Mediastinal Mass with Unusual Etiology.

1. Sneha Butala, MD* 2. Saloni Sheth, MD* 3. Keval Parikh, MD† 4. Connie Piccone, MD‡,§ 1. *Department of Pediatrics, Rainbow Babies and Children’s Hospital, Cleveland, OH 2. †Department of Radiology, University Hospitals Cleveland Medical Center, Cleveland, OH 3. ‡Department of Pediatrics, Division of Pediatric Hematology Oncology, Rainbow Babies and Children’s Hospital, Cleveland, OH 4. §Case Western Reserve University, Cleveland, OH A 15-year-old previously healthy female presents to an emergency department with chest pain. The chest pain developed acutely 1 day prior to presentation without an identifiable trigger. It was initially mild but progressed to a level of 7 out of 10 over 24 hours and radiated to her shoulders. She further developed associated dyspnea with deep inspiration, prompting her to seek care. She reports no history of fever, cough, headache, chills, night sweats, or weight loss. She has had no recent illness or known sick contacts. She moved from northern California to Ohio 2 years prior but reports no other recent travel. Her immunizations are up to date. Her past medical history is significant for 2 previous episodes of community-acquired pneumonia of unknown etiology. These infections occurred when she was a young child, but neither required hospitalization. She is not on any medications and has no known allergies. She reports no sexual activity or recreational drug use. She is hemodynamically stable and well-appearing. Her physical examination is pertinent for mild tenderness to palpation over the sternum. An electrocardiogram demonstrates sinus tachycardia. Her complete blood cell count reveals mild leukopenia of 1.6 × 109/L. The complete metabolic panel is normal. Her D-Dimer is elevated to 562 ng/mL fibrinogen equivalent unit (normal ≤ 500 ng/mL fibrinogen equivalent unit). A chest radiograph demonstrates asymmetric fullness of the right hilar region (Fig 1). A computed tomography (CT) pulmonary angiogram demonstrates no pulmonary embolism; however, a 2.8 × 3.1 × 3.8 cm (anteroposterior × transverse × craniocaudal dimensions) anterior mediastinal soft tissue mass is seen exerting minimal mass effect with effacement of the distal trachea and anterior displacement of the left brachiocephalic vein (Fig 2). Additionally, a 2.0-cm right hilar mass (Fig 3) and 3 pulmonary nodules measuring up to 0.8 cm are …