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Background: Trauma clinicians utilise the presence of a widened mediastinum on a chest radiograph (CXR) as the commonest indication for chest computed tomography (CT) in cases of suspected blunt traumatic aortic injury (BTAI). Evaluating the practical implementation and accuracy of this tool could improve the degree of interdepartmental agreement on its correct application. Objectives: To establish the proportion of requests by requesting clinicians citing a widened mediastinum on radiography that met the established criteria for true widening. A secondary objective was to determine the percentage of confirmed blunt traumatic aortic injury and other serious injuries in our study population at Groote Schuur Hospital. Methods: A retrospective descriptive study was conducted measuring the mediastinal widths on chest radiographs of all patients suspected of BTAI that had chest CT at Groote Schuur Hospital over a three-year period from 01 January 2017 to 31 December 2019 to establish the accuracy of this sign as a predictor of aortic injury. Results: In total, 223 patients had chest CT performed to exclude BTAI. 85.7 % of clinicians' requests for chest CT met the current criteria for a widened mediastinum on supine CXR or LODOX. Aortic injury was confirmed in 4 patients (2%). Other serious injuries included thoracic vertebral fractures of at least one vertebral body which was present in 19 patients (8.5%), and 1 patient (0.45%) had a diaphragmatic rupture. None of the patients had a cardiac injury. 200 out of 223 patients (89.7%) had neither an aortic injury nor any of the serious injuries described above. Conclusion: The study demonstrated a high level of accuracy by clinicians in diagnosing widening of the mediastinum on LODOX and CXR. These findings can be used to further improve interdepartmental agreement in the evaluation and management of patients with suspected BTAI.

RESUMEN Los tumores neuroendocrinos primarios (NET) del mediastino son muy raros. Presentamos el caso de un tumor carcinoide atipico primario de timo. Un hombre de 52 anos que fue a un examen medico porque se quejaba de tos no productiva sin hemoptisis. Se solicito una radiografia de torax donde se evidencio un mediastino notablemente ensanchado, con una tomografia de torax que mostro una masa tumoral de 90 x 50 mm en el mediastino anterosuperior que comprime el arco aortico y la arteria pulmonar sin un plano de clivaje adecuado. Debido a que el tumor era infiltrativo, se proporciono escision quirurgica completa, quimioterapia y radioterapia al mediastino. El objetivo principal de nuestro estudio fue evaluar los hallazgos de CT y MRI con relacion a la literatura mundial. ABSTRACT Primary neuroendocrine tumors (NET) of the mediastinum are very rare. We present the case of a primary atypical carcinoid tumor of the thymus. A 52-year-old man who went to a medical examination because he complained of a non-productive cough without hemoptysis. A chest radiograph was requested where a markedly widened mediastinum was evidenced, with a thoracic tomography showing a tumor mass of 90 x 50 mm in the anterosuperior mediastinum that compresses the aortic arch and pulmonary artery without an adequate cleavage plane. Because the tumor was infiltrative, complete surgical excision, chemotherapy and radiotherapy were provided to the mediastinum. The main objective of our study was to evaluate the findings of CT and MRI in relation to universal literature.

Background Aortic transection, or aortic rupture, is a rare diagnosis in trauma patients and carries a high mortality. Case Report We present the case of a 61-year-old man presenting to a Level I trauma center after being struck by a motor vehicle, found to have an aortic transection. He was initially hypotensive and resuscitated with blood products due to concern for hemorrhagic shock. Aortic injury was suspected after chest x-ray study demonstrated a widened mediastinum. Traumatic thoracic aortic transection with pseudoaneurysm was diagnosed on computed tomography of the aorta, and the patient was taken to the operating room for thoracic endovascular repair of the aorta. Why Should an Emergency Physician Be Aware of This? Diagnosis of aortic injury can be challenging, especially in trauma patients presenting with hypotension. Aortic injury must be suspected in patients presenting after a high-velocity mechanism injury. It is an uncommon cause of hemorrhagic shock in trauma patients and must be considered even if other traumatic injuries are identified, as it commonly occurs with other significant injuries. Although chest x-ray study can be useful, a negative chest x-ray study does not rule out aortic injury. Aortic injury is a time-sensitive diagnosis, and early identification is key to these patients surviving to receive definitive management in the operating room.

A 56-year-old man presented to our hospital as he presented progressive hemiplegia of the right upper limb with no other symptoms, including chest pain. Inter-arm blood pressure difference was not observed. Laboratory investigations revealed an elevated D-dimer value (2.4 μg/ml). Chest X-ray study showed normal findings without widened mediastinum. Brain MRI showed acute multiple brain infarcts in the left posterior limb of the internal capsule and right pons on diffusion-weighted imaging. Bilateral internal carotid arteries were non-occlusive in MRA. Carotid duplex ultrasonography revealed normal internal carotid artery flow velocities bilaterally. Because ischemic lesions were found in multiple vascular territories, and D-dimer value was elevated, the patient underwent thoracic contrast-enhanced-CT to exclude malignant tumors. Stanford type A aortic dissection limited to the ascending aorta was detected. As the plaque had accumulated in the false lumen, we suspected that plaque in the false lumen could be an embolic source. After ascending aortic replacement surgery, brain infarction did not recur during hospitalization. In cases of ischemic stroke wherein multiple vascular territories are detected, and D-dimer value is elevated, even in patients without chest pain, the possibility of painless Stanford type A aortic dissection should be ruled out as an embolic source.

