Boerhaave syndrome - case report / Síndrome de Boerhaave - relato de caso

ABSTRACT CONTEXT: Boerhaave syndrome consists of spontaneous longitudinal transmural rupture of the esophagus, usually in its distal part. It generally develops during or after persistent vomiting as a consequence of a sudden increase in intraluminal pressure in the esophagus. It is extremely rare in clinical practice. In 50% of the cases, it is manifested by Mackler's triad: vomiting, lower thoracic pain and subcutaneous emphysema. Hematemesis is an uncommon yet challenging presentation of Boerhaave's syndrome. Compared with ruptures of other parts of the digestive tract, spontaneous rupture is characterized by a higher mortality rate. CASE REPORT: This paper presents a 64-year-old female patient whose vomit was black four days before examination and became bloody on the day of the examination. Her symptoms included epigastric pain and suffocation. Physical examination showed hypotension, tachycardia, dyspnea and a swollen and painful abdomen. Auscultation showed lateral crackling sounds on inspiration. Ultrasound examination showed a distended stomach filled with fluid. Over 1000 ml of fresh blood was extracted by means of nasogastric suction. Esophagogastroduodenoscopy was discontinued immediately upon entering the proximal esophagus, where a large amount of fresh blood was observed. The patient was sent for emergency abdominal surgery, during which she died. An autopsy established a diagnosis of Boerhaave syndrome and ulceration in the duodenal bulb. CONCLUSION: Boerhaave syndrome should be considered in all cases with a combination of gastrointestinal symptoms (especially epigastric pain and vomiting) and pulmonary signs and symptoms (especially suffocation).

RESUMO CONTEXTO: A síndrome de Boerhaave é uma ruptura longitudinal transmural espontânea do esôfago, normalmente da parte distal. Ela geralmente se desenvolve durante ou após vômitos persistentes como consequência do aumento repentino da pressão intraluminal no esôfago. É extremamente rara na prática clínica. Em 50% dos casos, manifesta-se pela tríade de Mackler: vômitos, dor torácica inferior, enfisema subcutâneo. Hematêmese é uma apresentação incomum porém desafiadora da síndrome de Boerhaave. Em comparação com rupturas de outras partes do tubo digestivo, a ruptura espontânea é caracterizada pela taxa de mortalidade mais elevada. RELATO DO CASO: O artigo apresenta uma paciente do sexo feminino de 64 anos de idade, cujo vômito era preto, quatro dias antes do exame, e continha sangue no dia do exame. Os sintomas incluíam dor epigástrica e sufocação. No exame físico, foi verificada hipotensão, taquicardia, dispneia e abdômen inchado e doloroso. Ausculta revelou estertores laterais na inspiração. A ultrassonografia mostrou estômago dilatado, preenchido com conteúdo líquido. Sucção nasogástrica evacuou mais de 1.000 ml de sangue fresco. Esofagogastroduodenoscopia foi abortada imediatamente ao se entrar no esôfago proximal, onde foi observada grande quantidade de sangue fresco. A paciente foi encaminhada com urgência para cirurgia abdominal, durante a qual faleceu. Autópsia estabeleceu diagnóstico de síndrome de Boerhaave e úlcera no bulbo-duodenal. CONCLUSÃO: A síndrome Boerhaave deve ser considerada em todos os casos com uma combinação de sintomas gastrointestinais (especialmente dor epigástrica e vómitos) e sintomas e sinais pulmonares (especialmente sufocação).

Transbronchial needle aspiration with rapid on-site evaluation: A prospective study on efficacy, feasibility and cost effectiveness.

Background. Transbronchial needle aspiration (TBNA) has an established role in diagnosis of hilar and mediastinal lesions. Rapid on-site evaluation (ROSE) of TBNA smears can determine the adequacy of TBNA smears that can obviate the need for repeat procedures, thus avoiding added cost. There is paucity of data from India showing efficacy and cost-effectiveness of ROSE. Hence, this study was carried out to assess the efficacy, feasibility and cost implications of ROSE assisted TBNA. Methods. Forty consecutive patients undergoing TBNA were enrolled and ROSE was performed on TBNA smears. The results were analysed using a comparative study design. Results. It was found that 45% of patients would have required a repeat bronchoscopy due to inadequacy of material, if ROSE was not used. Inadequate smears were more common in benign aetiologies than malignant ones. TBNA of mass lesions and lesions with endoluminal bulge give better results than TBNA of lymph nodes and without endoluminal bulge. Conclusions. ROSE was found to increase the yield of TBNA and help to prevent repeat procedures. It proved to be simple, cost-effective and feasible in Indian settings.

