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A Case of a Mediastinal Mass in a Teenager Causing Chest Pain CPJXXX10.1177/0009922820915888Clinical PediatricsChang and Ang 915888research-article2020 Resident Rounds Clinical Pediatrics 1 –4 A Case of a Mediastinal Mass in a © The Author(s) 2020 Article reuse guidelines: sagepub.com/journals-permissions Teenager Causing Chest Pain, DOI:https://doi.org/10.1177/0009922820915888 10.1177/0009922820915888 Difficulty Breathing, and Emesis: A journals.sagepub.com/home/cpj Rare Complication of a Relatively Common Disease Tiffany F. Chang, MD1,2,3 and Jocelyn Y. Ang, MD2,3 Case Report The clinical picture was suggestive of infectious eti- ology, specifically tuberculosis and fungal infection A 16-year-old female from Southeast Michigan with a (histoplasmosis, blastomycosis, and coccidioidomyco- history of Raynaud’s disease presented with 2 weeks of sis). Her mother was an intensive care unit nurse with cough, shortness of breath, fever, and right-sided chest previous tuberculosis exposure 3 years ago, but cur- pain. The chest pain was described as a constant, sharp rently asymptomatic. Otherwise, she denied any other pain radiating to the right axilla, worsening with cough significant exposures. Respiratory culture was normal; and lying flat, and improving while standing. The cough PPD (purified protein derivative) skin test and acid-fast was productive of white sputum without hemoptysis. bacilli sputum stains were negative. Blood culture and She reported fatigue and night sweats, but no weight β-D-glucan were negative. Blastomyces antigen and loss. The chest pain and fever acutely worsened 2 days coccidioides antigen were both negative. Histoplasma prior to admission. urine antigen was negative and titers of histoplasma Physical examination was significant for right-sided antibodies by complement fixation (CF) were 1:8, an crackles on auscultation. Significant laboratory findings inconclusive result. However, M and H bands were included an elevated white blood cell count at 14 900/ 3 detected by immunodiffusion, conclusively diagnosing mm , with neutrophilic predominance (83%), and ele- the patient with histoplasmosis. On further questioning, vated erythrocyte sedimentation rate at 75 mm/h. Chest the patient recalled that she was managing large metal X-ray was unremarkable. coils covered in bird feces with her father 2 months A computed tomography scan of the thorax was per- prior. formed due to this subacute history of dyspnea, fever, She was treated with 0.5 mg/kg prednisone daily for and cough. It revealed a 4.6-cm calcified soft tissue 7 days and itraconazole 200 mg 3 times a day for 3 days, mass in the right subcarinal region with bilateral hilar followed by 200 mg twice a day for 12 weeks, based off lymphadenopathy and mild compression of the right of Infectious Diseases Society of America guidelines.1 middle lobe bronchi and esophagus without complete Immunoglobulin levels were normal, excluding immu- obstruction. It also showed a 1.1-cm calcified soft tissue nodeficiency. Repeat computed tomography scan after nodule in the left lower lobe (Figure 1). During the treatment showed that the subcarinal mass decreased in admission, the patient developed gastroesophageal size from 4.6 cm to 1.6 cm (Figure 2), along with the reflux symptoms with intermittent emesis, which was bilateral calcified hilar lymph nodes. This correlated attributed to the esophageal compression. with improvement in symptoms. Evaluation for malignancy included lactate dehydro- genase, lactic acid, ferritin, and uric acid, which were within normal limits. Peripheral smear showed signifi- 1Detroit Medical Center, Detroit, MI, USA 2 cant neutrophilia and flow cytometry showed no clonal Wayne State University, Detroit, MI, USA 3Children’s Hospital of Michigan, Detroit, MI, USA population suggestive of leukemia. Due to the history of Raynaud’s disease, tests for sarcoidosis, autoimmune, Corresponding Author: and connective tissue diseases were performed (ANA, Tiffany F. Chang, Department of Internal Medicine—Pediatrics, Detroit Medical Center, 4201 St. Antoine Street, Suite 5C, Detroit, dsDNA, ANCA, lysozyme, and angiotensin converting MI 48201, USA. enzyme) and were all negative. Email: [email protected] 2 Clinical Pediatrics 00(0) Discussion Histoplasma capsulatum is a fungus that is endemic to the central and eastern United States, specifically the Mississippi and Ohio River valleys. It is typically found in soil contaminated by bird or bat excrement, barns, and caves.2 After aerosolized conidia are inhaled, they germinate in the distal bronchioles and pulmonary alve- oli, where they transition to their yeast phase, then pro- liferate within macrophages.2,3 Immunocompetent people develop T-lymphocyte immunity after 1 month, and macrophages activate to kill the fungus and