Skip to main content

Main menu

  • Home
  • COVID-19
    • Articles & podcasts
    • Blog posts
    • Collection
    • News
  • Content
    • Current issue
    • Past issues
    • Early releases
    • Collections
    • Sections
    • Blog
    • Infographics & illustrations
    • Podcasts
    • Classified ads
  • Authors
    • Overview for authors
    • Submission guidelines
    • Submit a manuscript
    • Forms
    • Editorial process
    • Editorial policies
    • Peer review process
    • Publication fees
    • Reprint requests
  • CMA Members
    • Overview for members
    • Earn CPD Credits
    • Print copies of CMAJ
    • Career Ad Discount
  • Subscribers
    • General information
    • View prices
  • Alerts
    • Email alerts
    • RSS
  • JAMC
    • À propos
    • Numéro en cours
    • Archives
    • Sections
    • Abonnement
    • Alertes
  • CMAJ JOURNALS
    • CMAJ Open
    • CJS
    • JAMC
    • JPN

User menu

Search

  • Advanced search
CMAJ
  • CMAJ JOURNALS
    • CMAJ Open
    • CJS
    • JAMC
    • JPN
CMAJ

Advanced Search

  • Home
  • COVID-19
    • Articles & podcasts
    • Blog posts
    • Collection
    • News
  • Content
    • Current issue
    • Past issues
    • Early releases
    • Collections
    • Sections
    • Blog
    • Infographics & illustrations
    • Podcasts
    • Classified ads
  • Authors
    • Overview for authors
    • Submission guidelines
    • Submit a manuscript
    • Forms
    • Editorial process
    • Editorial policies
    • Peer review process
    • Publication fees
    • Reprint requests
  • CMA Members
    • Overview for members
    • Earn CPD Credits
    • Print copies of CMAJ
    • Career Ad Discount
  • Subscribers
    • General information
    • View prices
  • Alerts
    • Email alerts
    • RSS
  • JAMC
    • À propos
    • Numéro en cours
    • Archives
    • Sections
    • Abonnement
    • Alertes
  • Visit CMAJ on Facebook
  • Follow CMAJ on Twitter
  • Follow CMAJ on Pinterest
  • Follow CMAJ on Youtube
  • Follow CMAJ on Instagram
SynopsisC

A 36-year-old man with hemoptysis

Darrell Tan, Michael Hutcheon and Tae Bong Chung
CMAJ September 14, 2004 171 (6) 573; DOI: https://doi.org/10.1503/cmaj.1040557
Darrell Tan
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Michael Hutcheon
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Tae Bong Chung
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • Article
  • Figures & Tables
  • Responses
  • Metrics
  • PDF
Loading
  • © 2004 Canadian Medical Association or its licensors

A 36-year-old previously healthy man from southwestern Ontario presented to the emergency department with an episode of cough producing 50 mL of bright red blood after a 2-week history of coughing up green sputum. He was otherwise asymptomatic, and his physical examination was unremarkable. A chest radiograph showed mild airspace disease at the left lung base. A CT scan of the thorax with intravenous contrast medium revealed narrowing of the left descending pulmonary artery and an increase in soft tissue in the mediastinum, with extensive calcification in the subcarinal and left hilar region (Fig. 1, white arrows). This soft tissue extended posterior to the left atrium and along the left posterior mediastinum (Fig. 2, black arrows). The right inferior pulmonary vein was normal (Fig. 2, arrowhead), but the left inferior pulmonary vein was unopacified, indicating occlusion (Fig. 2, white arrow). Interlobular septal thickening due to venous obstruction (image not shown) within the left lower lobe was seen. The findings were pathognomonic of fibrosing mediastinitis. Bronchoscopy with bronchoalveolar lavage was performed to rule out other causes of hemoptysis. The patient was otherwise well and was discharged home, but 1 month later he reported mild dyspnea and chest discomfort, and he was given prednisone at 0.5 mg/kg daily. His symptoms improved over the next month.

Figure1
  • Download figure
  • Open in new tab
  • Download powerpoint

Figure 2.

Figure2
  • Download figure
  • Open in new tab
  • Download powerpoint

Figure 1.

Fibrosing mediastinitis is characterized by the proliferation of fibrous tissue in the mediastinum, which usually arises as a rare (< 1%), late complication of Histoplasma capsulatum infection in regions where the fungus is endemic.1,2 In North America, these regions include the St. Lawrence River valley, southwestern Ontario, and the central, mid-Atlantic and southeastern states, particularly in the Ohio and Mississippi River valleys. Because the fungus is common in soils contaminated with bat or bird droppings, people who work with soil are at increased risk for histoplasmosis. Immunocompromised people are at particular risk for disseminated infection. Fibrosing mediastinitis fibrosis appears to arise when fungal antigen spills out of mediastinal lymph nodes and precipitates an extensive fibrotic immune response, resulting in encasement of mediastinal structures.2 Risk factors for the disease are uncertain, although male predilection, an association with idiopathic retroperitoneal fibrosis and a correlation with human leukocyte antigen-A2 have been reported.3 The most common manifestation is superior vena cava syndrome, which leads to dyspnea, facial plethora and neck distention. Compression of the bronchopulmonary tree may cause obstructive respiratory symptoms and infections, and esophageal involvement may lead to dysphagia. Pulmonary venous involvement may cause pulmonary edema, resulting in interlobular septal thickening, as seen in our patient. Hemoptysis may result from postobstructive necrotizing pneumonia, pulmonary venous hypertension or the development of fistulas between the pulmonary and bronchial arterial circulations. Mortality has been reported to be as high as 30%.1

