Education And Debate

Grand Rounds—St Bartholomew's Hospital: A lump in the chest

BMJ 1995; 311 doi: (Published 02 December 1995) Cite this as: BMJ 1995;311:1491

A common problem in an unusual setting

We present the case of a patient with an intrathoracic mass. Anthony Weetman, professor of medicine in Sheffield, comments on the case summary.

Case history

A 45 year old woman presented with a three month history of dyspnoea, itchy skin, palpitations, increased sweating, loose stools, orthopnoea, and muscle weakness. On examination she looked unwell, and she had a pulse of 200 beats/min in atrial fibrillation, a jugular vein pulse raised 5-6 cm, normal heart sounds, and a central trachea with bibasal crackles. The thyroid was not palpable. Electrocardiography confirmed atrial fibrillation. Echocardiography showed trivial mitral and tricuspid regurgitation with minimally impaired ventricular function.

A chest x ray film showed a mass adjacent to the left heart border; on lateral view it was located anteriorly with a well defined smooth superior border(fig 1). Computed tomography showed a left sided anterior mediastinal mass (fig 2). After injection of intravenous contrast medium, the heart and the great vessels were enhanced normally, with minimal enhancement of the mass 2 (centre)). Radiologically, the differential diagnosis (box) included an ectopic thyroid, but the characteristic features of continuity with the thyroid in the neck and intense enhancement with contrast were lacking( fig 2).

Fig 1

Top: Plain chest radiograph showing left sided paracardiac mass. Bottom: Chest radiograph (lateral view) showing this mass lying anteriorly in retrosternal region with smooth, well defined superior margin

Fig 2

Top: Computed tomogram before intravenous contrast medium at level of mid-ascending aorta showing left sided soft tissue mass of mixed density; a clear plain of fat can be seen between the mass and the mediastinal structures. Centre: Computed tomogram at slightly lower level after intravenous contrast medium, showing that, unlike a typical goitre, the mass does not enhance appreciably. Bottom: Computed tomogram at level of sternoclavicular junction after intravenous contrast medium without any evidence of soft tissue …

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