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Fibrosing Mediastinitis¹

¹ The opinions and assertions contained herein are solely the private views of the authors and are not to be construed as official nor as representing those of the Departments of the Air Force or Defense.

View larger version (132K): [in a new window]   Figure 1a.   Mediastinal granuloma due to histoplasmosis in a 30-year-old man with chest pain. (a) Posteroanterior chest radiograph shows a calcified right paratracheal mass (arrowhead). (b) CT scan (mediastinal window) shows the focal paratracheal mass with a low-attenuation center and extensive calcification (arrowhead). Note the mass effect on the trachea (T). A noninvasive, well-encapsulated mass containing viable H capsulatum organisms was found at resection.

View larger version (112K): [in a new window]   Figure 1b.   Mediastinal granuloma due to histoplasmosis in a 30-year-old man with chest pain. (a) Posteroanterior chest radiograph shows a calcified right paratracheal mass (arrowhead). (b) CT scan (mediastinal window) shows the focal paratracheal mass with a low-attenuation center and extensive calcification (arrowhead). Note the mass effect on the trachea (T). A noninvasive, well-encapsulated mass containing viable H capsulatum organisms was found at resection.

View larger version (117K): [in a new window]   Figure 2a.   Fibrosing mediastinitis associated with histoplasmosis in a 58-year-old man with a 6-month history of cough. (a) Computed tomographic (CT) scan (lung window) shows an infiltrating, soft-tissue right hilar mass extending into the right lower lobe along bronchovascular bundles. (b) CT scan (mediastinal window) shows the soft-tissue mass (arrowhead) and extensive calcification in the right hilum and subcarinal region. (c) Photograph of the cut surface of the resected specimen shows dense white fibrous tissue in the right hilum extending into the lung parenchyma along bronchovascular bundles (arrows).

View larger version (108K): [in a new window]   Figure 2b.   Fibrosing mediastinitis associated with histoplasmosis in a 58-year-old man with a 6-month history of cough. (a) Computed tomographic (CT) scan (lung window) shows an infiltrating, soft-tissue right hilar mass extending into the right lower lobe along bronchovascular bundles. (b) CT scan (mediastinal window) shows the soft-tissue mass (arrowhead) and extensive calcification in the right hilum and subcarinal region. (c) Photograph of the cut surface of the resected specimen shows dense white fibrous tissue in the right hilum extending into the lung parenchyma along bronchovascular bundles (arrows).

View larger version (129K): [in a new window]   Figure 2c.   Fibrosing mediastinitis associated with histoplasmosis in a 58-year-old man with a 6-month history of cough. (a) Computed tomographic (CT) scan (lung window) shows an infiltrating, soft-tissue right hilar mass extending into the right lower lobe along bronchovascular bundles. (b) CT scan (mediastinal window) shows the soft-tissue mass (arrowhead) and extensive calcification in the right hilum and subcarinal region. (c) Photograph of the cut surface of the resected specimen shows dense white fibrous tissue in the right hilum extending into the lung parenchyma along bronchovascular bundles (arrows).

View larger version (141K): [in a new window]   Figure 3.   Fibrosing mediastinitis. Medium-power photomicrograph (original magnification, x25; hematoxylin-eosin stain) demonstrates fibrous tissue (arrows) infiltrating mediastinal adipose tissue.

View larger version (220K): [in a new window]   Figure 4.   Fibrosing mediastinitis. High-power photomicrograph (original magnification, x100; hematoxylin-eosin stain) demonstrates paucicellular, eosinophilic mature collagen, findings typical of fibrosing mediastinitis.

View larger version (212K): [in a new window]   Figure 5a.   Histoplasmosis. (a) Medium-power photomicrograph (original magnification, x50; hematoxylin-eosin stain) of a hilar lymph node specimen shows a caseating granuloma composed of a rim of epithelioid histocytes (arrowheads) surrounding central caseous necrosis (N). Note peripheral lymphoid infiltrate (L). (b) Oil immersion photomicrograph (original magnification, x500; Grocott methenamine-silver stain) shows small oval-shaped yeasts of H capsulatum. Note the rare budding forms (arrowhead).

View larger version (180K): [in a new window]   Figure 5b.   Histoplasmosis. (a) Medium-power photomicrograph (original magnification, x50; hematoxylin-eosin stain) of a hilar lymph node specimen shows a caseating granuloma composed of a rim of epithelioid histocytes (arrowheads) surrounding central caseous necrosis (N). Note peripheral lymphoid infiltrate (L). (b) Oil immersion photomicrograph (original magnification, x500; Grocott methenamine-silver stain) shows small oval-shaped yeasts of H capsulatum. Note the rare budding forms (arrowhead).

