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Weekly Chest CasesArchive of Old Cases

Case No : 1047 Date 2017-11-20

  • Courtesy of Su Jin Lim, Hyun Jung Koo, Eun Jin Chae / Asan Medical Center, University of Ulsan College of Medicine
  • Age/Sex 74 / M
  • Chief Complaintacute-onset dyspnea and left chest pain
  • Figure 1
  • Figure 2
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Diagnosis With Brief Discussion

Diagnosis
Pancreatic pseudocyst of the mediastinum
Radiologic Findings
Fig 1. Chest PA shows large left pleural effusion with basal lung atelectasis.
Fig 2-8. On CT image, multiloculated left pleural effusion with pleural enhancement is noted. Multiloculated fluid collection with peripheral enhancement is also noted in the posterior mediastinum, around the esophagus and at the posterior aspect of pericardium. The lesion extends inferiorly along the posterior wall of the esophagus, gastroesophageal junction, stomach and into the peripancreatic region.
Fig 9-12. On coronal reconstructed image, fluid collection communicated with dilated pancreatic duct in the region of the pancreas tail. These findings suggest disruption of the pancreatic duct, rupture of pseudocyst and extension of pancreatic fluid to the mediastinum and the pleura.
The levels of amylase and lipase were elevated of 397 and 342 U/L on the analysis of left pleural effusion.
Brief Review
Pancreatic pseudocysts are a common complication of both acute and chronic pancreatitis. They are usually located in peripancreatic area and very rarely they may reach the mediastinum.
Patho-physiologically, mediastinal pseudocyst can develop after rupture of the pancreatic duct into the retroperitoneal space. The pancreatic fluid then tracks through the diaphragmatic openings such as esophageal and aortic hiatus into the mediastinum.
Symptoms are primarily the results of compression or invasion of the mediastinal structures and may include dysphagia, odynophagia, weight loss, abdominal, chest and/or back pain, dyspnea, and cough.
A chest radiograph may be undiagnostic but can show retrocardiac opacity, pleural effusion, and atelectasis of basal lungs. Contrast-enhanced CT scan can show a thin-walled low-attenuating cystic mass extended from the pancreas into the mediastinum. Magnetic resonance cholangiopancreatography can help identify the connection between the mediastinal and abdominal pseudocyst in cases where it not so evident on CT scan. Endoscopic ultrasound is increasingly used in evaluating pancreatic cysts due to its advantages in delineating contents and wall of the cysts.
An elevated amylase or lipase level in the aspirated fluid from the mediastinal pseudocyst can confirm the diagnosis.
Spontaneous regression of mediastinal pseudocysts is rare and therapeutic intervention is frequently required. It includes surgical drainage such as open laparotomy and percutaneous approach, and endoscopic drainage methods.
Pseudocysts should be considered as a differential diagnosis in the evaluation of mediastinal masses in patents with a history of pancreatitis.
References
1. Drescher R, Koster O, Lukas C. Mediastinal pancreatic pseudocyst with isolated thoracic symptoms: a case report. Journal of Medical Case Reports 2008, 2:180.
2. Gupta R, Munoz JC, Garg P, et al. Mediastinal Pancreatic Pseudocyst-A Case Report and Review of the Literature. Medscape General Medicine. 2007; 9(2): 8.
3. Kirchner SG, Heller RM, Smith CW. Pancreatic pseudocyst of the Mediastinum. Radiology 1997, 123:32-42.
Please refer to
Case 866
Keywords
Mediastinum, Pleura,

