Paediatrics radiology

seminar 2
(Pleural Effusion with
Anterior Mediastinal
Mass)
Patient’s details
Name: A

Age: 11 years old

Gender: Male

Race: Malay

RN: N815777
CHIEF/ PRESENTING
COMPLAINT
A, An 11 year old Malay boy was referred from KPJ Pasir
Gudang with a 2 months history of reduced effort tolerance
and easy fatigue which has been progressively worsening for
the past 5 days prior to admission.
HISTORY OF PRESENTING
COMPLAINT
•A becomes easily fatigued even upon minimal activities such as walking from
the living room to the kitchen (50m)
• Associated with worsening shortness of breath and orthopnea (2 pillows)
• Night sweats (2/12)
• Loss of weight of 9kgs (2/12)
• Loss of appetite (2/12)
• Otherwise, there were no complaints of shortness of breath occuring at rest,
chest pains and palpitations on admission.
Upon further questioning,
• Also complained of having abnormal swellings (3/12)
•

• localized at the left axillary region

• Noticed during bathing.
• There was 3 lumps in total
• sizes are approximately the size of a marble
• no increase in sizes
• not painful and no overlying skin changes

At KPJ Pasir Gudang,

• Done CXR and CT thorax (27/11/20) which showed
•

• large mediastinal mass with extension to the medial mediastinum and vascular encasement
• severe left pleural effusion
• pericardial effusion
• malted para aortic lymph nodes
•
• Managed on 29/11/2020 with a pigtail catheter insertion over left chest
wall and 300ml of cloudy pleural fluid was drained over 24 hours
• Chest Xray done post-procedure showed presence of mild right pleural
effusion and mediastinal shift
• Referred to PPUKM for further management of his condition.
•

• Excisional biopsy was done on 1/12/20 which confirms the diagnosis of T-

Lymphoblastic Lymphoma.
Past Medical/ Surgical:

• Nil

Allergy:

• Allergic to an antibiotic given on day 1 admission to KPJ but unsure of the name
(Presented with rashes localized over the chest region)

Immunization:

• Completed

Developmental & school:

• No learning issues in school

Diet:

• Breastfed up to 2 months old

• Complementary feeding started at 6 months
• Current diet
•

• Breakfast: Bread + Milo (1 box)

• Lunch: Rice (1 scoop) + Chicken (1 piece) + vegetables (1 scoop)
• Dinner: same as lunch
• Eats fruits, not a picky eater.

Family:

• No malignancies

Social:

• Lives in Pasir Gudang with family. Currently, an average standard 5 student. He was previously
active in sports before onset of disease.
Physical examination
On general examination patient is alert,not tachypneic,able to speak in sentence,not
cyanosed,have a good pulse volume,warm peripheries and capillary refill time is less than two
seconds.

Vital signs :

-Heart rate :117 beats per minute

-Respiratory rate :25 breath per minute

-Blood pressure :96/79 mmHg

-SpO2 :98%
 • Chest inspection :

There is left axillary lymph node swelling measures 3x3 cm which is mobile,non tender,no skin
changes and have a smooth surface.
Otherwise,there is no other lymphadenopathy noted.

• Chest expansion :

Equal chest expansion

• Percussion :

There is stony dullness on percussion on the left middle and lower zone

• Ascultation :

Reduced breath sound bilaterally where the left side is more reduced than the right side at the
middle and lower zone.
 • Vocal resonance
Reduced vocal resonance at the left side at the middle and lower zone

• Cardiovascular examination
-Apex beat is not displaced
-Dual rhythm no murmur

• Abdominal examination
Abdomen is not distended and there is no sign of hepatosplenomegaly.
Biochemical investigations
• Full blood count

