SUPERINFECTED MEDIASTINAL ABSCESS IN A PREGNANT PATIENT WITH A HISTORY OF FIBROSING MEDIASTINITIS

Abstract

TOPIC: Disorders of the Mediastinum TYPE: Medical Student/Resident Case Reports INTRODUCTION: Fibrosing Mediastinitis (FM) is a rare but serious condition characterized by idiosyncratic inflammation and aggressive fibrosis of mediastinal structures. Due to the lack of standardized diagnostic criteria, and variable clinical presentation and complications, FM is often misdiagnosed. We present a case of a superinfected mediastinal abscess with Streptococcus intermedius in a pregnant patient with a history of FM. CASE PRESENTATION: A 30-year-old woman (33 weeks pregnant, G1P0) with a history of FM secondary to presumed histoplasmosis diagnosed 4 years prior based on imaging with typical mediastinal lymph nodes and splenic calcifications presented with pleuritic chest pain and progressive right sided head/neck pressure. She had multiple prior presentations and was treated with courses of antibiotics and prednisone for presumed infection. Her symptoms progressed and presented to the ED where she was afebrile, tachycardic, and had diffuse ST elevations and PR depressions on EKG. CT noted a large mediastinal mass with SVC and tracheal compression, pericardial effusion, as well as right upper lobe consolidation concerning for post-obstructive pneumonia. She was started on broad spectrum antibiotics and given concerns for airway compromise she underwent successful delivery by cesarean section. Bronchoscopy with washing, transbronchial needle aspiration and pericardial fluid was negative for malignancy and infection. Given risk for re-accumulation of the pericardial effusion and progression of the mass she underwent a cervical mediastinoscopy with I&D of the abscess which was positive for Streptococcus intermedius. Patient was discharged home with complete resolution of the mediastinal abscess and clinical symptoms. DISCUSSION: We present a case of superinfected mediastinal abscess in a pregnant patient with FM. Because FM has variable complications our case highlights the importance of a high degree of clinical suspicion for progressive symptoms in patient with known history of FM. There are no curative treatments for FM but symptoms and complications can be medically and in rare cases surgically managed. Pregnancy is considered an immunocompromised state and plays a significant role in patient immunomodulation which suppression which may have contributed to the development of the superinfected mediastinal abscess in our patient. CONCLUSIONS: FM is a rare condition with variable presentations and complications which can be progressive and life-threatening if left untreated. Patients with a known history of FM should be frequently monitored for progression of symptoms with a low threshold to further evaluate and treat these complications should they arise. REFERENCE #1: Armstrong PA, Jackson BR, Haselow D, et al. Multistate Epidemiology of Histoplasmosis, United States, 2011–20141. Emerging Infectious Diseases. 2017;24(3):425-431. REFERENCE #2: Schowengerdt CG, Suyemoto R, Main FB. Granulomatous and fibrous mediastinitis. A review and analysis of 180 cases. J Thorac Cardiovasc Surg. 1969;57(3):365-379 DISCLOSURES: No relevant relationships by Alejandro Bribriesco, source=Web Response No relevant relationships by Lin Chen, source=Web Response No relevant relationships by Henrik Hahamyan, source=Web Response No relevant relationships by Mani Latifi, source=Web Response