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A Rare Cause of Widened Mediastinum
The Journal of Emergency Medicine, Vol. 43, No. 2, pp. 346–347, 2012 Copyright Ó 2012 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/$ - see front matter
doi:10.1016/j.jemermed.2010.06.009
Visual Diagnosis in Emergency Medicine
A RARE CAUSE OF WIDENED MEDIASTINUM Malford Tyson Pillow, MD,*† and Bhavika Kaul, BS* *Baylor College of Medicine, Houston, Texas, and †Department of Medicine – Section of Emergency Medicine, Ben Taub General Hospital, Houston, Texas Reprint Address: Malford Tyson Pillow, MD, Department of Emergency Medicine, Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030
A 53-year-old man with history of hypertension, coronary artery disease, and chronic left leg deep vein thrombosis on Coumadin (Bristol-Myers Squibb Company, Princeton, NJ) presented complaining of chest pain. The pain was dull, midsternal, gradual in onset, and rated 5/10. There was no radiation of the pain, and the patient initially said that this pain was similar to his previous cardiac pain. Review of systems was positive for mild exertional chest pain and occasional shortness of breath. Vital signs were stable and the examination was remarkable for a 2/6 systolic ejection murmur. Electrocardiogram showed right bundle branch block without ischemia. Cardiac enzymes were normal. Chest X-ray study (Figure 1) showed widened mediastinum. A computed tomography scan with angiography of the chest (Figure 2) revealed a pulmonary aneurysm with the main pulmonary artery dilatated to 71 mm and enlargement of both pulmonary arteries. An echocardiogram showed a severely dilatated right ventricle, moderate tricuspid regurgitation, and a pulmonary artery pressure of approximately 66 mm Hg, consistent with pulmonary hypertension. The patient’s pulmonary aneurysm was thought to most likely be secondary to chronic undiagnosed pulmonary embolisms causing pulmonary hypertension. His symptoms resolved, so he was medically optimized and discharged. The aneurysm has remained stable since his first visit. Pulmonary artery aneurysms are found in approximately 1 in 14,000 postmortem examinations (1). Congenital heart disease is thought to cause the majority of
cases. Other etiologies include infection, pulmonary hypertension, connective tissue disease, and trauma. Most cases of pulmonary artery aneurysm with pulmonary hypertension occur with other cofactors mentioned above; however, there are a few cases in which pulmonary hypertension is the only recognizable risk factor (2). Symptoms of pulmonary hypertension include edema, angina, chest pain, and dyspnea, made worse upon exertion. Pulmonary artery aneurysm alone produces no symptoms unless there are complications such as compression of vessels or rupture. We were able to find six cases of pulmonary
Figure 1. Chest X-ray study showing a significantly widened mediastinum (arrows).
RECEIVED: 17 February 2010; FINAL SUBMISSION RECEIVED: 8 May 2010; ACCEPTED: 13 June 2010 346
A Rare Cause of Widened Mediastinum
347
tests include an echocardiogram and coronary catheterization. Pulmonary angiography was considered the test of choice, but its role is unclear with improved noninvasive imaging techniques available (4). Debate still surrounds the use of surgical interventions. Operative treatment is recommended for patients at risk of rupture, but factors that contribute to risk of rupture are not well defined (5). REFERENCES
Figure 2. Computed tomography scan with a dilatated main pulmonary artery and bilateral dilatation of the pulmonary artery branches (arrows).
artery dissection associated with primary pulmonary hypertension (3). There are no firm guidelines for the treatment of pulmonary artery aneurysms. Possible diagnostic
1. Deterling RA, Claggett OT. Aneurysm of the pulmonary artery: a review of the literature and report of a case. Am Heart J 1947;34: 471–99. 2. Bartter T, Irwin R, Nash G. Aneurysm of the pulmonary arteries: review. Chest 1998;94:1065–75. 3. Senbaklavaci O, Kaneko Y, Bartunek A, et al. Rupture and dissection in pulmonary artery aneurysms: incidence, cause and treatment— review and case report. J Thorac Cardiovasc Surg 2001;121:1006–8. 4. Nair K, Cobanoglu A. Idiopathic main pulmonary artery aneurysm. Ann Thorac Surg 2001;71:1688–90. 5. Casselman F, Meyns B, Herygers P, Verougstraete L, Van Elst F, Daenen W. Pulmonary artery aneurysm: is surgery always indicated? Acta Cardiol 1997;52:431–6.
