PUI: Previously unexpected incidentaloma

Case Report Viral infections are among the leading causes for pediatric patients to present in both primary care and emergency department settings With the advent of telehealth, and its expanded use during the COVID-19 pandemic, pediatric patients are increasingly diagnosed and managed supportively without key portions of the physical exam Viral illnesses will often be suspected in children until they develop more severe symptoms such as chest pain, severe cough, or dyspnea as could be seen with an expanding anterior mediastinal mass This case report reviews an incidental diagnosis of a thymic teratoma spurred by workup of an otherwise benign COVID- 19 concern Case A previously healthy 2-year-old female had a fever, rhinorrhea, cough, and diarrhea for 5 days She was evaluated at a local Urgent Care, due to concern for COVID-19, where she was well-appearing without concerning symptoms on history Her exam, however, was pertinent for diminished breath sounds on the right chest that prompted an x-ray showing a large right-sided opacification and necessitating transfer to the Children's of Alabama A subsequent CT revealed a heterogeneous thymic mass Oncology and surgery consultations were obtained and the patient underwent urgent surgical resection Pathology confirmed the diagnosis of mature thymic teratoma Discussion Anterior mediastinal masses represent a broad differential including neoplasms such as thymomas, teratomas, and lymphomas Mature teratomas comprise roughly 70% of mediastinal germ cell tumors in children Patients are often initially asymptomatic with incidental diagnosis upon evaluation of other illnesses While definitive diagnosis lies in pathology, initial suspicion is often raised with CT/MRI demonstrating a heterogeneous mass Surgery is typically curative, though there are reported associations with hematologic malignancy Reported cases of thymic teratomas in children typically describe presenting symptoms as compressive complications secondary to delayed diagnosis We are unaware of previous cases diagnosed during the workup of a possible COVID-19 infection As we have anecdotally seen patients avoiding medical care centers due to COVID-19 concerns, this case emphasizes the importance of recognizing red flag symptoms and completing physical exams in a time of increasing telehealth dependence