Author(s): Yu, Louis; Baumann, Brigitte M; Raja, Ali S; Mower, William R; Langdorf, Mark I; Medak, Anthony J; Anglin, Deirdre R; Hendey, Gregory W; Nishijima, Daniel; Rodriguez, Robert M | Abstract: BACKGROUND:In the era of frequent head-to-pelvis computed tomography (CT) for adult blunt trauma evaluation, we sought to update teachings regarding aortic injury by determining 1) the incidence of aortic injury; 2) the proportion of patients with isolated aortic injury (without other concomitant thoracic injury); 3) the clinical implications of aortic injury (hospital mortality, length of stay [LOS], and rate of surgical interventions); and 4) the screening value of traditional risk factors/markers (such as high-energy mechanism and widened mediastinum on chest x-ray [CXR]) for aortic injury, compared to newer criteria from the recently developed NEXUS Chest CT decision instrument (DI). METHODS:We conducted a preplanned analysis of patients prospectively enrolled in the NEXUS Chest studies at 10 Level I trauma centers with the following inclusion criteria: age g 14nyears, blunt trauma within 6nhours of ED presentation, and receiving chest imaging duringnED trauma evaluation. RESULTS:Of 24,010 enrolled subjects, 42 (0.17%, 95% confidence interval [CI]n= 0.13% to 0.24%) had aortic injury. Most patients (79%, 95% CIn= 64% to 88%) had an associated thoracic injury, with rib fractures, pneumothorax/hemothorax, and pulmonary contusion occurring most frequently. Compared to patients without aortic injury this cohort had similar mortality (9.5%, 95% CIn= 3.8% to 22.1% vs. 5.8%, 95% CIn= 5.4% to 6.3%), longer median hospital LOS (11ndays vs. 3ndays, pnln0.01), and higher median Injury Severity Score (29 vs. 5, pnln0.001). High-energy mechanism and widened mediastinum on CXR had low sensitivity for aortic injury (76% [95% CIn= 62% to 87%] and 33% [95% CIn= 21% to 49%], respectively), compared to the NEXUS Chest CT DI (sensitivity 100% [95% CIn= 92% to 100%]). CONCLUSIONS:Aortic injury is rare in adult ED blunt trauma patients who survive to receive imaging. Most ED aortic injury patients have associated thoracic injuries and survive to hospital discharge.nWidened mediastinum on CXR and high-energy mechanism have relatively low screening sensitivity for aortic injury, but the NEXUS Chest DI detected all cases.

Patient: Female, 30-year-old Final Diagnosis: Idiopathic fibrosing mediastinitis Symptoms: Chest discomfort • numbness • palpitation • ptosis Medication: — Clinical Procedure: Balloon angioplasty • biopsy • endobronchial ultrasound-guided (EBUS) transbronchial needle aspiration • magnetic resonance image • PET-CT Specialty: Pulmonology Objective: Rare disease Background: Fibrosing mediastinitis is a rarely seen, progressive disease. It results from an excessive fibrotic reaction in the mediastinum. We describe a presentation of fibrosing mediastinitis that, to our knowledge, has never been seen before. Case Report: A 30-year-old female Colombian flight attendant presented with a right eyelid droop. Examination revealed partial right-sided ptosis and miosis but no anhidrosis. An ill-defined firm swelling was palpable at the root of the neck. Chest radiography revealed a widened mediastinum, and computerized tomography (CT) showed a right paratracheal mass without calcification extending to the thoracic inlet, encasing multiple blood vessels. All basic blood tests, magnetic resonance imaging of the head, and ultrasound Doppler of the neck vessels were normal. History and work up for infections including fungal diseases, granulomatous diseases, vasculitis, and autoimmune diseases were negative. Positron emission tomography (PET) showed significant FDG uptake in the mediastinum. Mediastinal biopsy was histologically consistent with fibrosing mediastinitis. All relevant immunohistochemistry and microbiological studies were negative. Subsequently, the patient developed signs of superior vena cava compression; this was managed by balloon angioplasty, which resulted in improvement of symptoms. However, over time, her symptoms worsened progressively, resulting in a left-sided ptosis and radiological progression of the mass on CT. She received treatment with rituximab and concomitant steroids, which yielded excellent results: the treatment led to both resolution of her symptoms and regression of the mass and its metabolic activity on PET scan. Conclusions: Fibrosing mediastinitis can present with an incomplete Horner’s syndrome. Treatment with rituximab and steroids shows promising results in select cases of metabolically active idiopathic fibrosing mediastinitis.