Tumor raro em mediastino: hamartoma / A rare mediastinum tumor: hamartoma

In the present paper we report a case of mediastinal tumor which we believe has never been reported. Since surgical treatment, the patient presented good evolution. We discuss the presentation, differential diagnosis and therapy. Finally, we stress the importance of the pathologic findings.

Boerhaave's syndrome: a differential diagnosis of acute chest pain following a vomiting illness / Síndrome de Boerhaave: un diagnóstico diferencial de dolor torácico, agudo tras enfermedad acompañada de vómitos

Spontaneous oesophageal rupture (Boerhaave's syndrome) is extremely rare in children. Presentation is usually in middle aged men as a result of vomiting following heavy food or alcohol consumption. We describe an unusual case of a 12-year old boy without significant past medical history presenting with acute chest pain following gastroenteritis.

La ruptura esofágica espontánea (síndrome de Boerhaave) es extremadamente rara en niños. Por lo general se presenta en hombres de mediana edad como resultado vómitos tras la ingestión de alcohol o alimentos pesados. Describimos un caso inusual de un niño de 12 años de edad sin antecedentes clínicos significativos, que acudió con dolor torácico agudo tras una gastroenteritis.

A case of mediastinal ectopic thyroid presenting with a paratracheal mass

Mediastinal ectopic thyroid is a very rare condition, with few reported cases in the literature and no reported cases in Korea. This report describes an asymptomatic 65-year-old man with a right paratracheal mass compressing the superior vena. Additionally, the epidemiology, clinical manifestation, diagnosis, and management of mediastinal ectopic thyroids are discussed. A mediastinal ectopic thyroid should be considered in the differential diagnosis of all mediastinal masses. Surgical excision is recommended for both the diagnosis and treatment of this condition, because of its potential for malignancy and compression of mediastinal structures. This case demonstrates the clinical importance of mediastinal etopic thyroid.

Inflammatory Pseudotumor in the Mediastinum: Imaging with 18F-Fluorodeoxyglucose PET/CT

Mediastinal inflammatory pseudotumor is a rare benign disease with its capability for local invasion and rapid growth. We present a case of middle-mediastinal inflammatory pseudotumor and report its contrast-enhanced chest computed tomography, 18F-fluorodeoxyglucose positron emission tomography/computed tomography and pathologic findings.

Neurofibroma arising from phrenic nerve.

We report a case of neurofibroma arising from the left phrenic nerve and not associated with neurofibromatosis in a 46-year-old male. The patient presented with gradually progressive breathlessness and pain in chest for six months. Radiological investigations revealed a posterior mediastinal mass on the left side of the chest. On postero-lateral thoracotomy, the resected tumour was found to be arising from the phrenic nerve. Histopathological examination confirmed it to be a neurofibroma. Absence of any other distinctive lesions of neurofibromatosis makes this an unusual presentation.

Cervical mediastinoscopy: Re-evaluation of an old technique in era of new imaging technology.

Context. With the advent of modern anatomical and functional imaging technologies, application of cervical mediastinoscopy has decreased in diagnosis and staging of mediastinal diseases. Aim. To evaluate the usefulness of cervical mediastinoscopy in assessing the mediastinal disease when imaging modalities are non-diagnostic. Settings and Design. Retrospective analysis of records of a tertiary care hospital. Patients and Methods. Thirty-nine patients with mediastinal pathology of varied aetiologies underwent cervical mediastinoscopy. Pre- and post-operative diagnosis was compared. Results. In 34 out of 39 cases (87.5%), cervical mediastinoscopy provided a confirmatory final diagnosis. One case had a major complication in the form of recurrent laryngeal nerve palsy. Conclusion. Cervical mediastinoscopy is useful, minimally invasive modality in a scenario where anatomical and functional imaging tools are non-diagnostic.