Diagnosis usually rests on a combination of typical clinical and radiographic findings on CT or MRI. Biopsy may be required in areas where Histoplasma is not endemic. Tissue culture is typically sterile. Serologic studies and fungal antigen testing for M and H bands are generally not helpful, since these tests are useful only for diagnosing acute infection. Antifungal agents and corticosteroids have been used in some cases, but there is little evidence of clinical benefit and these agents are generally not recommended unless there is active infection or inflammation.4 Surgery may be indicated for decompression of airway, vascular or esophageal obstruction.

Darrell Tan Department of Internal Medicine Michael Hutcheon Division of Respiratory Medicine University Health Network Toronto General Hospital Tae Bong Chung Department of Medical Imaging University of Toronto University Health Network and Mount Sinai Hospital Toronto, Ont.

References

  1. 1.↵
    Loyd JE, Tillman BF, Atkinson JB, Des Prez RM. Mediastinal fibrosis complicating histoplasmosis. Medicine (Baltimore) 1988;67:295-310.
  2. 2.↵
    Wheat LJ. Histoplasmosis susceptibility in humans. In: Jacobs PH, Nall L, editors. Fungal disease. New York: Marcel Dekker; 1997. p. 239.
  3. 3.↵
    Peebles RS, Carpenter CT, Dupont WD, Loyd JE. Mediastinal fibrosis is associated with human leukocyte antigen-A2. Chest 2000;117:482-5.
    OpenUrlCrossRefPubMed
  4. 4.↵
    Wheat J, Sarosi G, McKinsey D, Hamill R, Bradsher R, Johnson P, et al. Practice guidelines for the management of patients with histoplasmosis. Clin Inf Dis 2000;30:688-95.
    OpenUrlFREE Full Text
PreviousNext
Back to top

In this issue

Canadian Medical Association Journal: 171 (6)
CMAJ
Vol. 171, Issue 6
14 Sep 2004
  • Table of Contents
  • Index by author

Article tools

Respond to this article
Print
Download PDF
Article Alerts
To sign up for email alerts or to access your current email alerts, enter your email address below:
Email Article

Thank you for your interest in spreading the word on CMAJ.

NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

Enter multiple addresses on separate lines or separate them with commas.
A 36-year-old man with hemoptysis
(Your Name) has sent you a message from CMAJ
(Your Name) thought you would like to see the CMAJ web site.
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
Citation Tools
A 36-year-old man with hemoptysis
Darrell Tan, Michael Hutcheon, Tae Bong Chung
CMAJ Sep 2004, 171 (6) 573; DOI: 10.1503/cmaj.1040557

Citation Manager Formats

  • BibTeX
  • Bookends
  • EasyBib
  • EndNote (tagged)
  • EndNote 8 (xml)
  • Medlars
  • Mendeley
  • Papers
  • RefWorks Tagged
  • Ref Manager
  • RIS
  • Zotero
‍ Request Permissions
Share
A 36-year-old man with hemoptysis
Darrell Tan, Michael Hutcheon, Tae Bong Chung
CMAJ Sep 2004, 171 (6) 573; DOI: 10.1503/cmaj.1040557
Digg logo Reddit logo Twitter logo Facebook logo Google logo Mendeley logo
  • Tweet Widget
  • Facebook Like
  • Google Plus One

Jump to section

  • Article
    • References
  • Figures & Tables
  • Responses
  • Metrics
  • PDF

Related Articles

  • No related articles found.
  • PubMed
  • Google Scholar

Cited By...

  • No citing articles found.
  • Google Scholar

More in this TOC Section

  • Applying the 2005 Canadian Hypertension Education Program recommendations: 4. Managing uncomplicated hypertension
  • A newborn requiring selective bronchial intubation
  • Does β-blocker prophylaxis improve survival after major noncardiac surgery?
Show more Synopsis

Similar Articles

Collections

  • Topics
    • Respiratory medicine

Content

  • Current issue
  • Past issues
  • Collections
  • Sections
  • Blog
  • Podcasts
  • Alerts
  • RSS
  • Early releases

Information for

  • Advertisers
  • Authors
  • Reviewers
  • CMA Members
  • Media
  • Reprint requests
  • Subscribers

About

  • General Information
  • Journal staff
  • Editorial Board
  • Governance Council
  • Journal Oversight
  • Careers
  • Contact
  • Copyright and Permissions

Copyright 2021, Joule Inc. or its licensors. All rights reserved. ISSN 1488-2329 (e) 0820-3946 (p)

All editorial matter in CMAJ represents the opinions of the authors and not necessarily those of the Canadian Medical Association or its subsidiaries.

Powered by HighWire