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Elderly Woman With Dyspnea
and a Large Mediastinal Mass

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BACKGROUND

An 89-year-old woman with a 25-year history of hypertension presents to the emergency department because of progressive dyspnea that began 6 months ago. It first occurred with minimal exertion, and now it occurs at rest. She denies having chest pain, cough, fevers, orthopnea, paroxysmal nocturnal dyspnea, or lower extremity edema. She has never been hospitalized and does not recall ever undergoing chest radiography. Her medications include atenolol, lisinopril, and hydrochlorothiazide.

Physical examination reveals a blood pressure of 170/90 mm Hg in her right arm and 168/88 mm Hg in her left arm, a heart rate of 65 beats per minute, a respiratory rate of 26 breaths per minute, a temperature of 36.8°C, and an oxygen saturation of 88% on room air. The patient is alert and oriented and noted to be in mild respiratory distress. She has no jugular venous distension, her radial pulses are equal, and her lungs are clear to auscultation. Heart sounds are muffled anteriorly but present below the left scapula posteriorly. No cardiac murmurs are present. The rest of the physical examination findings are unremarkable.

An ECG demonstrates a normal sinus rhythm and left ventricular hypertrophy on the basis of voltage criteria. A chest radiograph showed a well-defined, diffusely enlarged mediastinum that occupies two thirds of the width of the chest (see Image 1). A CT scan is obtained to further define the mediastinal structure (see Image 2).

What is the diagnosis?

Hint
Follow the course and contour of the structure shown.

Authors:	Wissam Derian, MD, Division of Cardiology, Advocate Lutheran General Hospital, Park Ridge, Ill Michael J. Rosenberg, MD, Division of Cardiology, Advocate Lutheran General Hospital, Park Ridge, Ill

eMedicine Editor:	Erik D. Schraga, MD, Department of Emergency Medicine, Kaiser Permanente, Santa Clara Medical Center, Calif

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