Fibrosing mediastinitis: a squeeze on arterial and venous segments of the heart.

A 38-year-old woman developed fibrosing mediastinitis after an initial episode of histoplasmosis. She had history of frequent bronchitis as a teenager and developed symptoms suggestive of pneumonia unresponsive to conventional antibiotics. In addition to right lung infiltrates, she developed mediastinal lymphadenopathy. After transbronchial biopsy confirmation of histoplasmosis, she received therapy with oral itraconazole. Three years after her initial therapy with itraconazole, she presented with worsening dyspnea on exertion. Echocardiography suggested new-onset pulmonary hypertension and moderate tricuspid regurgitation. Cross-sectional imaging of the chest demonstrated thickened pleura and pericardium; calcified, enlarged lymph nodes; and prominent fibrosis in the hilar region. Thorascopic and mediastinoscopic biopsies confirmed the diagnosis of fibrosing mediastinitis. She was treated with courses of antibiotics and pulsed steroids over the years for symptoms of dyspnea, hemoptysis, and pleuritic chest pain associated with radiological evidence of disease progression. Notably, the steroids did not …