View larger version (195K): [in a new window]   Figure 6a.   Sclerosing diffuse large B-cell lymphoma. (a) High-power photomicrograph (original magnification, x400; hematoxylin-eosin stain) demonstrates hypercellular atypical lymphoid infiltrate. (b) High-power photomicrograph (original magnification, x400) of a specimen stained with immunohistochemistry for CD20 (B-cell marker) shows positive cytoplasmic staining.

View larger version (187K): [in a new window]   Figure 6b.   Sclerosing diffuse large B-cell lymphoma. (a) High-power photomicrograph (original magnification, x400; hematoxylin-eosin stain) demonstrates hypercellular atypical lymphoid infiltrate. (b) High-power photomicrograph (original magnification, x400) of a specimen stained with immunohistochemistry for CD20 (B-cell marker) shows positive cytoplasmic staining.

View larger version (90K): [in a new window]   Figure 7a.   Left main bronchus stenosis due to fibrosing mediastinitis treated with laser ablation, balloon dilation, and endobronchial stent placement. The patient also had a history of recurrent left lung pneumonia. (a) CT scan (mediastinal window) shows a wire mesh stent in the left main bronchus, calcified adenopathy (arrow) in the aortopulmonary window, and a subcarinal soft-tissue mass (arrowhead). * = esophagus. (b) CT scan (lung window) shows an outpouching (arrowhead) of the anterior esophageal lumen adjacent to the stent that was confirmed to represent a bronchoesophageal fistula at a barium swallow examination (not shown). Note lingular consolidation, which most likely represents pneumonia. The patient subsequently underwent esophagectomy and anterior gastric interposition.

View larger version (148K): [in a new window]   Figure 7b.   Left main bronchus stenosis due to fibrosing mediastinitis treated with laser ablation, balloon dilation, and endobronchial stent placement. The patient also had a history of recurrent left lung pneumonia. (a) CT scan (mediastinal window) shows a wire mesh stent in the left main bronchus, calcified adenopathy (arrow) in the aortopulmonary window, and a subcarinal soft-tissue mass (arrowhead). * = esophagus. (b) CT scan (lung window) shows an outpouching (arrowhead) of the anterior esophageal lumen adjacent to the stent that was confirmed to represent a bronchoesophageal fistula at a barium swallow examination (not shown). Note lingular consolidation, which most likely represents pneumonia. The patient subsequently underwent esophagectomy and anterior gastric interposition.

View larger version (125K): [in a new window]   Figure 8a.   Superior vena cava syndrome due to fibrosing mediastinitis treated with balloon dilation and endovascular stent placement. (a) Posteroanterior chest radiograph shows enlargement of the right hilum, a right paratracheal mass, and a well-circumscribed right upper lobe nodule (arrow). Note calcification in the right hilum and nodule. (b) Contrast material-enhanced CT scan (mediastinal window) shows the infiltrating soft-tissue mass (solid arrows) with dense calcification in the right paratracheal region. Note obstruction of the superior vena cava, enhancement of multiple mediastinal collateral veins (arrowheads), and the densely calcified pulmonary nodule (open arrow). (c) Frontal superior vena cavagram shows a balloon-tipped catheter traversing a distal stenosis (arrows) of the superior vena cava. Note the mediastinal collateral veins (arrowheads). The patient underwent balloon dilation of the superior vena cava stenosis followed by placement of a metallic mesh stent. (d) Collimated posteroanterior chest radiograph obtained at follow-up shows the metallic mesh stent in the brachiocephalic vein and superior vena cava. The patient experienced marked symptomatic relief following endovascular therapy.

View larger version (122K): [in a new window]   Figure 8b.   Superior vena cava syndrome due to fibrosing mediastinitis treated with balloon dilation and endovascular stent placement. (a) Posteroanterior chest radiograph shows enlargement of the right hilum, a right paratracheal mass, and a well-circumscribed right upper lobe nodule (arrow). Note calcification in the right hilum and nodule. (b) Contrast material-enhanced CT scan (mediastinal window) shows the infiltrating soft-tissue mass (solid arrows) with dense calcification in the right paratracheal region. Note obstruction of the superior vena cava, enhancement of multiple mediastinal collateral veins (arrowheads), and the densely calcified pulmonary nodule (open arrow). (c) Frontal superior vena cavagram shows a balloon-tipped catheter traversing a distal stenosis (arrows) of the superior vena cava. Note the mediastinal collateral veins (arrowheads). The patient underwent balloon dilation of the superior vena cava stenosis followed by placement of a metallic mesh stent. (d) Collimated posteroanterior chest radiograph obtained at follow-up shows the metallic mesh stent in the brachiocephalic vein and superior vena cava. The patient experienced marked symptomatic relief following endovascular therapy.

