Max Martin, MD
Fellow
Mayo Clinic College of Medicine
Rochester, Minnesota
Disclosure information not submitted.
Joseph Marion, MD
Physician
Mayo Clinic
Rochester, Minnesota, United States
Disclosure information not submitted.
Alice Gallo De Moraes, MD, FACP
Physician
Mayo Clinic
Rochester, Minnesota, United States
Disclosure information not submitted.
Title: Recurrent Hemoptysis and Neovascularization: A Dangerous Complication of Fibrosing Mediastinitis
Introduction: Fibrosing mediastinitis (FM) is a rare fibroinflammatory condition characterized by formation of invasive fibrous tissue within the mediastinum. While true pathogenesis is unknown, many cases are thought to be secondary to previous Histoplasma capsulatum infection. When fibrous proliferation is significant, it can lead to compression of the mediastinal vasculature. Here, we present a case of FM with complete pulmonary artery obstruction leading to recurrent hemoptysis.
Description: A 23-year-old gentleman with known FM was admitted to the intensive care unit for large volume hemoptysis. Computed tomography of the chest obtained on admission showed an infiltrative soft tissue mass encasing and severely compressing the left pulmonary artery. The patient was initially hemodynamically stable, but emergent intubation was performed due to active bleeding. Bedside bronchoscopy revealed copious bloody secretions coming from the left mainstem bronchus. An endobronchial blocker was immediately placed with cessation of hemoptysis. Due to inability to control bleeding bronchoscopically, the patient was sent for thoracic angiography and possible embolization. This demonstrated complete obstruction of the left pulmonary artery with markedly enlarged and tortuous left bronchial arteries, both of which were embolized. Despite this, he continued to have a large amount of bloody output from his endotracheal tube. Repeat angiography showed the development of multiple parasitized arteries arising from the intercostal arteries, gastric artery, and internal mammary artery. These were also embolized with resolution of further bleeding. The patient was extubated the following day and discharged from the hospital shortly thereafter. He is anticipating a repeat dose of rituximab in hopes of halting the progression of his FM.
Discussion: Conditions such as FM can cause partial or complete cessation of blood flow through the pulmonary arteries. When this occurs, blood is not only shunted to the bronchial arterial system, but also leads to vascular remodeling and neovascularization. These collateral vessels are fragile and prone to bleeding. As such, patients with FM are at risk for recurrent episodes of hemoptysis. The only acute management option is arterial embolization, although this is only temporary.