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Chest clinic
Case based discussions
Mediastinal mass in a healthy adolescent at The Children's Hospital at Westmead, Australia
  1. Ameneh Khatami1,
  2. Alex C Outhred1,
  3. Philip N Britton1,2,
  4. Emilie Huguon3,
  5. David J E Lord4,
  6. Melanie Wong5,
  7. Amanda Charlton6,
  8. Alison M Kesson1,2,
  9. David Isaacs1
  1. 1Department of Infectious Diseases and Microbiology, The Children's Hospital at Westmead, Sydney, Australia
  2. 2Discipline of Paediatrics and Child Health and Marie Bashir Institute for Infectious Diseases and Biosecurity, University of Sydney, Sydney, Australia
  3. 3Service de Pédiatrie, Hopital de Magenta, Nouméa, New Caledonia
  4. 4Department of Radiology, The Children's Hospital at Westmead, Sydney, Australia
  5. 5Department of Immunology, The Children's Hospital at Westmead, Sydney, Australia
  6. 6Department of Anatomical Pathology, The Children's Hospital at Westmead, Sydney, Australia
  1. Correspondence to Dr Ameneh Khatami, Department of Infectious Diseases and Microbiology, The Children's Hospital at Westmead, Locked Bag 4001, Westmead 2145, Australia; ameneh.khatami{at}health.nsw.gov.au, ameneh.khatami{at}gmail.com

https://doi.org/10.1136/thoraxjnl-2014-205764

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    Ameneh Khatami and Emilie Huguon

    A previously well adolescent from the tropical South Pacific island of Futuna was transferred due to a 3-month to 4-month history of intermittent fevers, anorexia, weight loss, lethargy and haemoptysis. A Mantoux test was negative. CT scan demonstrated a large mediastinal mass and lymphadenopathy with broncho-vascular compression, and bilateral pleural and pericardial effusions, (figure 1A). At admission, he was persistently febrile with non-tender cervical lymphadenopathy and hepatomegaly, and had moderate respiratory distress. The presumptive diagnosis was lymphoma.

    Figure 1

    Radiology investigations of patient with disseminated conidiobolomycosis. (A) CT scan on admission performed in prone due to respiratory distress demonstrating amorphous soft tissue mass filling the mediastinum and aortopulmonary window with compression of the right main bronchus (dotted arrow) and obstruction of the superior vena cava leading to accessory venous pathways filled with high-density contrast (solid arrow), bilateral pleural thickening and fluid (greater on the right) and irregular opacities in the right lung probably representing atelectasis. (B) CT scan after 3 weeks of antifungal treatment demonstrating several small, hypodense lesions throughout the liver (black arrows), multiple large wedge-shaped hypodense areas representing areas of infarction in the spleen and both kidneys and bilateral pleural effusions (greater on the left). (C) Positron emission tomography (PET) scan after 5 weeks highdose intravenous liposomal amphotericin demonstrating multiple foci of increased metabolic activity in the mediastinum, abdomen and soft tissues including in the right hand, bone involvement in the left 7th rib, a large left pleural effusion and non-uniform uptake in the cardiac muscle. (D) Follow-up PET scan after further 6 weeks intravenous liposomal amphotericin with addition of voriconazole and oral terbinafine, and 3 weeks of intravenous and oral prednisolone demonstrating significant clearance of infective foci.

    Initial blood tests demonstrated haemoglobin 92 g/L; white cell count 16×109/L (neutrophils 11×109/L, lymphocytes 1.3×109/L, eosinophils 1.2×109/L); erythrocyte …

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    Footnotes

    • Contributors All contributing authors were involved in the care of the patient. AK planned and prepared the first draft of the manuscript. All authors contributed to the development of the final version of the manuscript. AK is responsible for the overall content of the manuscript as guarantor.

    • Competing interests None.

    • Patient consent Obtained.

    • Ethics approval Sydney Children's Hospitals Network Human Research Ethics Committee.

    • Provenance and peer review Not commissioned; externally peer reviewed.

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