View larger version (155K): [in a new window]   Figure 8c.   Superior vena cava syndrome due to fibrosing mediastinitis treated with balloon dilation and endovascular stent placement. (a) Posteroanterior chest radiograph shows enlargement of the right hilum, a right paratracheal mass, and a well-circumscribed right upper lobe nodule (arrow). Note calcification in the right hilum and nodule. (b) Contrast material-enhanced CT scan (mediastinal window) shows the infiltrating soft-tissue mass (solid arrows) with dense calcification in the right paratracheal region. Note obstruction of the superior vena cava, enhancement of multiple mediastinal collateral veins (arrowheads), and the densely calcified pulmonary nodule (open arrow). (c) Frontal superior vena cavagram shows a balloon-tipped catheter traversing a distal stenosis (arrows) of the superior vena cava. Note the mediastinal collateral veins (arrowheads). The patient underwent balloon dilation of the superior vena cava stenosis followed by placement of a metallic mesh stent. (d) Collimated posteroanterior chest radiograph obtained at follow-up shows the metallic mesh stent in the brachiocephalic vein and superior vena cava. The patient experienced marked symptomatic relief following endovascular therapy.

View larger version (179K): [in a new window]   Figure 8d.   Superior vena cava syndrome due to fibrosing mediastinitis treated with balloon dilation and endovascular stent placement. (a) Posteroanterior chest radiograph shows enlargement of the right hilum, a right paratracheal mass, and a well-circumscribed right upper lobe nodule (arrow). Note calcification in the right hilum and nodule. (b) Contrast material-enhanced CT scan (mediastinal window) shows the infiltrating soft-tissue mass (solid arrows) with dense calcification in the right paratracheal region. Note obstruction of the superior vena cava, enhancement of multiple mediastinal collateral veins (arrowheads), and the densely calcified pulmonary nodule (open arrow). (c) Frontal superior vena cavagram shows a balloon-tipped catheter traversing a distal stenosis (arrows) of the superior vena cava. Note the mediastinal collateral veins (arrowheads). The patient underwent balloon dilation of the superior vena cava stenosis followed by placement of a metallic mesh stent. (d) Collimated posteroanterior chest radiograph obtained at follow-up shows the metallic mesh stent in the brachiocephalic vein and superior vena cava. The patient experienced marked symptomatic relief following endovascular therapy.

View larger version (154K): [in a new window]   Figure 9a.   Idiopathic fibrosing mediastinitis in a 30-year-old man with superior vena cava syndrome. (a) Posteroanterior chest radiograph shows subtle thickening of the right paratracheal stripe and a calcified right upper lobe nodule (arrow). (b) Contrast-enhanced CT scan (mediastinal window) shows an infiltrating soft-tissue attenuation mass in the middle mediastinum. Note encasement and narrowing of the distal superior vena cava (white arrowhead) and right pulmonary artery (black arrowheads) and distention of the azygous vein (arrow). (c) Contrast-enhanced CT scan (mediastinal window) obtained at a more caudal level shows encasement and narrowing of the right superior pulmonary vein (arrowheads). (d) Frontal pulmonary arteriogram shows smooth long-segment narrowing (arrows) of the right main pulmonary artery (M). (e) Frontal superior vena cavagram shows smooth, eccentric stenosis (arrows) of the distal superior vena cava (S).

View larger version (102K): [in a new window]   Figure 9b.   Idiopathic fibrosing mediastinitis in a 30-year-old man with superior vena cava syndrome. (a) Posteroanterior chest radiograph shows subtle thickening of the right paratracheal stripe and a calcified right upper lobe nodule (arrow). (b) Contrast-enhanced CT scan (mediastinal window) shows an infiltrating soft-tissue attenuation mass in the middle mediastinum. Note encasement and narrowing of the distal superior vena cava (white arrowhead) and right pulmonary artery (black arrowheads) and distention of the azygous vein (arrow). (c) Contrast-enhanced CT scan (mediastinal window) obtained at a more caudal level shows encasement and narrowing of the right superior pulmonary vein (arrowheads). (d) Frontal pulmonary arteriogram shows smooth long-segment narrowing (arrows) of the right main pulmonary artery (M). (e) Frontal superior vena cavagram shows smooth, eccentric stenosis (arrows) of the distal superior vena cava (S).

View larger version (106K): [in a new window]   Figure 9c.   Idiopathic fibrosing mediastinitis in a 30-year-old man with superior vena cava syndrome. (a) Posteroanterior chest radiograph shows subtle thickening of the right paratracheal stripe and a calcified right upper lobe nodule (arrow). (b) Contrast-enhanced CT scan (mediastinal window) shows an infiltrating soft-tissue attenuation mass in the middle mediastinum. Note encasement and narrowing of the distal superior vena cava (white arrowhead) and right pulmonary artery (black arrowheads) and distention of the azygous vein (arrow). (c) Contrast-enhanced CT scan (mediastinal window) obtained at a more caudal level shows encasement and narrowing of the right superior pulmonary vein (arrowheads). (d) Frontal pulmonary arteriogram shows smooth long-segment narrowing (arrows) of the right main pulmonary artery (M). (e) Frontal superior vena cavagram shows smooth, eccentric stenosis (arrows) of the distal superior vena cava (S).

