Chief Complaint:

Chief Complaint: Cough, hemoptysis, chest pain
Kelly Kawaoka, M.D.
Loma Linda University Medical Center
Case Presentation
• 17 yo Hispanic female with Type I Diabetes Mellitus, multiple
previous admissions for diabetic ketoacidosis
• Presented initially with 10 days of chest pain, cough, and later
developed hemoptysis
• Diagnosed with diabetic ketoacidosis (DKA) and pericarditis
secondary to pneumonia by chest CT at an outside facility
• Bronchoscopy revealed necrotic tissue on the left mainstem
• DKA resolved with appropriate treatment, but only minor
clinical improvement of respiratory status with antibiotics
• On presentation, afebrile, saturating well on 2 liters/min
• Bilateral rhonchi, diminished on left with crackles, highpitched expiratory wheezes
White blood cell count: 19,700 per µL
Serum glucose 268 mg/dL
HgbA1C 10.1%
Westergren sedimentation rate (ESR) >140 mm/hr
[normal 0-20 mm/hr]
• C-reactive protein (CRP) 8.5 mg/dL [0-0.8 mg/dL]
• Chest CT
– Progressive consolidation in the lower left lobe with
persistent bilateral pleural effusions
– Thickening of the left lower lobe mainstem bronchus
– Enlarged subcarinal and left hilar lymph nodes
Chest CT
Mediasinal mass with infiltration into the left atrium
Hospital Course
• Bronchoscopy: no viral cytopathic changes,
atypia or malignant cells on washings
• Chest tube drainage (3)
• Video-Assisted Thoracoscopic Surgery (VATS)
– Abscess, granulation tissue, chronic inflammation
– Lymph node  benign
– Inconclusive for infection or malignancy
• Endoscopic ultrasound (EUS)
Endoscopic Ultrasound
Irregularly shaped hypoechoic mass in the left posterior
mediastinum measuring approximately 2.5 x 1cm
Non-septated hyphae in an inflammatory background
• Ambisome started, changed to posaconazole
and rifampin  slight clinical improvement
• Repeat bronchoscopy confirmed Mucor
• Pneumonectomy when the mass and
symptoms did not resolve with antibiotics
Case Discussion
• Pulmonary zygomycosis
– Rapidly progressive
– Affects the immunocompromised
• Present with fever and hemoptysis
• Spread locally to the mediastinum and heart or
hematogeneously to other organs
• Most common etiology: hematologic malignancy
• May see with diabetes, more frequent with rhinoorbital-cerebral infection
• When available, transesophageal biopsy with
EUS is preferred over thoracoscopy
– high diagnostic yield
– less invasive technique
– fewer complications
• No other cases using EUS to diagnose Mucor
in the current literature
Learning Objectives
• Know that diabetic patients are at higher risk for
developing infections
• Know that fungal infections can be devastating in the
immunocompromised host
• Know that the diagnosis of pneumonia in an
immunocompromised host may require aggressive
procedures, including bronchoscopy
• Review the differential diagnosis of a mediastinal
mass in children and adults
• Review presentation of mediastinal masses
Mediastinal Masses: Ddx
Neurogenic tumors (P)
Enterogeneous cysts (A)
Neurogenic tumors (P)
Thymomas (A)
Thymic cysts (A)
Lymphadenopathy* (M)
lymphoma (A)
More often symptomatic,
More often asymptomatic,
respiratory distress or
Vague complaints such as aching
recurrent pulmonary infection pain or cough
A = anterior, M = middle, P = posterior
*Due to infectious, malignant/metastatic, idiopathic causes
Mediastinal Masses: Presentation
• Airway compression  Recurrent pulmonary
infection or hemoptysis
• Esophageal compression  dysphagia
• Spinal column involvement paralysis
• Phrenic nerve damage  elevated hemidiaphragm
• Recurrent laryngeal nerve damage  hoarseness
• Sympathetic ganglion compression  Horner's
• Superior vena cava involvement  SVC syndrome
• Krasnik M; Vilmann P; Larsen SS; Jacobsen GK (2003).
“Preliminary experience with a new method of endoscopic
transbronchial real time ultrasound guided biopsy for
diagnosis of mediastinal and hilar lesions” Thorax.
• Tedder, M, Spratt, JA, Anstadt, MP, et al. “Pulmonary
mucormycosis: Results of medical and surgical therapy.” Ann
Thorac Surg 1994; 57:1044.
• Brown, RB, Johnson, JH, Kessinger, JM, Sealy, WC.
“Bronchovascular mucormycosis in the diabetic: An urgent
surgical problem.” Ann Thorac Surg 1992; 53:854.
• UpToDate. “Evaluation of Mediastinal Masses”
• A 3-year-old female is transported by ambulance to the
emergency department. She had been treated with
amoxicillin for the past eight days for suspected pneumonia
and now presents with worsening of symptoms: cough, fever,
and most recently coughing up blood. Physical examination
includes a respiratory rate of 40 breaths/min, heart rate of 85
beats/min, oxygen saturation of 92% on room air, blood
pressure of 100/70 mm Hg, and temperature of 102.3°F
(39°C). She is awake and alert but has difficulty speaking in
full sentences. On auscultation, you note diffuse crackles
throughout her lung fields. Chest x-ray shows a mediastinal
mass, which is confirmed to be anterior on CT.
• After initial stabilization, the BEST next step
in the management of this patient is to
Administer methylprednisolone
Start a different oral antibiotic
Measure the pH of the bloody secretions
Transfuse packed red blood cells
Answer - C
• Hemoptysis, is uncommon in pediatrics, but acute lower respiratory tract
infection is the leading cause today, accounting for 40% or more of cases.
Other causes include cystic fibrosis and congenital heart disease, both can
present as recurrent bleeding. In children younger than 4 years of age,
foreign body aspiration should be considered. Unlike in adults, neoplasm
is an uncommon cause of hemoptysis in children.
• The first step in the evaluation of a child who has hemoptysis is to
determine the source of the bleeding. Blood from hemoptysis is typically
bright red and frothy with an acidic pH rather than the dark or "coffee
ground" alkaline material produced in hematemesis. Epistaxis generally
can be established after careful examination of the oropharynx and
• The source of the bleeding for the child in the vignette likely is either
pulmonary infection or foreign body obstruction. Methylprednisolone
may be of benefit for a foreign body aspiration prior to bronchoscopy.
The presence of the mediastinal mass makes this scenario less likely.
Answer - C
• Initial therapy with antibiotics is appropriate only after
collection of blood and sputum samples if pneumonia is
suspected. IV antibiotics would be a more appropriate choice
given that she has failed oral therapy. Most hemoptysis in
children resolves spontaneously without the need for invasive
• This child had one episode of hemoptysis without massive
bleeding so would most likely not need a blood transfusion.
• Patients whose hemoptysis does not resolve spontaneously
or who experience marked blood loss may require
bronchoscopy to determine the source of the bleeding.