Components Result Reference value

White cell count 6.4 (5-13) x10^9 g/L

Red cell count 5.9 (4.0-5.2) x10^12/L

Haemoglobin 14.3 (11.5-15.5) g/dL

Mean cell volume 73.1 (73-95) fl

Mean corpuscular 24.1 (25-29) pg

haemoglobin
Platelet 307 (150-410) x10^9 /L
• Coagulation profile

Components Result Reference value

PT 10.2 (9.3-10.8) seconds

INR 0.94 ratio

APTT 23.1 (22.2-31.6) seconds

• Renal Profile
Components Result Reference value

Sodium 138 (136-145) mmol/L

Potassium 3.8 (3.5-5.1) mmol/L

Urea 4.3 (3.2-7.4) mmol/L

Creatinine 60.4 (63.6-110.5) umol/l

• Liver function test

Components Result Reference value

Albumin 37 (38-54) g/l

Total Bilirubin 7.7 (3.4-20.5) umol/l

ALT 15 (0-55) U/L

ALP 174 (40-150) U/L

RADIOLOGICA
L FINDINGS
imaging studies
The patient is slightly rotated over
to the left side.

Lower trachea deviated to the

right lung.

There is a homogenous opacity

over left lung.

Pleural line is visible.

Mediastinum shift over to the

right lung.

Loss of costophrenic angle of left

thorax.
USG of the chest.

Presence of mediastinum
mass.
A large anterior
mediastinum mass
with extension to
medial mediastinum.

Minimal left pleural

effusion and
pericardial effusion
with effacement of
pulmonary artery.
Differential diagnosis
Points for Points against

Lymphoma Orthopnea
Lethargy -
Loss of weight & loss of appetite.

Thymoma Orthopnea No dysphagia

Lethargy No clinical features of Myasthenia Gravis
Loss of weight & loss of appetite. (uncommon in children)

Germ cell tumours Lethargy No abdominal pain

Shortness of breath No constipation or dysuria
Loss of weight & loss of appetite No mass at the testicles or abdomen

Thymic cyst Shortness of breath No fever

No chest pain
No muscular weakness
 Points for Points against
Congestive cardiac failure Orthopnea & reduce effort tolerance. JVP not raised.
(uncommon in paediatric) Mediastinal shift. No pedal & sacral oedema.
Pleural Effusion. Heart sound normal with no murmur.

Cannot assess the heart border,size and

shape with vascular marking due to
mediastinal shift.
 • Biopsy finding

-Specimen :Anterior mediastinal mass

-Microscopic feature :Section shows a strip of tissue infiltrated by malignant lymphoid cells in
diffuse sheets.The cells are characterized by small size,fairly uniform,hyperchromatic nuclei
with scanty cytoplasm.Frequent mitoses is noted.The background stoma is desmoplastic.

-Diagnosis :Anterior mediastinal mass :Consistent with T-lymphoblastic lymphoma (T-ALL)

Learning points
● Pediatric mediastinal masses are the most common chest masses in children, with the anterior
mediastinum being the most common site.
● Computed tomography (CT) is the imaging modality of choice for evaluating mediastinal masses
detected by radiography or clinical presentation.
● Thoracic magnetic resonance (MR) imaging is a noninvasive way to characterize mediastinal
lesions, site of origin, and involvement of adjacent structures by providing higher soft tissue
contrast than CT, with superior tissue characterization and higher diagnostic specificity.
● Thoracic MR imaging of mediastinal masses can increase diagnostic certainty, reduce the number of
surgical interventions, and improve clinical decision making.
● As in adults, mediastinal masses are classified depending on anatomical sites:
- Anterior mediastinal masses
- Middle mediastinal masses
- Posterior mediastinal masses
-
Learning points
Anterior mediastinal masses
Basic approach to these lesions is by chest radiograph (PA and lateral) for localization followed by
contrast-enhanced CT for characterization.
● malignant lymphoma (Hodgkin and non-Hodgkin) - most common
● teratoma - common
● thymus (benign enlargement) - common
● thyroid (retro- or sub-sternal extension)
● thymic cyst
● angioma
● langerhans cell histiocytosis
● mesenchymal tumors
● lymphangioma (cystic hygroma) - generally extends from neck into mediastinum
●