View larger version (149K): [in a new window]   Figure 9d.   Idiopathic fibrosing mediastinitis in a 30-year-old man with superior vena cava syndrome. (a) Posteroanterior chest radiograph shows subtle thickening of the right paratracheal stripe and a calcified right upper lobe nodule (arrow). (b) Contrast-enhanced CT scan (mediastinal window) shows an infiltrating soft-tissue attenuation mass in the middle mediastinum. Note encasement and narrowing of the distal superior vena cava (white arrowhead) and right pulmonary artery (black arrowheads) and distention of the azygous vein (arrow). (c) Contrast-enhanced CT scan (mediastinal window) obtained at a more caudal level shows encasement and narrowing of the right superior pulmonary vein (arrowheads). (d) Frontal pulmonary arteriogram shows smooth long-segment narrowing (arrows) of the right main pulmonary artery (M). (e) Frontal superior vena cavagram shows smooth, eccentric stenosis (arrows) of the distal superior vena cava (S).

View larger version (159K): [in a new window]   Figure 9e.   Idiopathic fibrosing mediastinitis in a 30-year-old man with superior vena cava syndrome. (a) Posteroanterior chest radiograph shows subtle thickening of the right paratracheal stripe and a calcified right upper lobe nodule (arrow). (b) Contrast-enhanced CT scan (mediastinal window) shows an infiltrating soft-tissue attenuation mass in the middle mediastinum. Note encasement and narrowing of the distal superior vena cava (white arrowhead) and right pulmonary artery (black arrowheads) and distention of the azygous vein (arrow). (c) Contrast-enhanced CT scan (mediastinal window) obtained at a more caudal level shows encasement and narrowing of the right superior pulmonary vein (arrowheads). (d) Frontal pulmonary arteriogram shows smooth long-segment narrowing (arrows) of the right main pulmonary artery (M). (e) Frontal superior vena cavagram shows smooth, eccentric stenosis (arrows) of the distal superior vena cava (S).

View larger version (137K): [in a new window]   Figure 10a.   Fibrosing mediastinitis due to histoplasmosis in a 55-year-old man with cough and hemoptysis. (a) Posteroanterior chest radiograph shows a left hilar mass. (b) Coronal T1-weighted (repetition time msec/echo time msec = 870/20) magnetic resonance (MR) image demonstrates the left hilar mass (arrowheads) of heterogeneous low-to-intermediate signal intensity obstructing the left main bronchus (L). Note the subcarinal component of the mass (S). A = aorta, P = pulmonary artery, T = trachea.

View larger version (142K): [in a new window]   Figure 10b.   Fibrosing mediastinitis due to histoplasmosis in a 55-year-old man with cough and hemoptysis. (a) Posteroanterior chest radiograph shows a left hilar mass. (b) Coronal T1-weighted (repetition time msec/echo time msec = 870/20) magnetic resonance (MR) image demonstrates the left hilar mass (arrowheads) of heterogeneous low-to-intermediate signal intensity obstructing the left main bronchus (L). Note the subcarinal component of the mass (S). A = aorta, P = pulmonary artery, T = trachea.

View larger version (139K): [in a new window]   Figure 11a.   Fibrosing mediastinitis due to histoplasmosis in a 40-year-old man with superior vena cava syndrome. (a) Posteroanterior chest radiograph shows a focal right paratracheal mass (arrowhead). (b) Superior vena cavagram shows marked narrowing (arrows) of the superior vena cava at the level of the mass. Note opacification of multiple collateral veins (arrowhead).

View larger version (147K): [in a new window]   Figure 11b.   Fibrosing mediastinitis due to histoplasmosis in a 40-year-old man with superior vena cava syndrome. (a) Posteroanterior chest radiograph shows a focal right paratracheal mass (arrowhead). (b) Superior vena cavagram shows marked narrowing (arrows) of the superior vena cava at the level of the mass. Note opacification of multiple collateral veins (arrowhead).

View larger version (156K): [in a new window]   Figure 12.   Idiopathic fibrosing mediastinitis in a 38-year-old man with intermittent stridor. Linear tomogram shows diffuse narrowing of the trachea and both main bronchi and a soft-tissue mass encasing the distal trachea.

