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JAMA Clinical Challenge
June 19, 2018

A Mediastinal Mass in a Young Man

Author Affiliations
  • 1Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas
JAMA. 2018;319(23):2432-2433. doi:10.1001/jama.2018.7107

A previously healthy 18-year-old college student presented to the emergency department with a 6-month history of fatigue, dry cough, dyspnea, and unintentional weight loss of 18 kg (from 100 to 82 kg). Four months ago, he was treated for presumed pneumonia with azithromycin without improvement. He did not smoke, drink alcohol, or use intravenous drugs. He was born in the United States and had not traveled outside of the country. He took no medications.

On examination, his temperature was 37°C, heart rate 110/min, blood pressure 123/72 mm Hg, and respiratory rate 20/min. He had a palpable 2×2-cm firm, nontender, right supraclavicular lymph node and decreased breath sounds and dullness to percussion in the right lower lung field. No hepatosplenomegaly or leg edema was noted. Routine laboratory tests, including complete blood cell counts, renal function, electrolytes, and hepatic function, were within normal limits. A chest x-ray demonstrated diffuse homogeneous opacification of the right lung field. Computed tomography scans of the chest, abdomen, and pelvis revealed a 15 × 11-cm centrally necrotic mass in the right anterior mediastinum displacing the trachea to the left, a large right pleural effusion, and compression of the superior vena cava (Figure 1).