Via Research Recognition Day Program VCOM-Carolinas 2025

Case Reports

Coughs, Compression, and a Concerning Mass: Cracking the Case of Mediastinal Mayhem Sahil Kataria MD, Sarfo Asiedu MBChB, Mili Sheth MBBS, Ekata Abhulimen MD, David Jenkinson DO, Eugene Long MD Family Medicine Graduate Medical Education, Aiken Regional Medical Centers

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DISCUSSION

INTRODUCTION

RESULTS

The case of this 24-year-old female aligns closely with the typical demographic profile of Primary Mediastinal B-Cell Lymphoma (PMBCL), which predominantly affects young adults, especially women, with a median age of diagnosis in the mid-20s to early 30s. The patient's presentation of respiratory symptoms, including positional wheezing, cough, and rib pain from inhalation, is consistent with the common symptomatology of PMBCL, where a bulky mediastinal mass compresses nearby structures. However, this case diverges from some descriptions in the absence of B symptoms (fever, night sweats, weight loss), which occur in only a minority of PMBCL cases. The diagnostic approach, beginning with chest X-ray and progressing to contrast-enhanced CT of the thorax, follows recommended pathways. While advanced imaging is often favored for staging and treatment planning, the CT findings alone prompted timely oncology referral, aligning with guidelines for significant mediastinal involvement. The anticipated histopathological findings, once obtained, are expected to align with the established characteristics of PMBCL, including large B cells with clear cytoplasm and specific immunophenotypic markers. The case emphasizes the importance of early intervention and prompt referral to oncology to prevent rapid progression and potential life-threatening complications. While treatment had not yet been initiated at the time of the report, recommended therapies could significantly improve survival rates and minimize relapse risk.

CASE Primary mediastinal B-cell lymphoma (PMBCL) is a subtype of diffuse large B-cell lymphoma that arises from thymic B cells. It predominantly affects adolescents and young adults, with a higher incidence in females. PMBCL is characterized by a bulky mediastinal mass, often presenting with symptoms related to compression of mediastinal structures. Here we report a case of Primary Mediastinal B-Cell Lymphoma in a Caucasian female. 24 year old female with past medical history of anxiety/depression came to the clinic to establish care. She recently moved to South Carolina from Colorado. Her chief complaint was low frontal neck pain, wheezing while lying on her back, rib pain with inhalation, and a barking cough that been present for 6 weeks. She denied fever, productive cough, nasal discharge, or difficulty swallowing. She thought she had a lingering cold. She had no other significant past medical or surgical history. Family history was significant for breast cancer in her paternal grandmother and mantle cell lymphoma in her maternal grandmother. She denied any smoking, alcohol, or drug use. Her period had been regular in frequency, duration, & flow. She was formerly sexually active, always used condoms, nulliparous, and was on an OCP. She never had flu or COVID vaccines. Labs done one year ago were normal,. She was overdue for a TDAP booster and first pap smear. BP=110/75, HR=97, RR=20, O2= 98% RA. Pain=7/10 Physical exam abnormalities showed mild tenderness to palpation in the anteromedial inferior neck, barking cough, mild dysphonia. Lung exam was normal, but when patient was asked to lay supine mild rhonchi were noted in the apex bilaterally. Upon sitting up the dysphonia worsened and patient had a cough.

Labs showed RDW=11.5, LDL=126, and ALP =145. TSH, CBC, A1C, Lipid panel, and CMP was normal. A throat culture was negative. Albuterol inhaler and steroid dose pack prescribed resulted in no improvement. CXR showed mass like fullness of the superior mediastinum measuring 12.6 cm. CT Thorax with contrast showed: scarring vs atelectasis in the left lower lobe. 11.9 x 8.4 cm mildly heterogeneous solid mass in the anterior mediastinum with effect on the trachea which was narrowed in the anterior posterior direction. There was a small amount of pericardial fluid. Mediastinal adenopathy was also present. After this, the patient was referred to oncology.

REFERENCES

CONCLUSION

1.Barrington SF, Mikhaeel NG, Kostakoglu L, et al. Role of Imaging in the Staging and Response Assessment of Lymphoma: Consensus of the International Conference on Malignant Lymphomas Imaging Working Group. Journal of Clinical Oncology. 2014;32(27):3048-3058. 2.Dunleavy K, Wilson WH. Primary Mediastinal B-cell Lymphoma: Biology and Evolving Therapeutic Strategies. The Oncologist. 2018;23(9):1049-1059. 3.Martelli M, Gherlinzoni F, De Renzo A, et al. Diagnosis and Treatment of Primary Mediastinal Large B-Cell Lymphoma: Clinical Features, Diagnostic Role of PET Scan, and Therapeutic Outcomes. Annals of Oncology. 2007;18(1):83-88. 4.Savage KJ, Monti S, Kutok JL, et al. The Molecular Signature of Mediastinal Large B cell Lymphoma Differs from Other Diffuse Large B-cell Lymphomas and Shares Features with Classical Hodgkin Lymphoma. Blood. 2003;102(12):3871-3879.

Our case report highlights the presentation and diagnosis of PMBCL emphasizing the role of a comprehensive physical exam, work up, and imaging in early detection to optimize patient outcomes. Our case suggests standard chest x-ray for respiratory symptoms in young females.

2025 Research Recognition Day

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