View larger version (180K): [in a new window]   Figure 13a.   Fibrosing mediastinitis due to histoplasmosis in a 36-year-old woman with dyspnea. (a) Posteroanterior chest radiograph shows volume loss in the right hemithorax and findings of localized edema in the right lower lobe. The right hilum is enlarged. (b) CT scan (lung window) shows marked thickening of interlobular septa (arrows) in the right lung. (c) Contrast-enhanced CT scan (mediastinal window) shows a right hilar and subcarinal soft-tissue mass obstructing the right pulmonary artery (R) and superior pulmonary vein (arrowhead). More caudal images (not shown) demonstrated obstruction of the inferior pulmonary vein. Note punctate subcarinal calcification (arrow). A = aorta, S = superior vena cava. (d) Frontal pulmonary arteriogram shows mild, smooth narrowing of the right pulmonary artery (P) and marked narrowing of the truncus anterior (arrows) and right interlobar pulmonary artery (arrowhead).

View larger version (119K): [in a new window]   Figure 13b.   Fibrosing mediastinitis due to histoplasmosis in a 36-year-old woman with dyspnea. (a) Posteroanterior chest radiograph shows volume loss in the right hemithorax and findings of localized edema in the right lower lobe. The right hilum is enlarged. (b) CT scan (lung window) shows marked thickening of interlobular septa (arrows) in the right lung. (c) Contrast-enhanced CT scan (mediastinal window) shows a right hilar and subcarinal soft-tissue mass obstructing the right pulmonary artery (R) and superior pulmonary vein (arrowhead). More caudal images (not shown) demonstrated obstruction of the inferior pulmonary vein. Note punctate subcarinal calcification (arrow). A = aorta, S = superior vena cava. (d) Frontal pulmonary arteriogram shows mild, smooth narrowing of the right pulmonary artery (P) and marked narrowing of the truncus anterior (arrows) and right interlobar pulmonary artery (arrowhead).

View larger version (87K): [in a new window]   Figure 13c.   Fibrosing mediastinitis due to histoplasmosis in a 36-year-old woman with dyspnea. (a) Posteroanterior chest radiograph shows volume loss in the right hemithorax and findings of localized edema in the right lower lobe. The right hilum is enlarged. (b) CT scan (lung window) shows marked thickening of interlobular septa (arrows) in the right lung. (c) Contrast-enhanced CT scan (mediastinal window) shows a right hilar and subcarinal soft-tissue mass obstructing the right pulmonary artery (R) and superior pulmonary vein (arrowhead). More caudal images (not shown) demonstrated obstruction of the inferior pulmonary vein. Note punctate subcarinal calcification (arrow). A = aorta, S = superior vena cava. (d) Frontal pulmonary arteriogram shows mild, smooth narrowing of the right pulmonary artery (P) and marked narrowing of the truncus anterior (arrows) and right interlobar pulmonary artery (arrowhead).

View larger version (164K): [in a new window]   Figure 13d.   Fibrosing mediastinitis due to histoplasmosis in a 36-year-old woman with dyspnea. (a) Posteroanterior chest radiograph shows volume loss in the right hemithorax and findings of localized edema in the right lower lobe. The right hilum is enlarged. (b) CT scan (lung window) shows marked thickening of interlobular septa (arrows) in the right lung. (c) Contrast-enhanced CT scan (mediastinal window) shows a right hilar and subcarinal soft-tissue mass obstructing the right pulmonary artery (R) and superior pulmonary vein (arrowhead). More caudal images (not shown) demonstrated obstruction of the inferior pulmonary vein. Note punctate subcarinal calcification (arrow). A = aorta, S = superior vena cava. (d) Frontal pulmonary arteriogram shows mild, smooth narrowing of the right pulmonary artery (P) and marked narrowing of the truncus anterior (arrows) and right interlobar pulmonary artery (arrowhead).

View larger version (120K): [in a new window]   Figure 14.   Idiopathic fibrosing mediastinitis in a 30-year-old woman with chest pain. CT scan (mediastinal window) shows a soft-tissue attenuation mass in the anterior mediastinum. Biopsy specimen revealed fibrosing mediastinitis. A = aorta, S = superior vena cava.

View larger version (120K): [in a new window]   Figure 15.   Idiopathic fibrosing mediastinitis in a 43-year-old woman with chronic cough and dyspnea. CT scan (mediastinal window) shows a soft-tissue attenuation mass diffusely infiltrating the middle and posterior mediastinum, encasing the descending aorta (a), and extending into both pleural spaces. Note extensive calcification within the pleura.

View larger version (95K): [in a new window]   Figure 16a.   Fibrosing mediastinitis due to histoplasmosis in a 45-year-old woman with recurrent pneumonia. (a) CT scan (mediastinal window) demonstrates a calcified right hilar and mediastinal mass obstructing the right upper lobe bronchus. Note the right pleural thickening (arrows), patent bronchus intermedius (arrowhead), and enlarged azygous vein (a). R = right pulmonary artery, S = superior vena cava. (b) Axial T1-weighted (680/20) MR image shows an infiltrative hilar mass of intermediate signal intensity narrowing the right upper lobe bronchus (arrow). Note the narrowed but patent superior vena cava (arrowhead). Calcification seen on the CT scan (a) is not apparent. A = aorta, P = main pulmonary artery. (Reprinted, with permission, from reference 66.)