Simultaneous bilateral central retinal vein occlusion (CRVO) is a rare presentation that warrants consideration of an underlying hyperviscosity state. Increased serum viscosity can lead to the hematologic emergency of leukostasis with resultant vascular obstruction and hypoxic tissue damage. The following case demonstrates the first case of bilateral CRVO in a young adult secondary to acute lymphoblastic leukemia (ALL). A 23-year-old female presented to the emergency department (ED) with two days of worsening bilateral blurry vision and bitemporal headache. Her ocular exam was significant for bilateral intraretinal hemorrhages consistent with CRVO with chest radiograph demonstrating widened mediastinum with perihilar lymphadenopathy and serologic testing revealing ALL with blast crisis. The patient was subsequently admitted to the oncology service for induction chemotherapy. Patients with new headache and bilateral vision changes should prompt a thorough neurological and ophthalmologic exam to assess for underlying systemic pathologies. Concurrent bilateral CRVO is a rare but specific finding for systemic hyperviscosity syndrome, blood dyscrasia, polycythemia, or other serious illness. Early recognition and treatment of the underlying condition can prevent further vision loss and overall morbidity and mortality.

Acute widened mediastinum is an alarming finding. It has many possible differential diagnoses; aortic dissection (AD) is considered one that carries catastrophic outcomes. AD is relatively uncommon; it requires early and accurate diagnosis and treatment for better patient survival. However, acute mediastinal widening also can be present in more benign conditions. We report a case of a 50-year-old African American female with postoperative shortness of breath; initial imaging studies revealed an acute widened mediastinum, but on further management with diuresis and follow-up imaging, she was diagnosed with azygous vein continuation of the Inferior vena cava (IVC). This is considered as a rare benign cause of wide mediastinum. Clinicians must be aware of the presence of such a benign cause when dealing with acute wide mediastinum.

Introduction: Various anomalies in the development of the great thoracic veins of the embryo can be incidentally discovered in the normal adult. Duplication of superior vena cava (SVC) is a...

Introduction: Solid pseudopapillary tumour (SPN) is a rare neoplasm of the pancreas with an incidence rate between 0.1-2.7% of all exocrine pancreatic tumours). It is more common in women (10:1), aged between 10-30 years. It is often asymptomatic and is usually diagnosed incidentally by imaging. Method: A clinical case is presented as well as its clinical and therapeutic management. Results: We report the case of a 54 year old woman who was incidentally diagnosed when she suffered COVID pneumonia. Chest-x-ray showed widened mediastinum and a CT-scan revealed a mediastinum lipoma and a hypodense mass in the distal pancreas. The MRI revealed a cystic mass hypointense in T1 and hyperintense in T2 and endoscopic ultrasound with fine-needle aspiration characterized the mass as a solid pseudopapillary tumour. She underwent elective laparoscopic surgery performing a distal pancreatectomy and splenectomy procedure. Postoperative course was uneventful. Histopathologically study confirmed the preoperative diagnosed showing a 1.8cm tumour with perineural invasion. Immunochemistry profile of the tumour reveals positivity CD-10, vimentine and progesterone receptor (PR). Conclusion: SPNs are more commonly found in the body and tail of the pancreas and may content both solid and cystic components and occasional calcifications. Relative malignant potencial is moderate to high. Due to this malignant risk, they may be resected. Even if malignancy is already present, malignant SPNs can often be cured when resection is completed. SPN’s origin is unknown but may be relationated with hormone levels. Recent research related low expression of PR and a poorer prognosis. [Formula presented]

Solitary extramedullary plasmacytomas represent 3% of plasma cell neoplasms. Their most common locations are the upper gastrointestinal and respiratory tract. We report a 70-year-old male presenting with progressive dyspnea and cough. A chest radiography showed widened mediastinum. Chest computed tomography showed a mediastinal mass. A bronchoscopy showed an extrinsic compression and complete occlusion of the primary bronchus. A self-expandable prosthesis was installed in left bronchus. A population of plasmacytoid cells was evidenced in the mass biopsy. Immunohistochemistry revealed CD20+ and CD138+. These tumor cells stained positively for lambda light chains, but negatively for kappa chains. Therefore an extramedullary plasmacytoma was diagnosed. A multiple myeloma was discarded with a normal blood count, serum calcium and creatinine levels. Serum protein electrophoresis had a monoclonal spike, serum IgG was 1963 mg/dl. Bone marrow aspiration had 1% of plasma cells. Bone x-rays were normal. Computed tomographies of the neck, thorax, abdomen and pelvis ruled out other plasmacytomas. Eight cycles of chemotherapy with thalidomide, melphalan and prednisone were indicated, obtaining complete remission of the tumor. The review of the literature shows that mediastinal extramedullary plasmacytomas are extremely rare. They generally appear in men aged between 50 and 60 years. The treatment of choice is radiotherapy, but given the location in the present case, chemotherapy was considered the best option. Recurrence is approximately 10 to 30% and 10% of patients progress to myeloma, thus requiring close monitoring.

