Fibrosing mediastinitis is an uncommon disease associated with a multiplicity of clinical syndromes. The pathophysiology of this disease is predicated on the encasement of the mediastinal vital organ structures within a dense fibrotic tumor. This tumor appears to emanate from an invasive chronic inflammatory process causing erosion and external compression of these structures. Two cases of this disease are reported: one case of superior vena cava syndrome and one case of esophageal obstruction which evolved satisfactorily with conservative treatment.

Keywords: Sclerosing mediastinitis. Fibrosing mediastinitis. Superior vena cava syndrome.

Objective: This study aimed to use high-resolution computed tomography scans of the chest to characterize the principal alterations occurring in cases of hydrostatic pulmonary edema. Methods: A retrospective analysis was made of the tomography scans of 15 patients presenting clinical profiles of hydrostatic pulmonary edema. The cases were divided into five groups by etiology: congestive heart failure (n = 7); acute mitral valve disease (n = 2); acute myocardial infarction (n = 2); myocarditis (n = 2); and fibrosing mediastinitis (n = 2). Results: The principal findings in the cases of hydrostatic pulmonary edema were ground-glass opacities (in 100%), interlobular septal thickening (in 100%), pleural effusion (in 87%) and peribronchovascular interstitial thickening (in 80%). Other, less common, findings were increased blood vessel diameter, consolidations and air-space nodules. Conclusion: The predominant pattern found in the patients studied was that of ground-glass opacities accompanied by interlobular septal thickening (mosaic attenuation pattern) and bilateral (predominantly right-sided) pleural effusion.

Keywords: Pulmonary edema; Tomography, X-ray computed; Lung diseases

Sclerosing mediastinitis is a rare disorder characterized by an extensive fibrotic reaction involving the mediastinum. Due to the compression or invasion of mediastinal structures, the disorder mimics neoplasia. We present three cases of superior vena cava syndrome in which sclerosing mediastinitis was confirmed. The pathophysiological process is related to enlarged mediastinal lymph nodes, fibroblast proliferation and collagen deposition. The main causes of sclerosing mediastinitis are histoplasmosis and tuberculosis, both of which are prevalent in Brazil. It is difficult to make an accurate histopathological diagnosis using minimally invasive methods, and there is no effective treatment for this condition. In order to make a definitive diagnosis and resolve the aerodigestive tract obstruction, exploratory surgery is indicated.

Keywords: Mediastinitis/physiopathology; Mediastinum; Pulmonary fibrosis; Mediastinal neoplasms; Diagnosis, differential; Case reports [Publication type].

A rare case of descending necrotizing mediastinitis secondary to a non-traumatic submandibular abscess is reported. Although most reports emphasize surgical treatment as indispensable in this disease, this case had an excellent outcome using only intensive care. Thus, even complicated descending necrotizing mediastinitis can be treated by non-surgical procedures.

Keywords: Mediastinitis. Sepsis.

Ludwig's angina is an infection of the submandibular space generally caused by an infection of the 2nd or 3rd lower molar. As a consequence, descending necrotizing mediastinitis, a rare and severe form of mediastinal infection, may occur. The descending necrotizing mediastinitis represents a rare form of mediastinal infection. It presents a high mortality and to decrease that rate it is necessary prompt diagnosis and surgical treatment. Two cases of descending necrotizing mediastinitis due to Ludwig's angina were treated with excellent results in our hospital. The transcervical mediastinal drainage is justified in patients with disease limited to the upper mediastinum. Even so, when there is extensive involvement of the whole mediastinum it is suitable the accomplishment of a wide thoracotomy.

Keywords: Ludwig's angina. Mediastinitis. Diagnosis. Treatment. Surgery.

Objective: To evaluate the epidemiological and clinical aspects of acute mediastinitis and to characterize its treatment. Methods: A retrospective study conducted through review of the medical charts of patients diagnosed with acute mediastinitis at the Hospital Escola da Faculdade de Medicina do Triângulo Mineiro (Triângulo Mineiro Medical School Hospital) between 1987 and 2004. Results: A total of 21 patients were studied. Most (76.2%) were male, and the mean age was 52.5 years. Six patients (28.6%) died. The most common cause (in 38.1%) was median sternotomy, followed by esophageal perforation (in 33.3%) and cervical infection (in 14.3%). Staphylococcus aureus and Staphylococcus epidermidis were the causative agents most frequently isolated. In most cases, the treatment of choice was antibiotic therapy accompanied by surgery. The most frequent complications of the acute mediastinitis were pleural effusions (in 23.8%) and osteomyelitis (in 19.0%). The average hospital stay was 26.6 days. Conclusion: Acute mediastinitis is a serious complication of some diseases and procedures. Despite its low incidence, the mortality rate is high. Staphylococcus aureus and Staphylococcus epidermidis are the most common causative agents. The treatment used was antibiotic therapy accompanied by surgery.

