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A 20 Year-Old with a Mediastinal Mass

Case Editor - Kamyar Afshar

Reviewed By Allergy, Immunology & Inflammation Assembly

Submitted by

Tyler B. Anderson, MD

Fellow

Division of Pulmonary, Allergy, Critical Care and Sleep Medicine

The Ohio State University Medical Center

Columbus, Ohio

Jonathan P. Parsons, MD, MSc, FCCP

Associate Professor of Internal Medicine

Division of Pulmonary, Allergy, Critical Care and Sleep Medicine

The Ohio State University Medical Center

Columbus, Ohio

Submit your comments to the author(s).

History

A 20 year old Caucasian man with no significant past medical history presented to his primary care physician for chest discomfort and cough. Two months prior to presentation, he reported having an unremarkable viral syndrome which resolved with no medical intervention. His primary care physician prescribed a short course of antibiotics for empiric treatment of pneumonia with some initial improvement in symptoms. His chest discomfort returned and he developed progressive dyspnea on exertion which led to a chest radiograph (CXR) (Figure 1).

figure 1

Figure 1. Posterior-anterior chest x-ray (CXR) demonstrating left-sided mediastinal mass (arrows).

An abnormality was noted in the left mediastinum which prompted his physician to order a computed tomography (CT) of the chest and to refer him to a pulmonary specialist. This CT scan (Figures 2 and 3) revealed a rounded, well-demarcated mass in the superoanterior mediastinal compartment. The largest diameter measured 6.8 x 4.8cm.

figure 2

Figure 2. Computed tomography (CT) image of the chest demonstrating well-demarcated soft tissue mass in superoanterior mediastinal mass (arrow).

figure 3

Figure 3. Computed tomography (CT) image of the chest demonstrating well-demarcated soft tissue mass in superoanterior mediastinal mass (arrow).

Further review of systems revealed subjective fever/chills along with night sweats. He denied wheezing, hemoptysis, weight loss, scrotal mass, palpable lymph nodes or any neurologic deficits.

He was a non-smoker and did not take any medications or use illicit drugs.

Physical Exam

The patient was in no acute distress. Vital signs were unremarkable. Cardiac exam demonstrated regular rate and rhythm with no murmur, gallop or rub. Lungs were clear to auscultation bilaterally without wheezes or rales. Abdomen was soft with no hepato/splenomegaly. There was no palpable cervical, supraclavicular or axillary lymphadenopathy. Genitourinary exam was negative for testicular masses. Neurologic exam showed no focal deficits. Cranial nerves appeared intact.

Lab

White blood cell count 7.2 K/uL, 56% Neutrophils, 28% Lymphocytes, 7% Eosinophils
Chemistry and liver function testing was within normal limits
Human chorionic Gonadotropin (HCG), serum <0.5 MIU/mL (normal in males <5.0 MIU/ml)
Alpha-fetoprotein (AFP), serum 2.2 NG/mL (normal 0.0-8.3 NG/ML)

Question 1

What is the most common cause of an anterior mediastinal neoplasm?


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