View larger version (130K): [in a new window]   Figure 16b.   Fibrosing mediastinitis due to histoplasmosis in a 45-year-old woman with recurrent pneumonia. (a) CT scan (mediastinal window) demonstrates a calcified right hilar and mediastinal mass obstructing the right upper lobe bronchus. Note the right pleural thickening (arrows), patent bronchus intermedius (arrowhead), and enlarged azygous vein (a). R = right pulmonary artery, S = superior vena cava. (b) Axial T1-weighted (680/20) MR image shows an infiltrative hilar mass of intermediate signal intensity narrowing the right upper lobe bronchus (arrow). Note the narrowed but patent superior vena cava (arrowhead). Calcification seen on the CT scan (a) is not apparent. A = aorta, P = main pulmonary artery. (Reprinted, with permission, from reference 66.)

View larger version (128K): [in a new window]   Figure 17a.   Idiopathic fibrosing mediastinitis in a 25-year-old man with sickle cell anemia. (a) Contrast-enhanced CT scan (mediastinal window) shows a soft-tissue attenuation mass diffusely infiltrating the mediastinum. Note encasement and narrowing of the left main bronchus (*), ascending (A) and descending (D) aorta, proximal right (R) and left (L) pulmonary arteries, and esophagus (arrowhead). (b) Contrast-enhanced CT scan (mediastinal window) obtained at a more caudal level shows the subcarinal mass (M), encasement of the left main coronary artery (arrow), and narrowing of the left superior pulmonary vein (S). Note the small left pleural effusion. A = ascending aorta, D = descending aorta, P = main pulmonary artery. (c) Contrast-enhanced CT scan (mediastinal window) obtained at a more caudal level shows encasement of the descending aorta (D) and marked narrowing of the left inferior pulmonary vein (arrowhead). Note the small left pleural effusion. The periaortic mass continued into the upper abdomen (not shown). A = ascending aorta, LA = left atrium.

View larger version (131K): [in a new window]   Figure 17b.   Idiopathic fibrosing mediastinitis in a 25-year-old man with sickle cell anemia. (a) Contrast-enhanced CT scan (mediastinal window) shows a soft-tissue attenuation mass diffusely infiltrating the mediastinum. Note encasement and narrowing of the left main bronchus (*), ascending (A) and descending (D) aorta, proximal right (R) and left (L) pulmonary arteries, and esophagus (arrowhead). (b) Contrast-enhanced CT scan (mediastinal window) obtained at a more caudal level shows the subcarinal mass (M), encasement of the left main coronary artery (arrow), and narrowing of the left superior pulmonary vein (S). Note the small left pleural effusion. A = ascending aorta, D = descending aorta, P = main pulmonary artery. (c) Contrast-enhanced CT scan (mediastinal window) obtained at a more caudal level shows encasement of the descending aorta (D) and marked narrowing of the left inferior pulmonary vein (arrowhead). Note the small left pleural effusion. The periaortic mass continued into the upper abdomen (not shown). A = ascending aorta, LA = left atrium.

View larger version (138K): [in a new window]   Figure 17c.   Idiopathic fibrosing mediastinitis in a 25-year-old man with sickle cell anemia. (a) Contrast-enhanced CT scan (mediastinal window) shows a soft-tissue attenuation mass diffusely infiltrating the mediastinum. Note encasement and narrowing of the left main bronchus (*), ascending (A) and descending (D) aorta, proximal right (R) and left (L) pulmonary arteries, and esophagus (arrowhead). (b) Contrast-enhanced CT scan (mediastinal window) obtained at a more caudal level shows the subcarinal mass (M), encasement of the left main coronary artery (arrow), and narrowing of the left superior pulmonary vein (S). Note the small left pleural effusion. A = ascending aorta, D = descending aorta, P = main pulmonary artery. (c) Contrast-enhanced CT scan (mediastinal window) obtained at a more caudal level shows encasement of the descending aorta (D) and marked narrowing of the left inferior pulmonary vein (arrowhead). Note the small left pleural effusion. The periaortic mass continued into the upper abdomen (not shown). A = ascending aorta, LA = left atrium.

View larger version (107K): [in a new window]   Figure 18a.   Fibrosing mediastinitis due to histoplasmosis in a 45-year-old woman with dyspnea and hemoptysis. (a) CT scan (mediastinal window) shows a calcified right hilar mass (arrowhead). (b) CT scan (lung window) shows a peripheral wedge-shaped area of soft-tissue attenuation (arrows), a finding consistent with pulmonary infarct. At resection of the right lower lobe, venous infarction due to fibrosing mediastinitis was confirmed.

