1 Case Of Posterior Mediastinal Inflammation Accompanied With Hematoma And Review Of Literature

ObjectiveIn this paper,we report a rare case about posterior mediastinal inflammation(PMI)accompanied with hematoma.And through the studying of numerous domestic and international relevant reviews,we aim to strengthen the clinicians’ awareness of space-occupying lesion of non-tumor in the posterior mediastinum.Thus we can improve the ability of diagnosis and differential diagnosis,to reduce the misdiagnosis and mistreatment.MethodsUsing the retrospective analysis,we reviewed the clinical diagnosis and treatment of one case of posterior mediastinal inflammation with hematoma,combined with literature review,which were published from January 2007 to December 2016,10 years of domestic and foreign public magazine,at a total number of 30 cases report of posterior mediastinal hematoma(PMH).We compared,analyzed,collated,and summarized their clinical features,including the occurrence of the site,incentives,the basic disease,the main means of examination,the misdiagnosed diseases,treatment and prognosis.ResultsIn this case,the patient was confirmed by contrast-enhanced magnetic resonance imaging(eMRI)and CT guided needle biopsy(CT-GNB)of the posterior mediastinal mass.After giving positive anti-inflammatory,hemostatic and other symptomatic treatment,the disease was relieved and the lesion was significantly reduced.Then we reviewed 30 cases reported in the literature and the characteristics of posterior mediastinal hematoma are summarized as follows:(1)The sites of hematoma: 9 cases of hematoma located in the posterior mediastinum;9 cases of hematoma located in posterior mediastinum combined with thoracic cavity;5 cases of hematoma located in posterior mediastinum,mediastinal septum and thoracic cavity;5 cases of hematoma located in posterior mediastinum and retropharyneal sites;while other 2 cases even permeated posterior peritoneum or other sites.(2)Predisposing factors: 18 cases with definite inducement(60.0%)and 12 cases with unknown causes(40.0%).Among the 18,anticoagulant therapy in 2 cases(6.7%),history of trauma in 5 cases(16.7%),iatrogenic operation in 6 cases(16.7%),severe cough in 1 case(3.3%),vomiting occurred in 2 cases(6.7%),diet related 2 cases(6.7%),heavy physical induction in 2 case(6.7%).(3)Basic disease: There were 21 cases of chronic diseases such as heart,brain,lung,liver,kidney and endocrine system(70.0%),and there were 9 cases without basic diseases or underlying diseases were unknown(30.0%).(4)Onset mode: Acute onset of 28 cases,accounting for 93.3%;chronic onset in 2 cases,accounting for 6.7%.(5)Bleeding sources: 9 cases of aortic hemorrhage,accounting 30%;3 cases of large and medium-sized venous hemorrhage,accounting10.0%;as well as 8 cases from other definited veins,accounting 26.7%;while still 10 bleeding souse unknown,accounting 33.3%.(6)Clinical symptoms: chest pain as the first manifestation of a total of 19 cases,accounting for 63.3%;significant dyspnea in 10 cases,accounting for 33.3%;dysphagia in 4 cases,accounting for 13.3%;5 cases of nausea and vomiting,accounted for 16.7%;4 cases with abdominal pain,accounted for 13.3%;1 case of chill and fever,first diagnosed,accounted for 3.3%;4 cases had the symptom of shock,accounted for 13.3%.(7)The examination: 9 cases of X-ray or chest X-ray,showed widened mediastinum or enlargement,or cardiac enlargement;25 cases of CT or MRI examination,suggesting that hematoma or aneurysm in mediastinum in 19 cases accounted for 76.0%.(8)Misdiagnosed diseases: 4 people were once misdiagnosed at the first visit,accounting for13.3%;including esophageal perforation,esophageal hiatus hernia,retropharyngeal abscess,and malignant tumor.Ultimately,CT/ MRI or biopsy confirmed to be hematoma.(9)Treatment and prognosis: 10 people took the surgical treatment,1 people died,the mortality rate was 10.0%;6 people in interventional treatment,1 people died,the mortality rate was 16.7%;14 cases in conservative treatment,including 7 cases of tracheotomy or tracheal intubation and mechanical ventilation,accounting for 50.0 %,3 cases died,the mortality rate was 21.4%.The total mortality was 16.1%(5/31).Conclusion:(1)Posterior mediastinal hematoma is a rare disease,from the beginning of 2007 to the end of 2016,only 31 cases reported.(2)The causes of posterior mediastinal hematoma can be divided into two types: with clear causes and unknown,in particular,we need to be cautious of unknown type.Detailed medical history and physical examination,combined with the necessary imaging examinations such as MRI or CT,are of great significance in the diagnosis of posterior mediastinal hematoma.(3)The mechanism of the formation of the hematoma in the posterior mediastinum: acute patients consider the origin of large vessels while chronic patients consider the possibility of small blood vessels.In this case,we largely inferred that the rapid increase of the intrathoracic pressure caused by crying might result the injury of the small blood vessels in the mediastinum.(4)Chest pain is the most common clinical manifestation of the posterior mediastinal hematoma,other symptoms include dyspnea,dysphagia,upper abdominal pain and other non-specific symptoms.Posterior mediastinal hematoma is an acute onset,often in critical condition,if we can not treat it in time,the risk of deadly shock is very high,and therefore it must be taken seriously.(5)Anticoagulation therapy is an important cause of posterior mediastinal hematoma.For unexplained pain,unless there is evidence of clinical suspicion of pulmonary embolism,early prophylactic use of anticoagulant drugs(AD)is not recommended,so as not to conceal or aggravate the disease.