School of Medicine and Health Sciences Poster Presentations
Cracking the Case
Poster Number
148
Document Type
Poster
Publication Date
3-2016
Abstract
Chest pain is one of the most common chief complaints encountered by internists. It is important to recognize less common etiologies in a young healthy patient without cardiac risk factors or associated gastrointestinal or pulmonary symptoms. This case presented a 37-year-old female without any past medical history who presented with five days of constant, progressive, central pleuritic chest pain despite non-steroidal anti-inflammatory use. She had an associated non-productive cough with exquisite tenderness to palpation from the mid sternum to the xiphisternal junction with an otherwise normal cardiopulmonary exam. Imaging revealed a widened mediastinum. Although conventionally taught to immediately associate a widened mediastinum on chest x-ray with an ascending aortic dissection, in this patient who had no alarming symptoms to suggest this diagnosis, it was important to develop a broad differential for her widened mediastinum as treatment and outcomes vary drastically. The differential can be categorized into one of the following: traumatic, infectious, inflammatory/autoimmune, neoplastic, anatomic and vascular. In this patient who denied trauma and was afebrile without a leukocytosis but had significant lymphadenopathy, the differential narrowed fairly quickly. It was further narrowed when a sternal fracture with an anterior mediastinal mass was found. A mediastinal biopsy revealed classic bi-nucleated Reed-Sternberg cells, confirming Hodgkin’s Lymphoma.
This case highlights the importance of creating a broad differential diagnosis for chest pain including anterior mediastinal mass in the appropriate setting. While sternal fracture without trauma is a rare cause of chest pain, clinicians should consider it especially in the presence of an anterior mediastinal mass. Sternal fractures are most commonly due to trauma. Less commonly such fractures can be due to secondary malignancy, myeloma and rarely osteoporosis, frequently in the setting of glucocorticoid use. In this patient’s case, it was caused by contiguous spread of Hodgkin’s disease. Osseous involvement occurs in 5-20% of patients with Hodgkin’s disease, but is only observed in 1-4% of cases at initial presentation. When present at diagnosis, the sternum is the most common site affected.
Creative Commons License
This work is licensed under a Creative Commons Attribution-Noncommercial-No Derivative Works 4.0 License.
Open Access
1
Cracking the Case
Chest pain is one of the most common chief complaints encountered by internists. It is important to recognize less common etiologies in a young healthy patient without cardiac risk factors or associated gastrointestinal or pulmonary symptoms. This case presented a 37-year-old female without any past medical history who presented with five days of constant, progressive, central pleuritic chest pain despite non-steroidal anti-inflammatory use. She had an associated non-productive cough with exquisite tenderness to palpation from the mid sternum to the xiphisternal junction with an otherwise normal cardiopulmonary exam. Imaging revealed a widened mediastinum. Although conventionally taught to immediately associate a widened mediastinum on chest x-ray with an ascending aortic dissection, in this patient who had no alarming symptoms to suggest this diagnosis, it was important to develop a broad differential for her widened mediastinum as treatment and outcomes vary drastically. The differential can be categorized into one of the following: traumatic, infectious, inflammatory/autoimmune, neoplastic, anatomic and vascular. In this patient who denied trauma and was afebrile without a leukocytosis but had significant lymphadenopathy, the differential narrowed fairly quickly. It was further narrowed when a sternal fracture with an anterior mediastinal mass was found. A mediastinal biopsy revealed classic bi-nucleated Reed-Sternberg cells, confirming Hodgkin’s Lymphoma.
This case highlights the importance of creating a broad differential diagnosis for chest pain including anterior mediastinal mass in the appropriate setting. While sternal fracture without trauma is a rare cause of chest pain, clinicians should consider it especially in the presence of an anterior mediastinal mass. Sternal fractures are most commonly due to trauma. Less commonly such fractures can be due to secondary malignancy, myeloma and rarely osteoporosis, frequently in the setting of glucocorticoid use. In this patient’s case, it was caused by contiguous spread of Hodgkin’s disease. Osseous involvement occurs in 5-20% of patients with Hodgkin’s disease, but is only observed in 1-4% of cases at initial presentation. When present at diagnosis, the sternum is the most common site affected.
Comments
Presented at: GW Research Days 2016