A 44 y.o. woman presents with R chest pain

she has been treated for three weeks for pneumonia with azithromycin and cefdinir but continues to worsen.

because of a persistent infiltrate on cxr a PE protocol CT was done.

what do you notice on the PE protocol ct?

Our patient did not have a pulmonary embolus although there is a blockage in the pulmonary artery, a mass extends beyond the vessel itself. 

The mass extends beyond the pulmonary artery

Our patient had fibrosing mediastinitis which is thought to be the sequela of infection with Histoplasma capsulatum.  It begins as an asymptomatic pulmonary infection and spreads to mediastinal nodes. It can result in a granuloma commonly, but depending on the host response,  some patients develop fibrosis with involvement of vessels, heart or esophagus.  The organism is ubiquitous in the Ohio and Mississippi river valleys. People living in these areas are exposed in childhood and most have an asymptomatic illness.

fibrosing mediastinitis with bronchial narrowing

Whenever soil is disturbed the spores become airborne and can be sucked into airconditioning systems. An outbreak of histoplasmosis occurred in a school in Ohio.  On Earth Day, a courtyard was raked and the entire school building was contaminated with spores, infecting 384 students.

While histoplasmosis accounts for 80% of cases, rarely, tuberculosis, aspergillus, sarcoid and Wegeners have all been reported as causes. There is no treatment other than palliative care: stenting of airways, coiling bronchial vessels that develop because of SVC syndrome or debulking . Our patient had a resection of the fibrotic part of the pulmonary artery on the R with a bovine patch.  She is doing well, although her cxr still shows atelectasis of the RML.

Goodwin RA, Nickell JA, Des Prez RM. Mediastinal fibrosis complicating healed  primary histoplasmosis and tuberculosis . Medicine (Baltimore 1972;51:227.

 Wheat LJ, Slama TG, Eitzen HE, et al. A large urban outbreak of histoplasmosis; clinical features. Ann Intern Med 1981;94:331.

 Kern R. Peikert T, Edell E, et al. Bronchoscopic mangement of airway compression due to fibrosing mediastinitis.  Ann Am Thorac Soc  2017;14:1353.