Mediastinal hemangioma: Masquerading as pleural effusion
A 4-year-old male child presented to the out-patient department with the complaints of fever and cough of 3 months duration with respiratory distress of recent onset. Chest radiograph showed features of the right sided loculated pleural effusion []. Ultrasonography of the chest showed moderate pleural effusion with multiple thick irregular septa with low level internal echoes.\nOn needle thoracocentesis straw colored fluid was aspirated. Evaluation of pleural fluid revealed, cell count of 1,200/cu mm, proteins of 498 mg/dl and sugar of 59 mg/dl and no bacteria including acid fast bacillus was identified. Computed tomography (CT) of the chest revealed multiseptated lesion occupying lower 3/4th of the right hemithorax [].\nAn inter-costal drain (ICD) tube was placed in the right hemithorax as the child had respiratory distress. Post-procedure evaluation with chest radiograph and an ultrasonogram of thorax revealed a partially collapsed mediastinal mass lesion with residual cystic lesion, hence planned for surgical excision. Initially, video assisted thoracic surgery was attempted and converted to the right posterolateral thoracotomy through the 5th inter-costal space in view of poor visibility and obscure anatomy. The operative findings included, single well encapsulated cystic lesion with multiple loculations containing serosanguinous fluid. There were inflammatory adhesions to surrounding structures including lungs, parietal pleura and pericardium. The lesion was compressing middle and lower lobes with no invasion to surrounding structures. The cyst was excised in-to and subjected to histopathological examination. Post-operative recovery was uneventful. Post-operative chest radiograph showed well expanded lungs, ICD tube removed on the post-operative day 3 and the child was discharged on the next day.\nGross pathological examination of the tumor showed well encapsulated cystic lesion with multiple septations measuring 10 × 10 × 8 cm []. Microscopic examination revealed vascular spaces lined by flat endothelial cells; moderate intervening fibrocollagenous stroma along with few inflammatory cells []. These findings were diagnostic of capillary hemangioma. There was no evidence of cellular atypia or mitotic figures indicating that it was a completely benign lesion.\nPatient was followed-up in the out-patient department at 1 week, 1 month and 6 months and 1 year post-operatively and was doing well. The chest radiograph taken at 6 month follow-up visit was normal.