Wednesday, December 07, 2005

rEmerson Biguns

19 year old woman who is 26 weeks pregnant presented with 2 weeks of progressive shortness of breath, which was worse lying down and better sitting up and leaning forward. + wheezing. No fever/chills/sweats. No weight loss. No cough/sputum production.

No past medical history/social history/family history of significance.

The exam was notable only for inspiratory and expriatory wheezing.

9 comments - CLICK HERE to read & add your own!:

Baleeiro said...

That's huge! Any previous CxRays or any symptoms before pregnancy?

Jeff H said...

No previous films or symptoms, and her pregnancy has been uncomplicated.

Arenberg said...

To say this is an anterior mediastinal mass would be like saying the statue of liberty is a figurine. This sucka is big. I would suspect lymphoma.

We had a lady a few years back on the pulmonary service in whom we diagnosed a lymphoma during her pregnancy. She went on to get CHOP for four cycles and deliver a beautiful healthy baby girl in spite of it. After about twelve weeks gestation, I am told that the fetus just laughs off the chemotherapy. Interesting when you consider that the baby is growing at least as fast as the lymphoma at that point.

Mike L said...

Just out of curiosity, how did the surgeons do the biopsy... general anesthesia or local?
Any role for debriding that first as it puts her (and her baby) at risk for SVC syndrome, in-situ thrombus dev'pt in the Pulmonary Artery, etc?

Jeff H said...

Mike, you bring up a great point regarding biopsies, as there was a lot of discussion about the best approach. The fist thing we did was a thoracentesis to send for flow, while calling the thoracic surgeon.

Because of the airway comprimise (distal trachea and both main stem bronchi are significantly compressed) there was a fear that general aneshesia could lead to loss of the airway distal to any endotracheal tube. We considered CT-guided core biopsies, but the patient could not lay down. So, the biopsy was done via a mini-thoracotomy under local anesthesia with the patient sitting up.

As for SVC syndrome, there were no indications/symptoms of that on presentation. However, if you look at the contrast-enhanced CT scan, you will see that the right PA is significantly compressed. She did have evidence of RV strain on an echo.

I'll leave some more time for comments, and tomorrow I will post the diagnosis and a bit of follow-up.

Eugene O said...

Hodgkin is more common than non-Hodgkin during pregnancy. I hope this is Hodgkin because many pregnant patients with newly diagnosed Hodgkin can be cured.

Jeff H said...

I'll wrap this one up. The thoracentesis suprisingly yielded only 4cc--the differential was almost all lymphocytes, but it was not enough for flow cytometry.

The surgical biopsy showed a non-hodgekin's T-cell lymphoblastic lymphoma. She received a few doses of IV Decadron (see the post-decadron CXR that I've added), and is now receiving CHOP. The hope is to get the baby to 30 weeks, then deliver.

Anonymous said...

At my hospital we had a lady present with lymphoma around her 30th week. We were concerned about CHOP in pregnancy, so decided to go with Rituxan monotherapy. The Rituxan prevented any disease progression and permitted her to carry the baby to term. The week after delivery, we added CHOP to the Rituxan and she is doing well.

Arenberg said...

The reported use of Rituxan interests me. There is substantially more data available for the safe use of CHOP during pregnancy than there is for Rituxan. I'd have been much more worried about the liability of using Rituxan than of CHOP.