Introduction Acute aortic dissection (AAD) is a rare and potentially fatal condition that has been known to be missed in diagnoses. Our primary objective was to determine if the availability of 24-hour emergency department (ED) specialist coverage and an on-site computed tomography (CT) scanner reduced the rate of missed diagnoses of AAD. Methods We selected records of patients diagnosed with dissection of the aorta from a hospital's discharge database and death register in the period of January 1998 to December 2014. AAD was defined as missed if imaging to diagnose AAD or a cardiology/cardiothoracic surgical consultation was not obtained in the ED. We compared the rates of missed diagnosis before and after the availability of 24-hour ED specialist coverage and an on-site CT scanner in the ED. Results Among 145 patients, 42 (29.0%) had a missed diagnosis. The proportion of missed AAD was lower in the post-implementation period compared to the pre-implementation period (20.0% vs. 37.3%, odds ratio [OR] 0.42, 95% confidence interval [CI] 0.20‒0.89; p = 0.023). After adjusting for confounders, the difference remained significant (OR 0.31, 95% CI 0.14‒0.70; p = 0.005). In the post-implementation period, concurrent signs of congestive cardiac failure (OR 33.51, 95% CI 1.42‒789.20; p = 0.024) and absence of a widened mediastinum on chest radiography (OR 11.52, 95% CI 1.37‒96.80; p = 0.029) were independent predictors of missed diagnoses. Conclusion The availability of 24-hour ED specialist coverage and an on-site CT scanner improved the diagnosis of AAD in our study.

BACKGROUND It is commonly taught that a widened mediastinum (WM) on chest X-ray (CXR) is a marker for aortic injury (AI). We sought to describe the epidemiology of injuries for all patients with WM and compare their CXR to those of patients with confirmed AI. METHODS Adults (age ≥ 18) sustaining blunt traumatic injuries from January 2017 to June 2017 with both CXR (supine, anterior-posterior) and chest CT were included. We excluded those whose CT preceded CXR and those with missing data. Basic demographics, injury characteristics, mediastinal width (MW), mediastinal-to-thoracic width ratio (MTR), and all thoracic imaging findings were analyzed. MW > 8 cm was considered WM. We also queried our registry for all AI patients over a 4-year period. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of WM on CXR for AI were calculated. Multivariate logistic regression was performed to identify factors associated with positive traumatic findings, controlling for body mass index (BMI), sex, high-energy mechanism, MTR, and mediastinal width. RESULTS Of 749 included subjects, 502 (67%) had an MW > 8 cm: mean age was 48 ± 20 y, 381 (76%) were men, and BMI was 28 ± 5 kg/m2. Mechanism of injury was motor vehicle crash in 335 (67%); fall in 113 (23%); assault in 31 (6%); other (jet-ski accidents, etc.) in 17 (3%), and unknown in 6 (1%). Only 128 (26%) of patients with WM had positive findings on CT, with the most common [80 (16%)] being nontraumatic findings (pericardial infusion, lymph nodes, etc.), followed by hemomediastinum/pneumomediastinum [32 (6%)], sternal fractures [18 (4%)], multiple findings [15 (3%)], and vertebral fractures [6 (1%)]. Only 2 (1%) had AI. The sensitivity was 100%, specificity was 33%, PPV was 0.4%, NPV was 100%, and accuracy was 33%. From 2013 to 2017, 38 patients had AI: mean age was 46 ± 19 y, 26 (68%) were men, and BMI was 28 ± 4 kg/m2. Motor vehicle crash was the most common mechanism (89%), followed by "other" trauma mechanism (5%), fall (3%), and assault (3%). On univariate analysis, compared with all patients with WM, patients with AI had significantly greater MW (9.5 [8.8-10.4] versus 10.2 [9.1-11.1]; P = 0.042) and MTR (0.31 [0.28-0.34] versus 0.32 [0.31-0.37]; P = 0.001), although the actual differences were not clinically significant. The regression analysis did not identify any factors associated with traumatic CXR findings. CONCLUSIONS Most bluntly injured adults have a WM, and the majority have either no findings or nontraumatic findings. The PPV of a WM for AI is

High-speed deceleration injuries such as motor vehicle crashes and falls from great heights can lead to blunt aortic injury, which is commonly just distal to the takeoff of the left subclavian artery. Initial management includes advanced trauma life support protocols to assess airway, breathing, and circulation. Initial imaging is done with a chest x-ray, and findings concerning for a thoracic aortic injury include a widened mediastinum, apical cap, and left hemothorax, among other findings. A computed tomography (CT) scan of the chest with contrast should then be obtained to definitively diagnose an aortic injury. Blood pressure and heart rate should be maintained below 100 mmHg and 100 beats per minute, respectively, with medications. Urgent vascular or thoracic surgery consult should be obtained for definitive management. Either an endovascular or open approach can be done depending on patient stability and anatomy. Blunt aortic injury can effectively be ruled out if the CT scan is negative, and further trauma work-up should be guided by history and physical exam.

Mycotic aneurysms can pose a diagnostic dilemma due to their variable presentations. We present a case of a 93-year-old man initially presenting with fevers, intermittent chest pain and normocytic anaemia refractory to repeated blood transfusions. He received intravenous ceftriaxone as Escherichia coli grew in his blood cultures. His chest X-ray showed a widened mediastinum. A subsequent CT of the chest discovered a mycotic aneurysm at the descending thoracic aorta. He had a good outcome and was thriving after 1 year post endovascular repair.

