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Ann Thorac Surg 2009;87:323. doi:10.1016/j.athoracsur.2008.03.007
© 2009 The Society of Thoracic Surgeons
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Images in Cardiothoracic Surgery

Fibrosing Mediastinitis Associated With Complete Occlusion of the Left Main Pulmonary Artery

Chadrick E. Denlinger, MD, Felix G. Fernandez, MD, George Alexander Patterson, MD, Daniel Kreisel, MD, PhD*

Division of Cardiothoracic Surgery, Department of Surgery, Barnes-Jewish Hospital, Washington University in St. Louis, St. Louis, Missouri

* Address correspondence to Dr Kreisel, Division of Cardiothoracic Surgery, Campus Box 8234, 660 South Euclid Avenue, St. Louis, MO 63110 (Email: kreiseld{at}wudosis.wustl.edu).

A 35-year-old female presented with the complaints of a persistent headache and chest pain. In addition, worsening shortness of breath and night sweats had been noted over the previous several months. The majority of her life was spent in the Midwestern United States and she denied any significant recent travel history. Her physical exam was unremarkable. A head computed tomography (CT) scan was normal. An echocardiogram was performed that showed a mildly dilated left atrium, normal left ventricular function, mild tricuspid regurgitation with mild pulmonary hypertension and mild mitral regurgitation. A CT angiogram of the chest with intravenous contrast showed extensive left hilar lymphadenopathy with heavily calcified hilar lymph nodes. This was associated with near complete obstruction of the left pulmonary artery (Fig 1; arrow indicates occlusion of left main pulmonary artery). There was only mild atelectasis in the left lower lobe. A ventricular perfusion scan scan showed normal ventilation of both lungs (Figs 2A and 2B), but no perfusion of the left lung was seen (Figs 2C and 2D).


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  		Fig 1.
 

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  		Fig 2.
 
Mediastinal fibrosis associated with large calcified lymph nodes, resulting from indolent histoplasmosis infections is relatively common in the Midwestern United States. This disease most commonly causes airway obstruction that is often amenable only to surgical resection [1]. In this particular patient, the lymphadenopathy was limited to her left pulmonary hilum. Conservative management was selected rather than any attempt to bypass the obstructed vessel. This treatment was chosen based on previous unpublished observations from our institution in which a pulmonary artery bypass was attempted in a patient who had presented with similar pathology. Extensive collateral blood flow through the bronchial arteries resulted in retrograde flow through the pulmonary artery bypass necessitating ligation of the bypass.


   References
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 References
 

  1. Garrett Jr HE, Roper CL. Surgical intervention in histoplasmosis Ann Thorac Surg 1986;42:711-722.[Abstract/Free Full Text]



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