[Diagnostic yield of tran bronchial needle aspiration in mediastinal adenopathies]

Transbronchial needle aspiration [TBNA] is a minimally invasive alternative technique for evaluating mediastinal adenopathies. Transbronchial needle aspiration has proved its efficacy, safety, and cost-effectiveness in diagnosing and staging bronchogenic carcinoma as well as in diagnosing benign diseases such as sarcoidosis and tuberculosis. To evaluate the diagnostic yield of transbronchial needle aspiration in mediastinal adenopathies. The final diagnosis was evaluated for 122 patients investigated in division of chest diseases in Internal Medicine in Al-mowassat Hospital, Damascus University. Age of patients ranges 18-74 years.The technique was performed in cases of mediestinale denopathies confirmed by chest CT and non diagnosed by other procedures. we used standard flexible bronchoscopy model Olympus with 21 gauge needle for cytological examination. All patients had simple chest X.Ray and chest CT. 55 cases diagnosed by TBNA out of 99 cases [55,55%], 52 cases were malignant, and 3 cases were benign. . Diagnosis included: 41 cases carcinoma [26 NSCC, 14 SCC, 1 metastase], 8 lymphoma, 2 malignancy, 1 thymoma. Transpronchial needle aspiration was negative in 29 cases of malignancy confirmed by other procedures. 23 cases dropped because of inadecuate penetration [7 cases], discharged against medical advise [6 cases] and inadecuate information [10 cases]. 18 cases were benign, 3 cases of theme diagnosed by TBNA [16,66%]. This study demonstrate that TBNA is a minimally invasive diagnostic technique with a high yield in the diagnosis of mediastinal adenopathies. Malignancy and type of malignancy are major determinants of TBNA yield. TBNA based on CT should be considered an integral part of the bronchoscopic examination when evaluating patients for mediastinal adenopathies

Ruptura espontânea do esôfago: síndrome de Boerhaave / Spontaneous rupture of the esophagus: boerhaave's syndrome

Boerhaave's syndrome, the spontaneous rupture of the esophagus, is associated with a 35% death rate. Perforated esophagus is a surgical emergency; it is the most serious, and frequently the most rapidly lethal, perforation of the gastro-intestinal tract. Three cases of Boerhaave's syndrome are presented, with their variants and resolutions. Treatment and outcome are largely determined by the time of presentation. We reviewed our experience with esophageal perforations to determine the overall mortality and whether the time of presentation should influence management strategy.

Mediastinal hydatid disease: An unusual presentation.

Hydatid disease is a significant health problem in endemic areas. While occurrence of the cysts in the liver and lung is common, mediastinal localisation is extremely rare. We report the case of a 35-year-old male who presented with a painless swelling on the right side of the neck and features of superior vena caval obstruction. Chest radiography and computed tomography (CT) suggested a cyst in the right upper lobe, extending into the right supraclavicular region as well as another cyst in the left lung. Thoracotomy revealed that the right-sided cyst was actually mediastinal in location and had herniated through the thoracic inlet compressing the superior vena cava (SVC). Both cysts were removed in two separate operations and symptoms of SVC compression subsided after removal of the right-sided cyst. Histopathology was consistent with a hydatid disease.

Benign superior mediastinal syndrome due to intrathoracic tuberculosis in a child-association with endobronchial tuberculosis.

A 5-year-old boy presented with fever, cough, breathlessness and facial swelling. He was pale with distended veins over neck and chest, cervical and axillary lymphadenopathy and bilateral expiratory wheeze. Chest radiographs showed superior mediastinal widening. A computed tomography scan of the chest revealed mediastinal lymph nodes compressing superior vena cava and trachea. Bronchoscopy revealed nodular lesions in trachea and bronchi and compression of trachea. Broncho-alveolar lavage revealed acid fast bacilli. Diagnosis of superior mediastinal syndrome (SMS) secondary to tuberculosis was made and child was treated with antitubercular treatment along with oral prednisolone with good response.

Thymic atypical carcinoid.