Background The early and accurate identification of patients with blunt thoracic aortic injury (BTAI) remains a challenge. Traditionally, a portable AP chest X-ray (CXR) is utilized as the initial screening modality for BTAI, however, there is controversy surrounding its sensitivity. The purpose of this study was to assess the sensitivity of CXR as a screening modality for BTAI. Methods After IRB approval, all adult (≥18 yo) blunt trauma patients admitted to LAC+USC (01/2011–12/2013) who underwent CXR and chest CT were retrospectively reviewed. Final radiology attending CXR readings were reviewed for mediastinal abnormalities (widened mediastinum, mediastinal to chest width ratio greater than 0.25, irregular aortic arch, blurred aortic contour, opacification of the aortopulmonary window, and apical pleural haematoma) suggestive of aortic injury. Chest CT final attending radiologist readings were utilized as the gold standard for diagnosis of BTAI. The primary outcome analyzed was CXR sensitivity. Results A total of 3728 patients were included in the study. The majority of patients were male (72.6%); mean age was 43 (SD 20). Median ISS was 9 (IQR 4–17) and median GCS was 15 (IQR 14–15). The most common mechanism of injury was MVC (48.0%), followed by fall (20.6%), and AVP (16.9%). The total number of CXRs demonstrating a mediastinal abnormality was 200 (5.4%). Widened mediastinum was present on 191 (5.1%) of CXRs, blurred aortic contour on 10 (0.3%), and irregular aortic arch on 4 (0.1%). An acute aortic injury confirmed by chest CT was present in 17 (0.5%) patients. Only 7 of these with CT-confirmed BTAI had a mediastinal abnormality identified on CXR, for a sensitivity of 41% (95% CI: 19–67%). Conclusion The results from this study suggest that CXR alone is not a reliable screening modality for BTAI. A combination of screening CXR and careful consideration of other factors, such as mechanism of injury, will be required to effectively discriminate between those who should and should not undergo chest CT.

Ankylosing spondylitis is an inflammatory rheumatoid disease with severe osteoporosis affecting the spine with a tendency to fracture. Cervical spine fractures resulting in posterior mediastinal hematoma are rare. We present a patient with widened mediastinum secondary to fracture of a cervical ankylosing spondylitis and discuss its presentation and the current literature on the disease.

A woman in her 70s with rheumatoid arthritis presented to the emergency department with progressive dysnoea and sharp chest pain radiating to her back over the preceding day. No recent thoracic trauma was recollected. Examination demonstrated frailty, hypotension with a mean arterial pressure of 50, normal heart sounds and reduced air entry at the right base on ausculation of lung fields. No radial asymetry or pulsus paradoxus was present. An ECG demonstrated left bundle-branch block. Twenty-four hour high sensitivity troponin was negative. Serial arterial gas haemoglobin within 30 min demonstrated haemoglobin drop from 10.8 g/dL to 8 g/dL. Chest X-ray demonstrated widened mediastinum, appearing wider than prior imaging a year previously. Emergency echocardiogram revealed a 1 cm pericardial effusion with fibrin deposition extending 1.8 cm anteriorly. No diastolic ventricular collapse or respiratory …

A 54-year-old man who has a medical history of untreated hypertension presented to the emergency department with sudden onset of back pain and sweat. His back pain suddenly started while he was washing the dishes. The pain was sharp, continuous and radiating to his chest. His vital signs were normal and physical examination revealed neither heart murmur nor pulse deficit. Laboratory test revealed elevated D-dimer level of 2.5 µg/mL (reference range

Although there are several reports of intracranial hemorrhage associated with vitamin K deficient bleeding, there are few reported cases of extracranial manifestations, specifically involving the thymus. Here, we discuss the unique case of a 4-week-old infant presenting with scrotal discoloration, respiratory distress, and widened mediastinum, found to have thymic hemorrhage related to confirmed coagulopathy secondary to late-onset vitamin K deficiency bleeding of the newborn.

Central venous catheters are placed in approximately five million patients annually in the US. The preferred site of insertion is one with fewer risks and easier access. Although the right internal jugular vein is preferred, on occasion, the left internal jugular may have to be accessed. A patient was admitted for septic shock, cerebrovascular accident, and non-ST-segment elevation myocardial infarction. A central venous line was needed for antibiotic and vasopressor administration. Due to trauma from a fall to the right side and previously failed catheterization attempts at the left subclavian and femoral veins, the left internal jugular vein was accessed. On chest radiography for confirmation, the left internal jugular central venous catheter was seen projecting down the left paraspinal region. It did not take the expected course across the midline toward the right and into the superior vena cava (SVC). A review of a computed tomography (CT) scan of the chest with contrast done on a prior admission revealed a duplicated SVC on the left side that had not been reported in the original CT scan interpretation. A left-sided SVC is present in approximately 0.3% to 0.5% of the population, with 90% of these draining into the coronary sinus. During placements of central venous lines and pacemakers, irritation of the coronary sinus may result in hypotension, arrhythmia, myocardial ischemia, or cardiac arrest. A widened mediastinum can be an indication of a duplicated SVC. When attempting a left internal jugular vein central venous catheter placement, it is important to be aware of venous anomalies in order to prevent complications.

