Thread by @david_furfaro

1/ Enjoy another tweetorial from a recent case:
A man in his 40s with OSA and GERD presents with dyspnea, and headaches.
@JohnsHopkinsDOM @OslerResidency @thecurbsiders @CPSolvers @tony_breu @DxRxEdu @Dr_DanMD @AmitGoyalMD @medrants @sanjayvdesai

2/ He reports DOE sometimes associated with chest pain. He has worsening dyspnea and a headache when lying flat, and when bending forward to tie his shoes. On exam, he has a ruddy complexion and facial swelling. Lungs are CTAB and CV exam reveals distant heart sounds.

3/ The patient was asked to raise both arms over his head so that they were touching his cheeks. Within 15 - 30 seconds he had increasing plethora, followed by dyspnea, chest pain and coughing. What does this signify?

4/ This is Pemberton's Sign and it indicates SVC syndrome. Here is a great NEJM image demonstrating this finding: tinyurl.com/yxc7cygp. To further investigate, the patient had a PA and lateral CXR:

5/ Based on the patient's CXR, where is the abnormality and the cause of his symptoms?

6/ The patient has an anterior mediastinal mass. The PA CXR shows mediastinal widening and obscuration of the right paratracheal stripe (circle) which is suspicious for a mass. On the lateral, there is obliteration of the retrosternal space (arrows).

7/ The inferior mediastinum can be divided into 3 compartments that can be differentiated on lateral CXR. Note: some sources will say that all structures behind the posterior percaridum, including the descending aorta and esophagus, are in the posterior compartment

8/ Here is my differential diagnosis for mediastinal masses based on compartment location

9/ CT scan shows an anterior mediastinal mass that is not only compressing, but also invading into and filling, the superior vena cava.

10/ The mass was biopsied and showed B-cell lymphoma. The patient was transferred to the oncology service and started on R-CHOP. He is currently doing well, was able to be discharged, and will follow up for further care.