An unusual cause of chest pain in a young man: bronchogenic cysts and their cardiac manifestations

Abstract

A 24-year-old previously healthy man was admitted to our casualty department with a two-day history of worsening central retrosternal chest pain, diaphoresis and dyspnoea. An electrocardiogram showed ischaemic changes ( Figure 1) and a subsequent echocardiogram showed a mass, posterior to the right atrium. The mass, which was not arising from the heart, was impinging on the oesophagus (Figure 2) and right pulmonary arteries. A computed tomography (CT) scan of the thorax revealed a homogeneous, hypodense mass, about 6 cm in diameter, behind the right atrium, and excluded the possibility of an aortic aneurysm (Figure 3). The patient was treated symptomatically with opiate analgesia due to the severity of the pain. A causal connection between the symptoms and clinical findings was assumed and surgery was carried out a few days after admission. Histological examination of the mass showed fragments of connective tissue covered by pseudostratified and squamous epithelium. The presence of ciliated epithelium in some places made bronchogenic cyst the most likely diagnosis. The patient has remained symptom-free to the present day, one year after surgery.The mechanisms underlying the pathophysiology of the ischaemic changes in our patient are not clear. Given that he has remained free of symptoms post-operatively, the most likely cause of his symptoms was impingement of the cyst on the coronary vessels producing the ischaemic changes. In our literature review we draw attention to the association between cardiac ischaemia and anginal symptoms and the presence of a bronchogenic cyst. Infection is thought to have played a part in the cyst becoming symptomatic, possibly due to an acute increase in fluid content, although the fluid cultures remained sterile.Cysts of the mediastinum that are benign masses constitute a small but important diagnostic group, representing 12-18% of all primary mediastinal tumours. The classification of mediastinal cysts is based on their aetiology, encompassing bronchogenic, oesophageal duplication cysts of foregut origin, mesothelial-derived pericardial/pleural cysts and thymic cysts. Bronchogenic cysts are classified as foregut cysts, together with oesophageal cysts, and occur more frequently than oesophageal cysts.1 The first reported case of a bronchogenic cyst was by Meyer in 1859. 2 An unusual cause of chest pain in a young man: bronchogenic cysts and their cardiac manifestations ABSTRACT We report a case of a 24-year-old man who presented with chest pain and electrocardiographic evidence of myocardial ischaemia. An abnormal structure located behind the heart on the urgent transthoracic echocardiogram and a computed tomography scan of the mediastinum led to prompt surgery with eventual resection of the lesion. The histology revealed fragments of connective tissue covered by squamous epithelium and ciliated epithelium, consistent with a bronchogenic cyst. The case study is accompanied by a literature review of the pathogenesis, diagnosis and management of bronchogenic cysts and their associati...