Author(s): Adamson, Joseph; Altwail, Mina; Jones, Shanna | Abstract: ABSTRACT: History of present illness: A 32-year-old male smoker with a BMI of 38.1 kg/m2, history of esophageal stricture, gastroesophageal reflux disease (GERD), and years of intermittent dry cough presented with three weeks of exacerbated, persistent cough worse in the morning and after eating. He denied fever, constitutional symptoms, dysphagia, or vomiting. He presented to the emergency department following an abnormal outpatient chest X-ray. Bilateral expiratory wheezing was noted on exam. Significant findings: The chest X-ray demonstrated a markedly widened mediastinum (red brackets), raising concern for thoracic aortic aneurysm/aortic dissection, which prompted labs and contrast-enhanced computed tomography (CT) of the chest. The CT revealed a dilated proximal esophagus that narrowed distally (yellow tracing and red arrow), with particulate material, mass-effect on the trachea (purple outline), and bilateral patchy opacities suggesting aspiration. Barium esophagram showed a drastically dilated esophagus filled with contrast (yellow arrow), terminating into the classic “bird’s beak sign” (red arrow) at the lower esophageal sphincter (LES). Esophageal manometry later confirmed achalasia, proving that widened mediastina can have unexpected etiologies. Discussion: Achalasia is a rare (prevalence ~0.3-9.5/100,000, increasing with age) digestive disorder characterized by denervation to the distal esophagus, promoting regional aperistalsis and tonic contraction of the LES.1-3 Achalasia most commonly presents as acute, simultaneous dysphagia to both solids and liquids, but can present as heartburn, regurgitation, or even unexplained cough.1-3 A dilated esophagus with narrowing at the LES (“Bird’s Beak Sign”) and delayed esophageal emptying on barium esophagram are pathognomonic for achalasia (sensitivity 90%, specificity 95%),4 as is distal aperistalsis with increased resting LES tone on high-resolution manometry (sensitivity 98%, specificity 96%).5 Pharmacologic LES relaxation may be trialed, but surgical myotomy is usually necessary.1,2,3,6 Our patient underwent laparoscopic Heller myotomy resulting in a dilated, aperistaltic esophagus with no evidence of obstruction and is being followed for continued GERD and dysphagia. Topics: Achalasia, widened mediastinum, acute dysphagia, barium esophagram, lower esophageal sphincter, esophageal dysmotility, aspiration, gastroenterology.

An aortic aneurysm is a permanent localized arterial dilation with more than 50% of the artery diameter. Among the complications of an aortic aneurysm, one of the rarest is the aorto-bronchial fistula, which presents with massive hemoptysis; this condition is lethal if not treated surgically. We report a 90-year-old man with no significant medical history who presented to the emergency department with abrupt onset of hemoptysis; his chest X-ray displayed left upper lobe opacity with widened mediastinum. CT chest revealed aneurysmatic dilatation of the aorta, left upper lobe opacity suspicious of pulmonary aortic fistula. Thoracic surgery was consulted but due to his poor functional status surgery was deferred. On the second day of hospitalization, the patient developed another episode of massive hemoptysis resulting in hypovolemic shock and expired. This case epitomizes the relevance of broad differential diagnosis for hemoptysis and the prompt assessment and management of the patients with this condition.

No abstract available. Article truncated after 150 words. A 78-year-old gentleman presented to the hospital via EMS with altered mental status. An urgent CT of the head performed in the emergency room demonstrated a large, right intraparenchymal hemorrhage with intraventricular extension into the right lateral ventricle. His Glascow Coma Scale score was 6, and he was intubated for airway protection. A chest radiograph performed to verify placement of the endotracheal tube demonstrated prominence of the upper mediastinum in the region of the right paratracheal strip (Figure 1). A CT of the chest (Figure 2) demonstrated a double aortic arch corresponding to the upper mediastinal abnormality noted on the chest radiograph. In speaking with the patient’s family after acquiring the CT of the chest, they stated that the patient had long-term issues with dysphagia – specifically choking with solid foods. Unfortunately, the patient passed away from complications of his large intraparenchymal hemorrhage. A double aortic arch results from persistence of …

WOS: 000393517800011 PubMed: 27239627 Patients with vertebral fractures are frequently encountered and those with thoracic and lumbar spine fractures are likely to have associated injuries. Detection of a widened mediastinum after trauma is very nonspecific and most of the time it is related to aortic injury or mediastinal hematoma. Vertebral or sternal fractures can also be the cause of mediastinal hematoma with or without aortic injury. This report reviews an unusual case of rapid onset mediastinal hematoma due to vertebral fracture after a fall. in the case, there was a mediastinal hematoma adjacent to a burst fracture of the T8 vertebral body. There was a rapid increase in identified hematoma during the emergency follow up and urgent erythrocyte transfusion was carried out. We would like to raise awareness of this infrequent presentation of mediastinal hematoma, as it is insidious and possibly fatal. in the evaluation of mediastinal hematoma, the detection of osseous injuries is a requirement. Copyright (C) 2016 the Emergency Medicine Association of Turkey. Production and hosting by Elsevier B.V. on behalf of the Owner.

