Sofya Malashanka, BS1, William Quinones, MD2, Joshua Obuch, MD, MSc2
1Geisinger Health System, Scranton, PA; 2Geisinger Health System, Wilkes-Barre, PA
Introduction: Jugular venous pulsations (JVP) usually have associated cardiac or pulmonary pathology. In this case report we explore a patient with JVP due to an otherwise asymptomatic mediastinal mass.
Case Description/Methods: A 44 year old male with no significant prior history presented to the ER after 5 months of intensifying unilateral pulsations (Figure 1), He denied neck pain, visual changes, dysphagia/odynophagia, palpitations, dyspnea, or weight loss. Lab evaluation revealed normal CBC, CMP, TSH, pro-BNP, and troponin level. Neck CT showed no vascular dilation or masses. Chest CT revealed a large lobulated mass in the posterior mediastinum arising from the gastroesophageal junction (GEJ) (Figure 2a-c). Follow up PET CT showed FDG avidity. EGD revealed a large diverticulum adjacent to the GEJ as well as diffuse gastritis with biopsies positive for H.Pylori. Endoscopic ultrasound (EUS) was performed (Figure 3a, 3b) for tissue acquisition with pathology showing a benign smooth muscle proliferation with immunophenotypic profile positive for desmin, smooth muscle actin and vimentin (SMA), and negative for S100, CD117 and DOG-1, consistent with leiomyoma. The patient underwent esophagectomy with gastric pull-through. Final pathology showed low-grade spindle cell neoplasm with similar immunohistochemical staining as EUS specimens consistent with a leiomyoma. Postoperative course was complicated by chylothorax requiring thoracic duct embolization as well as mild gastric outlet obstruction.
Discussion: This case of unilateral JVP in the setting of a posterior mediastinal mass illustrates the need for a low threshold for imaging in the setting of otherwise unexplained exam findings. Esophagogastric leiomyomas are rare and may have an association with H.Pylori infection as seen in this patient, which warrants exploration between the cause and effect of H. Pylori and leiomyomas (1). While hypermetabolic tumors on PET scan typically indicate malignancy, there are reports of leiomyomas appearing hypermetabolic on PET scan (2) as seen in this patient.
1) Meshikhes A.-W. N., Al-Khalaf E. A., Al-Bahar S. H. Gastric leiomyoma. Is there an association with Helicobacter pylori? Saudi Medical Journal. 2004;25(11):1758–1759.
2) Nero LD, Moscatelli A, Fazio V, Pellegatta G, Bongioanni F, Sambuceti G,Savarino V, Giannini EG. Positive PET in a Patient With Esophageal Leiomyoma. Am J Gastroenterol. 2016 Jun;111(6):767
Citation: Sofya Malashanka, BS; William Quinones, MD; Joshua Obuch, MD, MSc. P1243 - JUGULAR VENOUS PULSATIONS WITH NEOPLASTIC IMPLICATIONS: A CASE OF UNILATERAL EXTERNAL JUGULAR VENOUS PULSATIONS IN THE SETTING OF A MEDIASTINAL MASS. Program No. P1243. ACG 2019 Annual Scientific Meeting Abstracts. San Antonio, Texas: American College of Gastroenterology.