doi:10.1016/j.jemermed.2010.06.009
Visual Diagnosis in Emergency Medicine
A RARE CAUSE OF WIDENED MEDIASTINUM Malford Tyson Pillow, MD,*† and Bhavika Kaul, BS* *Baylor College of Medicine, Houston, Texas, and †Department of Medicine – Section of Emergency Medicine, Ben Taub General Hospital, Houston, Texas Reprint Address: Malford Tyson Pillow, MD, Department of Emergency Medicine, Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030
A 53-year-old man with history of hypertension, coronary artery disease, and chronic left leg deep vein thrombosis on Coumadin (Bristol-Myers Squibb Company, Princeton, NJ) presented complaining of chest pain. The pain was dull, midsternal, gradual in onset, and rated 5/10. There was no radiation of the pain, and the patient initially said that this pain was similar to his previous cardiac pain. Review of systems was positive for mild exertional chest pain and occasional shortness of breath. Vital signs were stable and the examination was remarkable for a 2/6 systolic ejection murmur. Electrocardiogram showed right bundle branch block without ischemia. Cardiac enzymes were normal. Chest X-ray study (Figure 1) showed widened mediastinum. A computed tomography scan with angiography of the chest (Figure 2) revealed a pulmonary aneurysm with the main pulmonary artery dilatated to 71 mm and enlargement of both pulmonary arteries. An echocardiogram showed a severely dilatated right ventricle, moderate tricuspid regurgitation, and a pulmonary artery pressure of approximately 66 mm Hg, consistent with pulmonary hypertension. The patient’s pulmonary aneurysm was thought to most likely be secondary to chronic undiagnosed pulmonary embolisms causing pulmonary hypertension. His symptoms resolved, so he was medically optimized and discharged. The aneurysm has remained stable since his first visit. Pulmonary artery aneurysms are found in approximately 1 in 14,000 postmortem examinations (1). Congenital heart disease is thought to cause the majority of
cases. Other etiologies include infection, pulmonary hypertension, connective tissue disease, and trauma. Most cases of pulmonary artery aneurysm with pulmonary hypertension occur with other cofactors mentioned above; however, there are a few cases in which pulmonary hypertension is the only recognizable risk factor (2). Symptoms of pulmonary hypertension include edema, angina, chest pain, and dyspnea, made worse upon exertion. Pulmonary artery aneurysm alone produces no symptoms unless there are complications such as compression of vessels or rupture. We were able to find six cases of pulmonary
Figure 1. Chest X-ray study showing a significantly widened mediastinum (arrows).
RECEIVED: 17 February 2010; FINAL SUBMISSION RECEIVED: 8 May 2010; ACCEPTED: 13 June 2010 346
A Rare Cause of Widened Mediastinum
347
tests include an echocardiogram and coronary catheterization. Pulmonary angiography was considered the test of choice, but its role is unclear with improved noninvasive imaging techniques available (4). Debate still surrounds the use of surgical interventions. Operative treatment is recommended for patients at risk of rupture, but factors that contribute to risk of rupture are not well defined (5). REFERENCES
Figure 2. Computed tomography scan with a dilatated main pulmonary artery and bilateral dilatation of the pulmonary artery branches (arrows).
artery dissection associated with primary pulmonary hypertension (3). There are no firm guidelines for the treatment of pulmonary artery aneurysms. Possible diagnostic
1. Deterling RA, Claggett OT. Aneurysm of the pulmonary artery: a review of the literature and report of a case. Am Heart J 1947;34: 471–99. 2. Bartter T, Irwin R, Nash G. Aneurysm of the pulmonary arteries: review. Chest 1998;94:1065–75. 3. Senbaklavaci O, Kaneko Y, Bartunek A, et al. Rupture and dissection in pulmonary artery aneurysms: incidence, cause and treatment— review and case report. J Thorac Cardiovasc Surg 2001;121:1006–8. 4. Nair K, Cobanoglu A. Idiopathic main pulmonary artery aneurysm. Ann Thorac Surg 2001;71:1688–90. 5. Casselman F, Meyns B, Herygers P, Verougstraete L, Van Elst F, Daenen W. Pulmonary artery aneurysm: is surgery always indicated? Acta Cardiol 1997;52:431–6.