View larger version (132K): [in a new window]   Figure 18b.   Fibrosing mediastinitis due to histoplasmosis in a 45-year-old woman with dyspnea and hemoptysis. (a) CT scan (mediastinal window) shows a calcified right hilar mass (arrowhead). (b) CT scan (lung window) shows a peripheral wedge-shaped area of soft-tissue attenuation (arrows), a finding consistent with pulmonary infarct. At resection of the right lower lobe, venous infarction due to fibrosing mediastinitis was confirmed.

View larger version (123K): [in a new window]   Figure 19a.   Fibrosing mediastinitis due to histoplasmosis in a 53-year-old man with recurrent pneumonia. (a) CT scan (mediastinal window) shows a calcified subcarinal mass obstructing the bronchus intermedius (arrowhead). (b) Volume-rendered shaded-surface-display image shows long-segment narrowing of the bronchus intermedius (arrows). L = left main bronchus, R = right main bronchus, U = right upper lobe bronchus. (Reprinted, with permission, from reference 67.)

View larger version (107K): [in a new window]   Figure 19b.   Fibrosing mediastinitis due to histoplasmosis in a 53-year-old man with recurrent pneumonia. (a) CT scan (mediastinal window) shows a calcified subcarinal mass obstructing the bronchus intermedius (arrowhead). (b) Volume-rendered shaded-surface-display image shows long-segment narrowing of the bronchus intermedius (arrows). L = left main bronchus, R = right main bronchus, U = right upper lobe bronchus. (Reprinted, with permission, from reference 67.)

View larger version (150K): [in a new window]   Figure 20a.   Fibrosing mediastinitis due to histoplasmosis in a 33-year-old woman with recurrent right lower lobe pneumonia. (a) Axial T1-weighted (667/20) MR image shows a heterogeneous right hilar and subcarinal mass (arrows) that encases and narrows the bronchus intermedius (arrowhead). The mass has slightly increased signal intensity compared with that of skeletal muscle. Note the mass effect on the right superior pulmonary vein (*) and left atrium (L). S = superior vena cava. (b) Axial T2-weighted (2,667/80) MR image obtained at the same level as a shows foci of both low and high signal intensity within the mass (arrows). S = superior vena cava. (c) Axial T1-weighted (667/20) MR image obtained at a more caudal level shows the mass obliterating the right inferior pulmonary vein (arrowheads) and extending into the lung parenchyma (solid arrow). Note partial right middle lobe atelectasis (open arrow). L = left atrium. (d) Axial T2-weighted (2,667/80) MR image obtained at the same level as c shows that the mass (arrow) has predominantly low signal intensity, consistent with fibrous tissue. (Reprinted, with permission, from reference 66.)

View larger version (143K): [in a new window]   Figure 20b.   Fibrosing mediastinitis due to histoplasmosis in a 33-year-old woman with recurrent right lower lobe pneumonia. (a) Axial T1-weighted (667/20) MR image shows a heterogeneous right hilar and subcarinal mass (arrows) that encases and narrows the bronchus intermedius (arrowhead). The mass has slightly increased signal intensity compared with that of skeletal muscle. Note the mass effect on the right superior pulmonary vein (*) and left atrium (L). S = superior vena cava. (b) Axial T2-weighted (2,667/80) MR image obtained at the same level as a shows foci of both low and high signal intensity within the mass (arrows). S = superior vena cava. (c) Axial T1-weighted (667/20) MR image obtained at a more caudal level shows the mass obliterating the right inferior pulmonary vein (arrowheads) and extending into the lung parenchyma (solid arrow). Note partial right middle lobe atelectasis (open arrow). L = left atrium. (d) Axial T2-weighted (2,667/80) MR image obtained at the same level as c shows that the mass (arrow) has predominantly low signal intensity, consistent with fibrous tissue. (Reprinted, with permission, from reference 66.)

View larger version (145K): [in a new window]   Figure 20c.   Fibrosing mediastinitis due to histoplasmosis in a 33-year-old woman with recurrent right lower lobe pneumonia. (a) Axial T1-weighted (667/20) MR image shows a heterogeneous right hilar and subcarinal mass (arrows) that encases and narrows the bronchus intermedius (arrowhead). The mass has slightly increased signal intensity compared with that of skeletal muscle. Note the mass effect on the right superior pulmonary vein (*) and left atrium (L). S = superior vena cava. (b) Axial T2-weighted (2,667/80) MR image obtained at the same level as a shows foci of both low and high signal intensity within the mass (arrows). S = superior vena cava. (c) Axial T1-weighted (667/20) MR image obtained at a more caudal level shows the mass obliterating the right inferior pulmonary vein (arrowheads) and extending into the lung parenchyma (solid arrow). Note partial right middle lobe atelectasis (open arrow). L = left atrium. (d) Axial T2-weighted (2,667/80) MR image obtained at the same level as c shows that the mass (arrow) has predominantly low signal intensity, consistent with fibrous tissue. (Reprinted, with permission, from reference 66.)

