Case Report
An accidental mass Matthew Brooks, Colin Royse, Damon Eisen, Paul Sparks, Krishna Bhagwat, Alistair Royse Lancet 2011; 377: 1806 Cardiology Department (M Brooks MBBS, P Sparks FRACP), Department of Anaesthesia and Pain Management (Prof C Royse FANZCA), Victorian Infectious Disease Service (D Eisen FRACP), and Cardiothoracic Surgery Department (K Bhagwat MBBS, A Royse FRACS), Royal Melbourne Hospital, Melbourne, Victoria, Australia; and Department of Pharmacology, University of Melbourne, Melbourne, Victoria, Australia (Prof C Royse) Correspondence to: Mr Alistair Royse, Cardiothoracic Surgery Department, Royal Melbourne Hospital, Melbourne, VIC 3050, Australia
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In June, 2010, a 27-year-old Indian woman was brought to our emergency department after being hit by a car. She had pelvic fractures. A routine trauma CT series of the chest showed incidental right pulmonary nodules, hilar lymphadenopathy, and a large inferior mediastinal mass (figure A). The mass invaded the superior vena cava and right inferior pulmonary vein. Her body-mass index (BMI) was 16 kg/m², but the physical examination was otherwise unremarkable. Apart from recent weight loss, she had been well and was a non-smoker. The pelvic fractures were managed conservatively. The chest imaging suggested advanced malignancy. Bronchoscopy washings and an endobronchial ultrasound guided mediastinal biopsy sample showed no abnormalities, including Mycobacterium tuberculosis. A right thoracotomy showed extensive adhesions and a tumour-like infiltrate of the right lower lung lobe and mediastinum. Biopsy samples showed necrotising granulomatous inflammation and fungal hyphae. Cultures were not done but pan-fungal 18s rRNA PCR testing was positive for an aspergillus species (Westmead Hospital, Sydney). PCR for M tuberculosis was negative. ESR was 102 mm/h (normal
