophagus. HRCT shows patchy ground glass haze involving bilateral lung fields maximally involving left lower zone with thickening of interlobular septae. Intrapulmonary vessels are prominent with ill-defined small nodular opacities in bilateral lung fields. Pleural thickening is seen on left side.

Fibrosing mediastinitis (Sclerosing mediastinitis) is a rare benign disorder. It most commonly affects the middle mediastinum. The anterior and posterior mediastinum are less frequently involved. [1],[2]. On chest radiographs it manifests as non-specific widening of the mediastinum, with distortion and obliteration of the normally recognizable mediastinal interfaces or lines [1]. CT is considered the mainstay for diagnostic evaluation of patients with known or suspected fibrosing mediastinitis. On CT, it presents as two distinctly different radiographic patterns [3].

a) Focal type typically manifests on CT as localized calcified mass in the paratracheal or subcarinal regions or pulmonary hila. This is probably caused by idiosyncratic fibro-inflammatory reaction to previous Histoplasma capsulatum infection (seen in endemic areas infested with H. capsulatum) or in tuberculosis.

b) Diffuse type manifests as diffusely infiltrating, non-calcified mass that affects multiple mediastinal compartments. This is probably not related to histoplasmosis but occurs in association with other idiopathic fibrosing disorders. Diffuse infiltration can lead to encasement and narrowing of the pulmonary arteries, veins, oesophagus, bronchi and aorta. Pulmonary venous obstruction results in focal or diffuse regions of increased lung attenuation, ground glass haze and thickening of interlobular septae. Pulmonary arteries show long segment, smooth and funnel like stenoses of affected vessels. Airway involvement can lead to narrowing usually at level of carina and mainstem bronchi. Findings of oesophageal involvement include circumferential narrowing, long segment strictures and "down hill" oesophageal varices [4],[7]. Findings of diffuse involvement were observed in our case. Fibrosing mediastinitis typically manifests on T1 weighted MR Images as heterogenous infiltrative mass of intermediate signal intensity. It appearance on T2 weighted MR Images is more variable with regions of both increased (Active inflammation) and decreased signal intensity (fibrous tissue of calcification) seen in same lesion [5]. Microscopic examination reveals abundant paucicellular fibrous tissue infiltrating the adipose tissue. Flider and Colleagues [6], established a 3 step staging system based on histopathological spectrum :-

I. Composed mainly of edematous fibromyxoid tissue.

II. Glassy band of cosinophilic hyaline material

III. Dense paucicellular collagen

The differential diagnosis of fibrosing mediastinitis include other infiltrative lesions of mediastinum such as lung carcinoma, metastatic carcinoma, lymphoma, mediastinal sarcoma or rarely mediastinal desmoid tumors [3]. Diagnosis is made by surgical sampling performed during mediastinoscopy, thoracoscopy or open thoracotomy. Possible avenues for treatment include-systemic antifungal or corticosteroid therapy, surgical resection and local therapy for complications[7].

References

1Feign DS, Eggleston JC, Sigelman SS, The multiple roentgen manifestations of selerosing mediastinitis, Johns Hopkins Med J 1979; 144: 1-8.
2Kountz PD, Molina PL, Sagel SS, Fibrosing mediastinitis in the posterior thorax. Am J. Roentgenol 1989; 153: 489-490.
3Sherrick AD, Brown LR, Harms GF, Myers JL, The radiographic findings of fibrosing mediastinitis. Chest 1994; 106: 484-489.
4Kalweit G, Huwer H, Straub U, Gams E, Mediastinal compression syndromes due to idiopathic fibrosing mediastinitis: Report of three cases and review of literature. Thorac Cardiovasc. Surg 1996; 44: 1505-09.
5Rodriguez E, Soler R, Pumbo F, Requejo I, Montero C, Fibrosing mediastinitis. CT and MRI findings. Clin Radiol. 1998; 53: 907-910.
6Fleider DB, Suster S, Moran CA, Idipathic fibroinflammatory lesions of mediastium: a study of 30 cases with emphasis on morphologic heterogenicity. Mod. Pathol 1999; 12: 257-264.
7Davis AM, Pierson RN, Loyd JE, Mediastinal fibrosis - Seminars in respiratory infections.