OBJECTIVES Acute aortic dissection is a life-threatening condition due to a tear in the aortic wall. It is difficult to diagnose and if missed carries a significant mortality. METHODS We conducted a librarian-assisted systematic review of PubMed, MEDLINE, Embase, and the Cochrane database from 1968 to July 2016. Titles and abstracts were reviewed and data were extracted by two independent reviewers (agreement measured by kappa). Studies were combined if low clinical and statistical heterogeneity (I2

A 21-year-old male involved in a motorcycle crash presented with abdominal hemorrhage and a widened mediastinum on chest radiograph. He required an initial exploratory laparotomy for mesenteric injuries. An aortic injury was confirmed on computed tomography imaging and he subsequently underwent attempted endovascular repair. During that procedure, the patient experienced massive thoracic hemorrhage with cardiac arrest and profound respiratory failure. Damage-control thoracic surgery and rescue extracorporeal membrane oxygenation were successfully utilized with a favorable outcome.

Background Descending necrotizing mediastinitis (DNM) is a potentially fatal disease that requires aggressive treatment, including mediastinal exploration. The inflammation associated with DNM may involve the heart, which produces acute changes in the electrocardiogram (ECG). As a result, the ECG may mimic pericarditis, causing some diagnostic confusion. Objectives The objectives of this case report are to describe a case of DNM presenting electrocardiographically with pericarditis, and to discuss how to differentiate between benign viral pericarditis and DNM, and the management of these two diseases. Case Report We present the case of a previously healthy 50-year-old man who presented to the Emergency Department for chest pain and presumed pericarditis. The patient presented with ST elevation on multiple leads on ECG, tenderness in the neck, widened mediastinum on the chest radiograph, and nonspecific laboratory test results. Echocardiography revealed normal ventricle function and the presence of mild pericardial effusion. The emergency physician performed contrast-enhanced neck computed tomography (CT) to rule out deep-neck infection. The CT scan showed marginal rim-enhancing abscesses in the retropharyngeal, bilateral submandibular, and anterior visceral spaces with extension into the thoracic cavity. Contrast-enhanced chest CT was performed consecutively. The final diagnosis was deep-neck infection with DNM. The patient underwent mediastinoscopy-assisted drainage and neck fasciotomy twice and received 7 weeks of therapy with intravenous meropenem. Conclusion The present case highlights the importance of considering a mediastinal cause for acute ECG changes.

Fig 2. Axial computed tomography scan with angiographic contrast obtained at the level of the aortic arch. A64-YEAR-OLD, 86-kg, 183-cm man with prostate cancer was evaluated in the authors’ preoperative assessment clinic before a scheduled prostatectomy. He denied cardiac symptoms and described only mild shortness of breath with heavy exertion. His past medical history was notable for an acute type-A aortic dissection that occurred 14 years before the current evaluation. The medical records were obtained from a local community hospital where the patient had received care. According to the operative report, the intimal tear of the dissection was located in the mid-ascending thoracic aorta. The dissection extended retrograde into the sinuses of Valsalva, coronary ostia, and aortic valve annulus; proceeded antegrade into the iliac arteries; involved the innominate and right carotid arteries; and was associated with severe aortic valve insufficiency. During surgery, the native aortic valve was deemed to be unsalvageable and was excised; a 25-mm bileaflet mechanical prosthesis was implanted. The ascending thoracic aorta was replaced with a 28-mm woven Dacron graft (Hemashield, Maquet Cardiovascular, Wayne, NJ), and the coronary arteries were reimplanted. The aortic arch was not addressed. The patient made an uneventful recovery without neurologic or

A man aged 24 years who was assaulted was brought in by paramedics, boarded and collared, as a trauma notification. On primary survey, the patient was breathing spontaneously, saturating well on a non-rebreather mask. He had equal bilateral breath sounds with stable vital signs. On secondary survey, a 3 cm laceration was noted to the left of the sternal boarder at the fourth ICS. No active bleeding or evidence of sucking wound was evident. FAST examination was equivocal in the trauma bay. After obtaining a chest X-ray to exclude a pneumothorax and widened mediastinum, …

A 72-year-old male with known coronary artery disease presents to his community hospital’s emergency department (ED) with multiple long-bone fractures and a blood pressure of 65/40 following a severe motor vehicle accident. It is also noted that the patient has a widened mediastinum.

A 71 year old man presented with severe chest pain followed by collapse. On arrival he was hypotensive, tachycardic, and had a prominent left parasternal thrill. The chest x ray revealed a widened mediastinum. His previous medical history included dialysis dependent chronic renal failure, mild aortic stenosis, hypertension, and …

Summary Aortic dissection is a relatively uncommon illness, but it often presents with acute hemodynamic compromise and severe chest pain. Early diagnosis and treatment are crucial for survival. Patients with an aortic dissection typically present with an acute, severe, sharp, or “tearing” posterior chest or anterior chest pain or back pain. We describe one example of ascending aortic dissection show atypical symptoms. And the symptoms are similar to acute abdomen initially. We should always keep in mind that the possibility of aortic dissection when a widened mediastinum is noted despite of atypical symptoms for aortic dissection.

