P3.CR-33 Trichoptysis, Hemoptysis and Chest Pain: A Very Rare Presentation of Anterior Mediastinal Teratoma in a Young Patient

Abstract

1/Case History: A 28-year old patient who presented to the Emergency Department for a 2-week history hemoptysis, right chest pain and intermittent sebaceous expectorations. He had such intermittent chest pain for the last 2 months. He had no fever, breathlessness, loss of weight, joint pain or renal symptoms. He had no significant personal or family history of tuberculosis. On examination, he was afebrile.Full clinical examination revealed decreased breath sound in the left lung with a dull-percussion note. 2/Investigations: Laboratory investigations were normal.The coagulation tests were normal. The Tuberculin skin test was negative. The Chest CT-scan revealed a large well-circumscribed anterior mediastinal mass with heterogeneous mixed density (fat, soft tissue and calcifications), in the left hemi-thorax. It also showed intra-tumoral bleeding associated with a left massive hemomediastinum. This radiological aspect suggested a teratoma. Preoperative labs showed normal carcinoembryonic antigen (CEA), alpha-fetoprotein (AFP), CA-125 and beta-HCG level were normal. 3/Treatment: The multidisciplinary team decision was to perform surgery. A standard posterolateral thoracotomy was performed in the 5th intercostal space. Immediately upon entering the thoracic cavity, a bulky mediastinal mass was found to have a strong adhesion to the upper left lobe. The mass itself was originating from the thymus and extending down to the left lung. A complete thymectomy with a total removal of the tumor was therefore performed. The total amount of bleeding was about 900ml.This was completely evacuated from the thoracic cavity. The patient is currently doing well one year from his initial diagnosis. Although he had a benign teratoma, he was referred to a medical geneticist for further evaluation and management. 4/Discussion and conclusion: Teratomas are germ cell tumors arising from pluripotent cells. Most of them are asymptomatic. Hemoptysis is rare. It may result either from communication with tracheobronchial tree or they may result from bronchial bleeding due to the irritation caused by the tumor. In this case, the presence of hypervascularisation depending on the left internal mammary artery in the chest CT-scan suggests that the teratoma developed systemic blood supply which make our case original. Another pathognomonic symptom is Trichoptysis which is extremely rare . All these symptoms may mimic a pulmonary tuberculosis in young patients especially in our tuberculosis-endemic country. In our case, the tuberculin tests were negative. To conclude, it is a rare case of Teratoma of the anterior mediastinum. It should be considered in the differential diagnosis of Hemoptysis..