MEDIASTINAL MASS-INDUCED T WAVE INVERSION: FROM A ROUTINE EKG TO A MEDIASTINAL MASS

Abstract

TOPIC: Cardiovascular Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: T-wave inversion (TWI) is a negative T-wave of ≥1 mm in depth in two or more contiguous leads, with exclusion of leads aVR, III, and V1[1]. TWI has a wide differential diagnosis that can range from benign causes including normal variants to life-threatening causes including coronary artery disease and rarely can be related to non-cardiac causes [1]. CASE PRESENTATION: Our patient is an 18-years-old female with a past medical history of asthma and major depressive disorder. She presented to the psych emergency department (ED) because of suicidal attempts. Patient complaints of worsening feelings of sadness, loss of interest, and decreased energy. Also, she reported having suicidal ideations. Review of systems was unremarkable She was vitally stable. On physical examinations, lungs were clear to auscultation, cardiovascular exam of normal heart sounds, no murmurs or gallops. Labs were within normal limits, including electrolytes, TSH, D-Dimer, and cardiac enzymes. The routine evaluation protocol in the psych ED includes Electrocardiogram (EKG) mainly to look for QTC intervals, as many of the medications that are used for the psych population may alter the QTC interval. Her EKG showed sinus rhythm with T wave inversion in leads II, III, aVF, and V3-V6 with QTc of 483; there were no previous EKGs for comparison. The EKG was repeated on different days and showed the same findings. The patient reported no family history of cardiovascular diseases. Cardiology was consulted, an echocardiogram showed a large extracardiac mediastinal mass which appears to press on the right ventricle; otherwise, ejection fraction was normal, and no significant valvular disease was observed. A computerized tomography scan of the chest revealed a large, 12 x 7 x 6 cm mediastinal mass along the inferior wall of the heart, exerting mass effect and displacing the heart superiorly. The patient was discharged and referred to a cardiothoracic surgeon for further evaluation. DISCUSSION: Different clinical conditions can cause T-wave inversions, ranging from life-threatening events, such as acute coronary ischemia and pulmonary embolism, to entirely benign conditions[1]. The mediastinum is a potential space in the thoracic cavity that is subdivided into anterior, middle, posterior, and superior mediastinum to form a differential diagnosis for the lesion [2]. In our case, our patient was presented with Inferolateral TWI that was investigated and was found to have a lesion in the middle mediastinum that could be a pericardial cyst, bronchogenic cyst, esophageal implications cyst or lymph node enlargement that can be secondary to tuberculosis or sarcoidosis or histoplasmosis. CONCLUSIONS: This case highlights that inferolateral TWI should always be investigated thoroughly, including by imaging studies when the cause is not clear to prevent life threatening conditions. REFERENCE #1: Hayden GE, Brady WJ, Perron AD, Somers MP, Mattu A. Electrocardiographic T-wave inversion: differential diagnosis in the chest pain patient. Am J Emerg Med. 2002 May;20(3):252-62. doi: 10.1053/ajem.2002.32629. PMID: 11992349. REFERENCE #2: Mediastinum. In: Gurney JW, Winer-Muram HT, Stern EJ, et al, editors. Diagnostic imaging: chest. Section I. Salt Lake City (Utah): Amirsys; 2006 DISCLOSURES: No relevant relationships by Hasan Abuamsha, source=Web Response No relevant relationships by Abdul Rahman Al Armashi, source=Web Response No relevant relationships by Isaac Alsallamin, source=Web Response No relevant relationships by Ameed Bawwab, source=Web Response No relevant relationships by Eleonora Demyda, source=Web Response No relevant relationships by Faris Hammad, source=Web Response