Many conditions result in chronic interstitial lung disease (ILD), being classified as fibrosing ILDs, including idiopathic pulmonary fibrosis, connective tissue diseases, sarcoidosis, and fibrotic hypersensitivity pneumonitis. HRCT plays an important role in the clinical evaluation of fibrosing ILDs. Current treatment perspectives are encouraging and reinforce the need for HRCT scans of adequate technical quality for early detection of fibrosing ILD. Despite efforts in this regard, the significance and management of imaging findings of early interstitial lung abnormalities have yet to be clarified. After identification of CT findings consistent with fibrosing ILD, radiologists must be able to identify characteristic morphological patterns and, in some cases, features of specific clinical entities. In cases in which HRCT features are not sufficiently specific for a definitive diagnosis, HRCT can aid in selecting the best site for surgical lung biopsy. CT follow-up is useful for identifying progressive fibrosing ILDs and detecting complications unrelated to the underlying disease, including infections, acute exacerbations, and neoplasms. Automated quantification tools have clinical applicability and are likely to be available for use in imaging analysis in the near future. In addition, incorporation of CT evaluation into scoring systems based on clinical and functional parameters for staging fibrosing disease is likely to become valuable in determining prognosis. Knowledge of the clinical applications of CT evaluation is essential for specialists managing patients with fibrosing ILD and can have a positive impact on the clinical course of the disease.

Keywords: Tomography, X-ray computed; Diagnostic imaging; Pulmonary fibrosis.

Objective: To report a case series of patients with descending necrotizing mediastinitis (DNM) who were treated with minimally invasive thoracic surgery. Methods: We report three cases of male patients with DNM who underwent mediastinal debridement by video-assisted thoracic surgery at the Hospital São Paulo, located in the city of São Paulo, Brazil, from admission to the final outcome. Results: The postoperative evolution was favorable in all three cases. The mean length of hospital stay was 16.7 days. Conclusions: We conclude that video-assisted thoracoscopy is an effective technique for mediastinal drainage in the treatment of DNM, with the benefits common to minimally invasive surgery: less postoperative pain, lower production of inflammatory factors, earlier return to activities of daily living, and better aesthetic results.

Keywords: Mediastinitis; Thorax; Thoracic surgery, video-assisted.

Histoplasmosis is systemic mycosis caused by a small fungus, Histoplasma capsulatum var. capsulatum, whose natural habitat is soil contaminated by bat or bird excrement. The incidence of histoplasmosis is worldwide. In Brazil, the disease is found in all regions; however, the state of Rio de Janeiro is responsible for most of the microepidemics described. Human infection occurs when airborne spores of H. capsulatum are inhaled. The most common clinical presentation is asymptomatic. The symptoms of acute or epidemic histoplasmosis are high fever, cough, asthenia and retrosternal pain, as well as enlargement of the cervical lymph nodes, liver and spleen. The most common radiological findings are diffuse reticulonodular infiltrates in both lungs, as well as hilar and mediastinal lymph node enlargement. In chronic pulmonary histoplasmosis, the clinical and radiological manifestations are identical to those of reinfection with pulmonary tuberculosis. Histoplasmosis is diagnosed by means of the identification or culture growth of the fungus in sputum or fiberoptic bronchoscopy specimens. Histopathological examination reveals the fungus itself within or surrounding macrophages, as well as granulomatous lesions with or without caseous necrosis. Double agar gel immunodiffusion is the most easily used and readily available serologic test for making the immunological diagnosis. Acute histoplasmosis with prolonged symptoms requires treatment, as do the disseminated or chronic pulmonary forms of the disease. The drug of choice is itraconazole.

Keywords: Mycosis; Histoplasmosis; Lung diseases, fungal.

The superior vena cava is formed by the union of the right and left brachiocephalic veins. It is located in the middle mediastinum, to the right of the aorta and anterior to the trachea. Superior vena cava syndrome consists of a group of signs (dilation of the veins in the neck, facial swelling, edema of the upper limbs, and cyanosis) and symptoms (headache, dyspnea, cough, orthopnea and dysphagia) caused by the obstruction of blood flow through the superior vena cava to the right atrium. This obstruction can be caused by extrinsic compression, tumor invasion or thrombosis. Such obstruction may also occur as a result of insufficient venous return secondary to intra-atrial or intraluminal diseases. From 73% to 93% of all cases of superior vena cava syndrome occur during the development of an intrathoracic tumor. Most patients presenting superior vena cava syndrome secondary to malignant neoplasms are treated without surgery, through radiotherapy, chemotherapy or the use of intraluminal stents. When the etiology of superior vena cava syndrome is benign, it can be treated with clinical measures (anticoagulation, raising the head, etc.) or, in refractory cases, with angioplasty, stents or surgery.

Keywords: Superior vena cava syndrome/therapy; Superior vena cava syndrome/surgery; Superior vena cava syndrome/etiology; Superior vena cava syndrome /drug therapy; Superior vena cava syndrome /radiotherapy; Superior vena cava

Knowledge of the structure and function of pulmonary circulation has evolved considerably in the last few decades. The use of non-invasive imaging techniques to assess the anatomy and function of the pulmonary vessels and heart has taken on added importance with the recent advent of novel therapies. Imaging findings not only constitute a diagnostic tool but have also proven to be essential for prognosis and treatment follow-up. This article reviews the myriad of imaging methods currently available for the assessment of pulmonary circulation, from the simple chest X-ray to techniques that are more complex and promising, such as electrical impedance tomography.

Keywords: Pulmonary circulation; Diagnostic imaging; Hypertension, pulmonary.