control the disease.3 Histoplasma capsulatum causes symptoms in <5% to 10% of infected people depending on age, immuno- competence, and size of inoculum.3,4 Clinical manifesta- tions are classified according to site (pulmonary or disseminated), duration (acute, subacute, or chronic), and pattern (primary or reactivation) of infection.4 Most symptomatic patients develop acute pulmonary histo- Figure 1. Coronal image of computed tomography scan plasmosis, a brief, self-limited illness characterized by of thorax with contrast showing a 4.6-cm calcified soft fever, chills, nonproductive cough, and malaise.3 They tissue mass and bilateral hilar lymphadenopathy causing mild then recover without treatment after 2 to 3 weeks. compression of the right middle lobe bronchi. Disseminated disease and severe pulmonary histoplas- mosis are usually only seen in immunocompromised patients. Radiography may show hilar or mediastinal adenopathy, or diffuse interstitial or reticulonodular pul- monary infiltrates. As the presenting symptoms can be nonspecific, the initial differential will be wide and varied for a child presenting with a mediastinal mass. The differential diagnosis in the case presented above included lym- phoma, leukemia, sarcoidosis, tuberculosis, blastomy- cosis, and coccidioidomycosis. Diagnostic laboratory tests to confirm histoplasmosis include serologic tests, antigen detection via quantitative enzyme immunoassay (EIA), culture, and tissue and body fluid examination.3 Multiple positive results increase the positive predictive value of slightly positive serologic results. Rapid anti- gen EIA can be done on urine, serum, cerebrospinal fluid, and bronchoalveolar lavage fluid and is transiently positive. It is most sensitive for early active pulmonary infection and severe, disseminated infection.2 CF and immunodiffusion assays detect antibodies toward Figure 2. Coronal image of computed tomography scan Histoplasma. The CF test measures titers of antibody, is of thorax after treatment with steroids and itraconazole showing an interval decrease in size of subcarinal soft tissue directly proportional to the severity of infection, and is mass to 1.6-cm and hilar lymph nodes and improved patency more sensitive than the immunodiffusion test, although of the right middle lobe bronchus. less specific. The immunodiffusion precipitin test looks for M and H bands; H bands are more suggestive of Final Diagnosis active infection. It is more specific than CF, with only 5% cross reaction, but less sensitive as H bands are only Pulmonary histoplasmosis with mediastinal granuloma found in 23% of patients with acute pulmonary infection causing compressive symptoms. and M bands found in 76%.3 Culture is the definitive Chang and Ang 3 method of diagnosis. In some cases, all urine and serum primarily esophageal involvement,9,10 3 patients with tests may be negative, and it may require histologic primarily bronchial obstruction,5,11,12 and 1 patient with examination of lung tissue to isolate Histoplasma capsu- both esophageal and bronchial obstruction.13 Although latum.5 Identifying the typical intracellular yeast form gastrointestinal histoplasmosis can occur as a conse- by examination with Wright or Giemsa stains strongly quence of disseminated disease, esophageal involve- supports the diagnosis.2 Mediastinal granulomas tend to ment associated with impingement from mediastinal have negative EIA and cultures and can be “sometimes histoplasmosis lymphadenopathy is only reported in 5% positive” for CF and immunodiffusion antibody, which to 13% of cases.9 Here we present what we believe to be was demonstrated by the patient described above, with the second reported case of both esophageal and bron- an inconclusive CF titer but positive H and M bands but chial obstruction by mediastinal granuloma from pul- negative EIA and culture.3 monary histoplasmosis in the past 2 decades. Here we present a case of a rare complication of The recommended treatment for symptomatic medi- acute pulmonary histoplasmosis. Mediastinal granu- astinal lymphadenitis and severe cases of obstruction is loma causing compressive features is an uncommon, itraconazole 200 mg 3 times daily for 3 days and then but well-documented complication of histoplasmosis, 200 mg once or twice daily for 6 to 12 weeks plus pred- more commonly seen in children due to their greater nisone 0.5 to 1.0 mg/kg daily in tapering doses for 1 to 2 airway pliability.1 Mediastinal histoplasmosis can be weeks.1 For symptomatic mediastinal granulomas, treat- divided into 3 syndromes: mediastinal adenitis, medi- ment is itraconazole 200 mg 3 times daily for 3 days and astinal granuloma, and fibrosing mediastinitis.2,6 then 200 mg once or twice daily for 6 to 12 weeks, as Mediastinal adenitis is mostly asymptomatic, but can was
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