We aimed to explore the diagnostic accuracy of various mediastinal measurements in determining acute nontraumatic thoracic aortic dissection with respect to posteroanterior (PA) and anteroposterior (AP) chest radiographs, which had received little attention so far. We retrospectively reviewed 100 patients (50 PA and 50 AP chest radiographs) with confirmed acute thoracic aortic dissection and 120 patients (60 PA and 60 AP chest radiographs) with confirmed normal aorta. Those who had prior history of trauma or aortic disease were excluded. The maximal mediastinal width (MW) and maximal left mediastinal width (LMW) were measured by two independent radiologists and the mediastinal width ratio (MWR) was calculated. Statistical analysis was then performed with independent sample t test. PA projection was significantly more accurate than AP projection, achieving higher sensitivity and specificity. LMW and MW were the most powerful parameters on PA and AP chest radiographs, respectively. The optimal cutoff levels were LMW = 4.95 cm (sensitivity, 90 %; specificity, 90 %) and MW = 7.45 cm (sensitivity, 90 %; specificity, 88.3 %) for PA projection and LMW = 5.45 cm (sensitivity, 76 %; specificity, 65 %) and MW = 8.65 cm (sensitivity, 72 %; specificity, 80 %) for AP projection. MWR was found less useful and less reliable. The use of LMW alone in PA film would allow more accurate prediction of aortic dissection. PA chest radiograph has a higher diagnostic accuracy when compared with AP chest radiograph, with negative PA chest radiograph showing less probability for aortic dissection. Lower threshold for proceeding to computed tomography aortogram is recommended however, especially in the elderly and patients with widened mediastinum on AP chest radiograph.

A 76-year-old female, with a history of asthma and tracheal bronchitis, presented with a non-ST elevation, myocardial infarction. Chest x-ray on admission showed a widened mediastinum, which was further evaluated with a computed tomography (CT) scan. It disclosed a giant substernal goiter compressing the trachea and the ascending aorta. Cardiac catheterization showed significant coronary disease unsuitable for percutaneous intervention; thus, the patient was scheduled for coronary artery bypass grafting. Single stage thyroidectomy immediately followed by coronary artery bypass was performed. After surgery, her upper airway symptoms were improved, and no cardiac events were noted. Collaboration between otolaryngology and thoracic surgery teams contributed to good outcomes for this patient with substernal goiter and severe cardiac disease.

Introduction Blunt traumatic injury of innominate artery is uncommon and has been reported only in 132 cases. In the literature there has been a solitary case report of a stroke resulting from an innominate artery injury. We present a case of traumatic injury of the innominate artery resulting in an ischemic stroke. Case presentation A 20-year-old gentleman ejected from a two wheeler and run over by a truck presented to us with multiple bleeding facial wounds and severe crush injury of his upper torso. Bedside chest X-ray revealed a widened mediastinum and multiple rib fractures with pneumothoraces bilaterally which were drained with intercostal tubes. An hour into his stay in the ED he developed left hemiparesis. CT brain showed infarcts in right temporo-parietal and occipital regions. CT angiogram of neck vessels revealed an avulsion injury at the origin of the right innominate artery with pseudoaneurysm formation. Discussion The innominate artery is the 2nd most common site of great vessel injury after the ascending aorta. 71% die before reaching the hospital. Patients who present to the ED are often stable with associated major injuries including rib fractures, pneumothorax and closed head injuries. The diagnosis is aided by a thorough clinical examination or a chest X-ray revealing a widened mediastinum as seen in our patient. Lessons learnt Severe upper torso injuries involving the clavicle and upper ribs with pulse deficits or unexplained neurology should always raise a strong suspicion of major vascular injuries warranting further evaluation.

A 25 year old man was referred to the oncology unit with a three week history of a neck lump that was progressively increasing in size, and atypical lymphoid cells on fine needle aspiration cytology. The patient also reported mild exertional dyspnoea and drenching night sweats, but no weight loss, occupational exposure to harmful substances, recent travel, or high risk sexual behaviour. He had smoked cigarettes since he was 16. On examination, the right supraclavicular lymph node was palpable and measured 3 cm in diameter. Chest radiography showed a widened mediastinum but no lung lesions. Contrast enhanced computed tomography of the thorax was performed (fig 1). Core biopsy of the node showed partial effacement of nodal architecture by scattered large cells in a background of reactive lymphocytes, eosinophils, and plasma cells with some collagen fibrosis. These large cells stained positive for CD15 and CD30 and negative for CD45. Figure 2 shows an example micrograph from biopsy (not from the patient described). Fig 1 Axial contrast enhanced computed tomography of the thorax showing an anterior mediastinal mass, with a central hypodense area suggestive of necrosis (red arrow) Fig 2 Micrograph showing a Reed-Sternberg cell and normal lymphocytes. Reed-Sternberg cells are often binucleated with prominent nucleoli, having an …