Monday, March 19, 2007

Mediastinal adenopathy, hypoxia

Dr.Carrillo submitted a case for your enjoyment/pontification:

49yo Hx of ETOH and presumptive cirrhosis. Exposed to birds through his early years. 2000 had abnormal CT thorax with interlobular septal thickening, Pleural thickening encasing the lungs and multiple adenopathy in the med. Mediatinoscopy report says multiple venous collaterals may be early SVC.Thickened fat through the mediastinum.Bx of LN neg,no Cx sent. 2003 - Same CT findings.

Now presents with hypoxia and CT findings similar as before. The radiologist describes that the mediatinum looks abnormal with strading. I think this guy probably has histo with some fibrosis of the medistinum. I wonder if he has compression of the thoracic duct with causing his lymphatics to be prominent and show like interlobular septal thickening on CT and he had previous Chylo?. I was going to do broncoscopy with TBBX and TBNA and serologies. Any other idea or opinion about this case. Do you think I should further investigate the possible thoracic duct obstruction?

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

Baleeiro said...

That sounds like a reasonable Dx. Unfortunatelyy, bad Dz...

Anonymous said...

I agree. I don't think the transbronchial biopsies or transbronchial needle aspirates are going to be helpful, and that another mediastinoscopy would be necessary.

How would you further investigate for thoracic duct obstruction? I think that it is unlikely in the absence of a chylothorax.

darenberg said...

I don't think you need to invoke thoracic duct damage to explain the interlobular septal thickening. The obliteration of normal lymphatic drainage from the lung, by the mediastinal fibrosis, is probably enough to account for that. The thoracic duct largely drains lymphatics from below the diaphragm.

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