View larger version (159K): [in a new window]   Figure 20d.   Fibrosing mediastinitis due to histoplasmosis in a 33-year-old woman with recurrent right lower lobe pneumonia. (a) Axial T1-weighted (667/20) MR image shows a heterogeneous right hilar and subcarinal mass (arrows) that encases and narrows the bronchus intermedius (arrowhead). The mass has slightly increased signal intensity compared with that of skeletal muscle. Note the mass effect on the right superior pulmonary vein (*) and left atrium (L). S = superior vena cava. (b) Axial T2-weighted (2,667/80) MR image obtained at the same level as a shows foci of both low and high signal intensity within the mass (arrows). S = superior vena cava. (c) Axial T1-weighted (667/20) MR image obtained at a more caudal level shows the mass obliterating the right inferior pulmonary vein (arrowheads) and extending into the lung parenchyma (solid arrow). Note partial right middle lobe atelectasis (open arrow). L = left atrium. (d) Axial T2-weighted (2,667/80) MR image obtained at the same level as c shows that the mass (arrow) has predominantly low signal intensity, consistent with fibrous tissue. (Reprinted, with permission, from reference 66.)

View larger version (119K): [in a new window]   Figure 21.   Idiopathic fibrosing mediastinitis in a 27-year-old woman with dysphagia and Riedel thyroiditis. Oblique barium esophagogram shows narrowing (arrows) and mucosal irregularity of the distal third of the esophagus. Note a superior esophageal diverticulum (D).

View larger version (153K): [in a new window]   Figure 22a.   Fibrosing mediastinitis due to histoplasmosis in a 14-year-old girl with cough and hemoptysis. (a) Posteroanterior chest radiograph shows heterogeneous opacities in the right lower lobe and minimal thickening of the right paratracheal stripe (arrow). (b) Posterior view from Xe-133 ventilation scan (shown in reverse orientation to correspond to a) shows homogeneous ventilation of both lungs. Note the small right lung (R). (c) Posterior view from Tc-99m-labeled MAA perfusion scan (shown in reverse orientation to correspond to a) shows complete absence of perfusion to the right lung (R). (d) Axial T1-weighted (720/20) MR image demonstrates obliteration of the right pulmonary artery (R) by an intermediate-signal-intensity mass in the right hilum and subcarinal region (S). A = ascending aorta.

View larger version (148K): [in a new window]   Figure 22b.   Fibrosing mediastinitis due to histoplasmosis in a 14-year-old girl with cough and hemoptysis. (a) Posteroanterior chest radiograph shows heterogeneous opacities in the right lower lobe and minimal thickening of the right paratracheal stripe (arrow). (b) Posterior view from Xe-133 ventilation scan (shown in reverse orientation to correspond to a) shows homogeneous ventilation of both lungs. Note the small right lung (R). (c) Posterior view from Tc-99m-labeled MAA perfusion scan (shown in reverse orientation to correspond to a) shows complete absence of perfusion to the right lung (R). (d) Axial T1-weighted (720/20) MR image demonstrates obliteration of the right pulmonary artery (R) by an intermediate-signal-intensity mass in the right hilum and subcarinal region (S). A = ascending aorta.

View larger version (143K): [in a new window]   Figure 22c.   Fibrosing mediastinitis due to histoplasmosis in a 14-year-old girl with cough and hemoptysis. (a) Posteroanterior chest radiograph shows heterogeneous opacities in the right lower lobe and minimal thickening of the right paratracheal stripe (arrow). (b) Posterior view from Xe-133 ventilation scan (shown in reverse orientation to correspond to a) shows homogeneous ventilation of both lungs. Note the small right lung (R). (c) Posterior view from Tc-99m-labeled MAA perfusion scan (shown in reverse orientation to correspond to a) shows complete absence of perfusion to the right lung (R). (d) Axial T1-weighted (720/20) MR image demonstrates obliteration of the right pulmonary artery (R) by an intermediate-signal-intensity mass in the right hilum and subcarinal region (S). A = ascending aorta.

View larger version (122K): [in a new window]   Figure 22d.   Fibrosing mediastinitis due to histoplasmosis in a 14-year-old girl with cough and hemoptysis. (a) Posteroanterior chest radiograph shows heterogeneous opacities in the right lower lobe and minimal thickening of the right paratracheal stripe (arrow). (b) Posterior view from Xe-133 ventilation scan (shown in reverse orientation to correspond to a) shows homogeneous ventilation of both lungs. Note the small right lung (R). (c) Posterior view from Tc-99m-labeled MAA perfusion scan (shown in reverse orientation to correspond to a) shows complete absence of perfusion to the right lung (R). (d) Axial T1-weighted (720/20) MR image demonstrates obliteration of the right pulmonary artery (R) by an intermediate-signal-intensity mass in the right hilum and subcarinal region (S). A = ascending aorta.