Pulmonary Artery Stenosis in a Patient with Prior Histoplasmosis and the Discovery of Complications

Abstract

Pulmonary hypertension (PH) results from varied etiologies, leading to progressive symptoms and limiting physical activity and quality of life, with associated morbidity and mortality. External compression of the pulmonary artery (PA) is a rare cause of PH and may give the clinician cause to investigate compression of nearby structures. In this E-Challenge, the authors present a case of PA stenosis in a patient with prior histoplasmosis scheduled for left PA stenting. However, because the pulmonary veins were not well-visualized on chest computed tomography, the anesthesia team performed a perioperative transesophageal echocardiogram (TEE) to help differentiate the causes of PH. TEE revealed external compression of the pulmonary veins. This case highlights the value of pathophysiologic understanding, preoperative planning, and the effect of echocardiography on clinical management and patient safety. In this case, TEE prevented possible morbidity and mortality.

Mediastinal Fibrosis, Pulmonary Vein Stenosis, and the Role of Transesophageal Echocardiography

“…Songster et al, in their E-challenge, titled "Pulmonary Artery Stenosis in a Patient with Prior Histoplasmosis and the Discovery of Complications," report on just such a case of a patient with pulmonary hypertension caused by external compression of the pulmonary vasculature. 1 In today's world of multimodal imaging, a patient can undergo myriad investigations and imaging before being taken to the operating room. The E-challenge notes that computed tomographic imaging with contrast failed to demonstrate the pulmonary veins, whereas intraoperative TEE was able to be used to diagnose abnormally high pulmonary vein velocities.…”

“…This discovery during perioperative echocardiography thus prevented morbidity and mortality. 1 Because fibrosing mediastinitis is a rare disorder, it is underrecognized. The clinical presentation can be variable and has commonalities with other granulomatous diseases, such as tuberculosis (TB); sarcoidosis; Behcet's disease; and as mentioned in the E-challenge, histoplasmosis.…”

“…Because fibrosing mediastinitis is an insidious process, it allows the body to adapt, and vascular compromise can go unnoticed owing to the formation of collaterals. 1 Patients infected with TB who develop fibrosing mediastinitis also develop life-threatening complications such as pulmonary vein thrombosis. These patients present with similar signs and symptoms of TB, but their condition can decompensate rapidly if unrecognized.…”