Only 2% of carcinoids originate from the thymus with an estimated incidence of 1.5 to 3 per 10,000,000 persons per year. We present the case of a 30-year-old female patient in whom the diagnosis was confirmed by a fine needle aspiration cytology of a large mediastinal mass.

Tireoide ectópica no mediastino anterior: [revisão] / Ectopic thyroid in the anterior mediastinum: [review]

A ectopia de tireoide é rara, e a sua localização no mediastino anterior é excepcional, estando descritos apenas 5 casos nos últimos 30 anos. Os autores apresentam 2 casos clínicos, além de uma revisão da literatura abordando a etiologia, a embriologia e manifestações clínicas de ectopia de tireoide.

Ectopic thyroid is a rare condition, and its location in the anterior mediastinum is even rarer, there having been only 5 reported cases in the past 30 years. Here, we describe 2 clinical cases and present a review of the literature regarding the etiology, embryology and clinical manifestations of ectopic thyroid.

Presentación de un caso de absceso paraespinal derecho con proyección retromediastínica / Report of a case of right paraspinal abscess with retromediastinal projection

Los abscesos paraespinales son relativamente infrecuentes y los pacientes afectados son diabéticos, desnutridos, inmunosuprimidos. La morbilidad y mortalidad depende de la precocidad del diagnóstico y el germen más frecuente es el Staphylococcus aureus. Se presenta el caso de un hombre de 65 años que ingresó por absceso recurrente en la región posterior derecha del tronco y dolor dorsal con características radiculares y, a la palpación, de las apófisis espinosas T11 y T12. Se encontró anemia, eritrosedimentación acelerada y anfígeno de hepatitis B positivo. La tomografía computarizada mostró absceso derecho paravertebral, masa en ese lugar y destrucción parcial de T12. Se realizó abordaje posterior de Oshner y se comprobó el absceso con prolongación retromediastínica. La biopsia informó hiperplasia epidérmica, en la dermis y el tejido celular subcutáneo, agregados de células inflamatorias agudas y crónicas con focos de necrosis. La conclusión fue una inflamación crónica activa no específica y el germen aislado fue un Staphylococcus aureus. El paciente egresó a las 6 semanas después de operado, con incremento de peso y la piel totalmente cerrada.

Paraspinal abscesess are relatively unfrequent and the affected patients are diabetic, malnourished, and immunosupressed. Morbidity and mortality depend on the precocity of the diagnosis. The most common germ is Staphylococcus aureus. The case of a 65-year-old male patient that was admitted due to recurrent abscess on the right posterior region of the trunk and dorsal pain with radicular characteristics and, on palpation, of the spinous apophises T11 and T12 vertebrae. Anemia, accelerated erythrosedimentation and hepatitis B positive antigen were found. The computerized tomography showed right paravertebral abscess, a mass in that place and partial destruction of T12. Oshner's posterior approach was performed and the abscess with retromediastinal prolongation was confirmed. The biopsy reported epidermal hyperplasia in the dermis and in the subcutaneous cellular tissue, and aggregates of acute and chronic inflammatory cells. The isolated germ was a Staphylococcus aureus. The patient was discharged 6 weeks after surgery with weight gain and the skin completely closured.

Fine needle aspiration cytology of anterior mediastinal masses.

OBJECTIVE: The main aim of the study is to evaluate the computed tomography (CT)-guided fine needle aspiration cytology (FNAC) of anterior mediastinal mass as a diagnostic procedure. MATERIALS AND METHODS: In all 135 cases, the material was obtained by CT-guided FNAC technique followed by staining with Papanicolaou and May-Grunwald-Giemsa stains. The histological material was obtained by needle biopsies, wedge biopsies and resection specimens. Immunohistochemical stains were used to confirm diagnosis in selected cases. RESULTS: Among 135 cases, cytohistology correlation was found in 92 cases. Correct typing was done in 53.33% cases. No correlation was found in 14.81% cases. Material was unsatisfactory in 18.51% cases. The diagnostic accuracy and positive predictive values were 85.71% and 78.26%, respectively. CONCLUSION: Although there are some limitations, most lesions of the anterior mediastinum can be diagnosed on FNAC.