tag:blogger.com,1999:blog-12660458.post112679557905721969..comments2023-09-01T10:33:09.297-04:00Comments on Pulmonary Roundtable: Referral for hypoxia.Unknownnoreply@blogger.comBlogger8125tag:blogger.com,1999:blog-12660458.post-1126817505177104842005-09-15T16:51:00.000-04:002005-09-15T16:51:00.000-04:00Hypoxemia will cause a secondaryerythrocytosis too...Hypoxemia will cause a secondaryerythrocytosis too and this need not be polycythemia. I don't remmember anterior mediastinal masses causing polycythemia... renal cell Ca can lead to increased erythropoetin and polycythemia and may certainly metastasize to the chest though that does not look like a typical renal cell met.<BR/>With his body habitus and AHI I would not expect persistent PHTN during the day. I may have missed but was he hypercapnic?Baleeirohttps://www.blogger.com/profile/03993066135160692535noreply@blogger.comtag:blogger.com,1999:blog-12660458.post-1126806132708903582005-09-15T13:42:00.000-04:002005-09-15T13:42:00.000-04:00I missed the part mentioning about his body habitu...I missed the part mentioning about his body habitus.......so obviously OHS is not an issue here. I would still attempt to obtain the report of the sleep study, to know what is his apnea/hypopnea index and also learn about the extent of the nocturnal desaturation (which happen both with apneas and hypopneas)..you have nothing to lose, and I am sure that you have been surprised many times to find severe sleep-disordered breathing in people without the typical body habitus. PFT is a great idea, and I would include with that muscle forces especially if he had hypercapnea on his ABG.<BR/>in regards to the anterior mediastiastinal opacity, one way to tie all this together would be to think of thymoma causing myasthenia gravis(as the author reported weakness/choking on food..) which can be associated sometimes with red cell aplasia (hence the polycythemia).....<BR/>I would get erythropoietin level, get neuro eval for myasthenia/serologic evaluation.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-12660458.post-1126805660270432542005-09-15T13:34:00.000-04:002005-09-15T13:34:00.000-04:00Ok then with anterior mediastinal mass and fatigue...Ok then with anterior mediastinal mass and fatigue I will ask what his Mips and MEPs are in case this is thymoma-related myasthenia. Other options include germ cell, with teratoma being one that can give you calcification.Jenningshttps://www.blogger.com/profile/04930453447603683057noreply@blogger.comtag:blogger.com,1999:blog-12660458.post-1126803347288863892005-09-15T12:55:00.000-04:002005-09-15T12:55:00.000-04:00I'll also take the blame for leading the discussio...I'll also take the blame for leading the discussion astray with my vascular abnormality hypothesis. I'll also take the hint, and speculate that this may be a "simple" anterior mediastinal mass...<BR/><BR/>Of course, I will point out that my initial post said that, if this were calcium and not a vascular lesion, than I would push for a mediastinoscopy. I still hold to that, and now think that tissue is the issue.Jeff Hhttps://www.blogger.com/profile/01209432708535732499noreply@blogger.comtag:blogger.com,1999:blog-12660458.post-1126799494999255652005-09-15T11:51:00.001-04:002005-09-15T11:51:00.001-04:00A couple of thoughts.First, if he has severe OSA, ...A couple of thoughts.<BR/>First, if he has severe OSA, he could get hypoxic vasoconstriction, pulmonary hypertension and hypoxemia with exercise. So, that sleep study would be helpful. I know better than to ask a Wed clinic man if you measured his neck circumference and graded his airway with Mallampati classification.<BR/>Second, I think full PFT's would be very helpful. A low DLCO in the absence of any PE would pretty much r/i pulmonary hypertension. Then, we would need a diagnosis.<BR/>To figure that out, I would MRI/MRA his chest to get a better idea on what that anterior abnormality is. I think I would avoid mediastinoscopy until you figure out if is vascular or not. Maybe Jennings could reconstruct the CT to see the vascular supply.<BR/>If the MRI/MRA is negative, I would do a right heart cath. While there, I would do both pressure measurements and saturations in the SVC, RA, RV and pulm artery.Mike Lhttps://www.blogger.com/profile/12177750268091750583noreply@blogger.comtag:blogger.com,1999:blog-12660458.post-1126799478490504662005-09-15T11:51:00.000-04:002005-09-15T11:51:00.000-04:00I think that the results of the sleep study are cr...I think that the results of the sleep study are crucial here. Positive may mean anything and you will need the report. It will be very significant if the result shows severe sleep apnea, with severe desaturation (which would explain the polycythemia from chronic hypoxia). is this a morbidly obese man? BMI? is obesity hypoventilation a possibility here? was there hypercapnea on his ABG? what was the A-a gradient?<BR/>The opacity anterior to the aorta is a different problem and will need separate workup.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-12660458.post-1126798365411964652005-09-15T11:32:00.000-04:002005-09-15T11:32:00.000-04:00I agree with JH about the close abuttment of the a...I agree with JH about the close abuttment of the abnormalitiy to the ascending aorta. It is concerning for a sacular aneurysm. The angle of the lower edge suggests it may be coming from the aorta and the lack of contrast may indicate clot. I would confirm this impression with a radiologist and if agreed, would go to a TEE to confirm this.Jenningshttps://www.blogger.com/profile/04930453447603683057noreply@blogger.comtag:blogger.com,1999:blog-12660458.post-1126796797839640832005-09-15T11:06:00.000-04:002005-09-15T11:06:00.000-04:00Thanks for the case DA. So, a 53 y/o previously h...Thanks for the case DA. So, a 53 y/o previously healthy man with hypoxia, fatigue, subjective weakness, some degree of pulmonary hypertension, and normal pulmonary mechanics.<BR/><BR/>The CT scan shows something anterior to the arch of the aorta. I don't know what that is, but it looks like it has some heterogenous attenuation and a "whiff" of either contrast or calcium. It looks contuguous with the aorta, but doesn't seem to be invading. Also, this is only one cut but there does seem to be an anomolous (?spelling?) vessel coming off of the aorta-same attenuation, and it doesn't look right for the PA.<BR/><BR/>He has no s/s to suggest an infection. As you stated, there is no parenchymal abnormality noted on the prior CT scan, and nothing suspicous for PE.<BR/><BR/>So, two possibilities come to mind here. 1) If that is contrast material, there would be a left-right shunt: this could cause pulmonary hypertension, but shouldn't cause the hypoxia unless the right sided pressures were so elevated that there was Eisenmenger's physiology. The prior echo did not seem consistent with that.<BR/><BR/><BR/><BR/>2) If that is calcium, I'd wonder about old granulomatous disease and consider fibrosing mediasteinitis.<BR/><BR/>Of course, I may be over-calling all of this... I think I'd repeat an echo here to get a better sence of the pulmonary hypertension, and then consider a PA-gram and an aortogram to further define the vascular anatomy. I suppose an MRA of the great vessels could be done first. If all of that is negative, I'd consider a mediasteinoscopy.<BR/><BR/>I'm very interested to see what others think, as all of this is a shot in the dark!Jeff Hhttps://www.blogger.com/profile/01209432708535732499noreply@blogger.com