An Unusual Case of Dysphagia and Mediastinal Lesion in a Young Female

Abstract

Granulomatous mediastinitis is characterized by massive enlargement of multiple nodes with central area of necrosis. It results as a complication of pulmonary histoplasmosis with symptoms related to encroachment of mediastinal structures. A 31-year-old woman with no past medical history, presented with complaints of dysphagia progressing to odynophagia and pleuritic chest pain for the past one month. Physical exam was normal. She was started on prednisone and proton pump inhibitor with no relief. Esophagogastroduodenoscopy revealed a 2-cm linear ulceration, and a 1cm fistula to the mediastinum with a bulge suggestive of an external mass compressing the middle third of the esophagus. Subsequently, an endoscopic ultrasound (EUS) was performed showing a large hypoechoic mediastinal lesion measuring 39.6 x 24.2 mm, containing multiple hyperechoic non-shadowing foci with cytological features consistent with scattered granulomas with acute and chronic inflammation. Cross- sectional imaging showed partially calcified subcarinal mass representing a granulomatous complex of lymph nodes. Due to the overall clinical picture, tuberculosis and histoplasmosis were included in the differential diagnosis with low suspicion for malignancy at this point. Histoplasma antibody and complement fixation results came back positive with confirmation of the diagnosis. Itraconazole was started with resolution of clinical signs and symptoms in six weeks. Histoplasmosis is an endemic mycosis in the midwestern US. Mediastinal disease, also known as granulomatous mediastinitis, is a result of enlargement of multiple lymph nodes undergoing caseating necrosis mimicking malignancy. These nodes can result in fistula formation into adjacent structures. Dysphagia as a presenting symptom of histoplasmosis is very uncommon. Malignancy should be ruled out with a broad differential kept in mind to unveil unusual presentations of diseases. With EUS-guided fine needle aspiration, safe accessibility to the mediastinum is possible which can differentiate benign from malignant conditions.Figure: EUS showing a large hypoechoic mediastinal lesion measuring 39.6 x 24.2 mm, containing multiple hyperechoic non-shadowing foci with cytological features consistent with scattered granulomas with acute and chronic inflammation.Figure: Upper endoscopy showing linear ulceration and fistula to mediastinum with a bulge suggestive of external mass compressing the middle third of esophagus.