This was a 30 year-old Caucasian-American male who had a past medical history that was significant for community acquired pneumonia and migraines. He presented to the clinic with a chief complaint of dysphagia for solids and weight loss. Chest x-rays both of the PA and lateral view were negative and without lymphadenopathy. A CT scan of the thorax was performed and was significant for the presence of a 2.8 x 2.9 cm mass in the sub carinal region causing external compression of the esophagus.
An upper endoscopy was performed which revealed intraluminal bulging as seen here.
Linear endoscopic ultrasound was performed and was significant for the presence of a 3 x 3cm mediastinal mass extending into the esophagus, creating external compression.
FNA was then performed with a 19 gauge needle. The specimen was significant for the presence of pus. Numerous passes revealed similar findings.
On endoscopic inspection of the FNA site, there was a small area of purulent discharge noted as seen here. As a result of this finding, jumbo biopsies were used to take biopsies of the overlying mucosa as well as deep well biopsies. This was done in an attempt to deroof the abscess cavity. As deeper biopsies were taken there was large amount of pus seen flowing from the lesion.
Given the location of the lesion and the presence of pus histoplasmosis was suspected as the etiology. Cultures and serum testing confirmed presence of active histoplasmosis.
Pulmonary histoplasmosis is rarely complicated by large, encapsulated, caseous mediastinal lymph nodes. This is also known as mediastinal granuloma. Overall, mediastinal granuloma causes low morbidity and is amenable to treatment. Compression of compliant structures such as the esophagus, pulmonary vessels, and occasionally the airways may result in a variety of symptoms including chest pain, cough, odynophagia, or as in our patient dysphagia. Rarely a bronchoesophageal or tracheoesophageal fistula may occur.
Our patient was treated with voriconazole and at present he is doing well.
Mankawal S. Sachdev, MD,