INTRAPULMONARY TERATOMA: A CAUSE OF SHORTNESS OF BREATH IN A YOUNG WOMAN

Abstract

SESSION TITLE: Tuesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/22/2019 01:00 PM - 02:00 PM INTRODUCTION: Intrapulmonary Teratoma (IPT) is a rare benign cystic lesion with fewer than 100 cases reported in medical literature(1). We report a case of an 18-year-old female with symptoms of shortness of breath, recurrent pulmonary effusions which, following thoracotomy, was attributed to a mature cystic teratoma containing respiratory and pancreatic tissue. CASE PRESENTATION: An 18-year-old female presented to the emergency room short of breath with right-sided chest pain. Notably, she had a month-long history of intermittent shortness of breath treated with antibiotics for presumed pneumonia only with marginal improvement in her symptoms. Initial vital signs and physical exam were unremarkable. Chest X-Ray showed a large right-sided pleural effusion, chest CT reported a large right-sided loculated pleural effusion with compressive atelectasis for which thoracentesis was done and a chest tube placed. She was given Ceftriaxone, Doxycycline along with tissue plasminogen activator (tPA) and dornase alpha (DNase), essentially managed as empyema. After clinical and radiographic improvement, she was discharged home on a 4-week course of Levofloxacin. 3 weeks from discharge, shortness of breath persisted with imaging notable for worsening right-sided pleural effusion(Figure 1). Subsequently, right thoracoscopy which was converted to right thoracotomy revealed a large complex multi-loculated cystic structure containing greenish material. Histology diagnosis was a mature cystic teratoma composed of respiratory and pancreatic tissue. Two-month follow up after removal of the teratoma in toto resulted in the patient having a complete clinical recovery. DISCUSSION: Since they were first described by Mohr, as few as 65 IPTs have been reported in literature between 1839 and 1996 (2).Patients age between 10 months and 68 years(3) with equal sex predilection and presenting complaints are often non-specific - chest pain (52%), hemoptysis (42%), cough (39%) and trichoptysis (13%), which is rare but pathognomonic. IPTs can appear as lobulated masses, cavitary lesions or as areas of consolidation on imaging. CT helps in estimating different elements that compose the teratoma (soft tissue/fluid/fat/calcification), differentiating ruptured from unruptured teratoma and, delineating degree of mediastinal invasion and/or proximity to vascular structures. Histopathologically, IPTs can demonstrate endo-, meso- or ectodermal elements like in our patient whose histology was impressive for respiratory epithelium and pancreatic tissue. There are reports of rupture of cysts containing pancreatic tissue owing to the production of proteolytic or digestive enzymes (2). For this reason and the possibility of being malignant, surgical excision is advised. CONCLUSIONS: IPTs are a rare entity and may present with non-specific symptoms. Radiographic imaging often assists in diagnosis and surgery is the mainstay of treatment. Reference #1: Ditah C, Templin T, Mandal R, Pinchot JW, Macke RA. Isolated intrapulmonary teratoma. J Thorac Cardiovasc Surg. 2016 Dec;152(6):e129–31. Reference #2: Asano S, Hoshikawa Y, Yamane Y, Ikeda M, Wakasa H. An intrapulmonary teratoma associated with bronchiectasia containing various kinds of primordium: a case report and review of the literature. Virchows Arch. 2000 Apr 10;436(4):384–8. Reference #3: Carter D, Eggleston JC. Teratoma. In: Hartmann WH, ed. Tumor of the Lower Respiratory Tract. Washington: Armed Forces Institute of Pathology, 1980: 325-6 DISCLOSURES: No relevant relationships by Rohit Aloor, source=Web Response no disclosure on file for Daniel Harley; No relevant relationships by ARJUN KANWAL, source=Web Response No relevant relationships by Vaishnavi Raman, source=Web Response No relevant relationships by Himanshu Rawal, source=Web Response