PMC6699471_01
Posterior-Anterior chest x-ray, showing small right sided pleural effusion with interstitial reticular infiltrate, kerley B-lines and prominent right pulmonary fissure.
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Chest x-ray showed mild right-sided pleural effusion with prominent interstitial markings on the right lung (Fig. 1).
[A;Axial, B;Coronal oblique] Chest CT images showing a large anterior mediastinal mass extending along the left brachiocephalic vein and SVC resulting in their obstruction, It encircled the ascending aorta and aortic arch. It also extended along the pericardium resulting in infiltration and extension to the posterolateral right atrial wall as well as infiltration of the right atrial appendage, the right atrial mass measured 4.5 x 4.3 x 4.8 cm in its largest diameters, it continued its extension along the pericardium to adhere to and infiltrate the left ventricle. Multiple anterior mediastinal lymph nodes were also appreciated as well as pleural deposits along the right crus of the diaphragm with few small retrocrural lymph nodes. [C; Axial, D; Coronal] CMR images showing complete resolution of the mass with normal chamber sizes, valves and EF, but small size SVC, with dilated IVC and azygous vein.
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ATT for a total of 9 months complicated by atrial flutter that was treated using ablation. A cardiac magnetic resonance was done after three years of treatment for follow-ups instead of CT because the patient developed an allergic reaction to the contrast, it showed complete resolution of the mass (Fig. 2, Panel C, D).
[A; Low power light microscopy picture x 200] showing chronic granulomatous inflammation. [B; high magnification light microscopy picture x 400] showing epithelioid granuloma containing giant cells.
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Mediastinotomy and biopsy from the mass were done showing necrotizing granulomatous inflammation and giant cells (Fig. 4).