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• W2894908277 abstract "SESSION TITLE: Kid cases SESSION TYPE: Fellow Case Reports PRESENTED ON: 10/07/2018 03:30 PM - 04:30 PM INTRODUCTION: Mycobacterium avium complex (MAC) is associated with bronchiectasis and is seen in children with cervical lymphadenitis. It is rarely described in older immunocompetent children. CASE PRESENTATION: A 15-year-old male presented with 4 days of back pain, cough, fever, and pleuritic chest pain. Patient was febrile, 98% SpO2 on room air, tachycardic, with wheezing and rhonchi. D-dimer was elevated. Chest CT revealed a posterior mediastinal soft tissue mass (6.2 cm in diameter) with intra-lesional air abutting the right bronchus intermedius (Figure 1). MRI did not suggest a neurogenic tumor. Empiric IV antibiotics were initiated to treat a presumably infected bronchogenic duplication cyst. The mass was resected via VATS (Figure 2). Post-operatively, a persistent air leak developed. Due to concern for airway injury or bronchial fistula, flexible bronchoscopy was performed, revealing an atypical orifice along the medial wall of the bronchus intermedius (Figure 3). Interrogation revealed a sac like structure. This was presumed to be an accessory cardiac bronchus, a rare anatomic bronchial variant. This structure was in close proximity to the resected tissue and presumably communicated with the pleural space. Histologic evaluation of the resected soft tissue mass identified lymph nodes with necrotizing granulomas without airway or lung tissue. No pathogens were identified and acid-fast bacilli (AFB) smear was negative. A subsequent sputum specimen smear was AFB positive with positive identification of MAC via nucleic acid hybridization. Sputum culture grew MAC at 19 days. Immunologic and infectious evaluations were unremarkable. A treatment course of azithromycin, rifampin, and ethambutol was initiated. Repeat bronchoscopy with BAL performed 2 months after presentation revealed resolution of previous airway abnormality, with negative AFB smear and culture on BAL fluid. Chest CT obtained 3 months after antibiotic therapy revealed resolution of the posterior mediastinal mass. DISCUSSION: Initial bronchoscopy was suggestive of an underlying airway anomaly (cardiac bronchus) as a possible nidus for MAC infection, and subsequent mediastinal erosion. However, given lack of bronchoscopic and imaging evidence supporting a persistent airway anomaly, this case is most consistent with MAC associated mediastinal lymphadenitis complicated by formation of a bronchial fistula. CONCLUSIONS: This case highlights an unusual presentation of MAC mediastinal lymphadenitis with erosion into the airway in an immunocompetent teenager. Although rare in children, MAC mediastinal lymphadenitis needs to be considered in the differential diagnosis of mediastinal masses, especially in patients with respiratory symptoms. If there is evidence on chest imaging of close communication between a mediastinal mass and the airways, clinicians should have a low threshold to perform bronchoscopy to closely evaluate the airways. Reference #1: Nolt, D., Michaels, M. G., & Wald, E. R. (2003). Intrathoracic disease from nontuberculous mycobacteria in children: two cases and a review of the literature. Pediatrics, 112(5), e434-e434. Reference #2: Freeman, A. F., Olivier, K. N., Rubio, T. T., Bartlett, G., Ochi, J. W., Claypool, R. J., … & Holland, S. M. (2009). Intrathoracic nontuberculous mycobacterial infections in otherwise healthy children. Pediatric pulmonology, 44(11), 1051. Reference #3: Desir, A., & Ghaye, B. (2009). Congenital abnormalities of intrathoracic airways. Radiologic clinics of North America, 47(2), 203-225. DISCLOSURES: No relevant relationships by Jason Caboot, source=Web Response No relevant relationships by Benjamin Garren, source=Web Response" @default.
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• W2894908277 date "2018-10-01" @default.
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• W2894908277 title "MYCOBACTERIUM AVIUM COMPLEX MEDIASTINAL LYMPHADENITIS IN AN IMMUNOCOMPETENT ADOLESCENT WITH EROSION INTO THE AIRWAY" @default.
• W2894908277 doi "https://doi.org/10.1016/j.chest.2018.08.736" @default.
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