No. of Applicants : 90

▶ Correct Answer : 58/90,  64.4%
  • - Hyogo Prefectural Amagasaki General Medical Center , Japan TOMOAKI OTANI
  • - Saitama-Sekishinkai Hosptal , Japan MIHOKO YAMAZAKI
  • - Kinki University Faculty of Medicine, , Japan MITSURU MATSUKI
  • - Showa University Fujigaoka Hospital , Japan KYOKO NAGAI
  • - Niigata University , Japan ATSUSHI UEHARA
  • - Higashi-Ohmi General Medical Center , Japan AKITOSHI INOUE
  • - The University of Tokyo Hospital , Japan Akifumi Hagiwara
  • - , Korea (South) HANKYUL KIM
  • - IRSA LA ROCHELLE , France, Metropolitan BIGOT
  • - Ajou university hospital , Korea (South) Pae Sun Suh
  • - The University of Tokyo Hospital , Japan Yusuke Watanabe
  • - Vita Hospital , Brazil DIOGO LAGO PINHEIRO
  • - Other , Korea (South) HEE SEOK CHOI
  • - Other , Korea (South) SEONG SU KANG
  • - Prince Sattam ibn Abdulaziz University hospital , Saudi Arabia ELBAGIR MOHAMED NASSIR
  • - Freelance resident in Reunion Island , Reunion Fabien HO
  • - Amagasaki General Medical Center , Japan GENKI FUKUMOTO
  • - Oita University, Faculty of Medicine , Japan Fumito Okada
  • - Beaulieu clinic Geneva , Switzerland gilles GENIN
  • - The Jikei university , Japan TAKU GOMI
  • - Onomichi municipal hospital , Japan Hirofumi Mifune
  • - The University of Tokyo Hospital , Japan TOSHIHIRO FURUTA
  • - Seoul National University Hospital , Korea (South) JI EUN KIM
  • - Chung buk national university hospital , Korea (South) hong gwon Byun
  • - Gifu University Hospital , Japan Yo Kaneko
  • - VDC, HYDERABAD , India KARTHIK RAYASAM
  • - Dong-A University, College of Medicine , Korea (South) KI-NAM LEE
  • - Kurashiki Central Hospital , Japan TORU KONISHI
  • - , United Kingdom KRISHNA PRASAD PREMNATH BELLAM
  • - Seoul National University Bundang Hospital , Korea (South) YOUNGJUNE KIM
  • - Samsung Medical Center , Korea (South) KYOWON GU
  • - Mallinckrodt Institute of Radiology , United States Naganathan BS Mani
  • - CLINIQUE STE CLOTILDE , Reunion PATRICK MASCAREL
  • - Diskapi Yildirim Beyazit Hospital, Ankara , Turkey MERIC TUZUN
  • - Other , Korea (South) HAYEON LEE
  • - University of Tsukuba, Dept of Radiology , Japan MANABU MINAMI
  • - Chungbuk national university hospital , Korea (South) Miran Yeon Yeon
  • - Azienda Ospedaliera di Cremona , Italy Pietro Sergio
  • - Chonbuk National University Hospital , Korea (South) KUM JU CHAE
  • - The University of Tokyo Hospital , Japan TAKU TAJIMA
  • - , United Arab Emirates GAGAN WAHI
  • - Yujin Yamazaki Hospital , Japan MASASHI TAKAHASHI
  • - Escola Paulista de Medicina , Brazil RENATO MASSON DE ALMEIDA PRADO
  • - Korea university medical center, guro hospital , Korea (South) Lee kyu chong
  • - Fortis hospital , Mohali , India SHALEEN RANA
  • - The First Affiliated Hospital of Nanjing Medical University , China ZHANG TENG
  • - Kizawa Memorial Hospital , Japan Shoji Okuda
  • - Ajou University Hospital , Korea (South) SUBIN HEO
  • - Teikyo University Hospital , Japan KAORU SUMIDA
  • - Ichinomiya Nishi Hospital , Japan Takao Kiguchi
  • - Seoul National University Hospital , Korea (South) YONGSUB SONG
  • - University of Tsukuba , Japan Toshitaka Ishiguro
  • - Pusan national university hospital , Korea (South) Jin Joo Kim
  • - University of Utah , United States AKIHIKO SAKATA
  • - Ajou University Hospital , Korea (South) YONG HO JANG
  • - Chungbuk National University Hospital , Korea (South) HYEONMI RYU
  • - Ewha Womans University Hospital , Korea (South) YOOKYUNG KIM
  • - Ajou University Hospital , Korea (South) YOO YOUNGJIN
▶ Correct Answer as Differential Diagnosis : 7/90,  7.8%
  • - ZIGONG TCM HOSPITAL OF CHINA , China Cao Cunyou
  • - Chonnam National University Hospital , Korea (South) JONG HYEON KIM
  • - HHS , Canada S LEE
  • - University of Tsukuba Hospital , Japan HIROAKI TAKAHASHI
  • - , Brazil MARCEL KOENIGKAM SANTOS
  • - ALHAYAH SCAN RADIOLOGY CENTER , Egypt ELSAYED ELSAYED MOUSA
  • - District TB centre, kasaragod,India , India rikhy krishnan
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