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Dr.

RAJENDRANSINSTITUTEOFMEDICALEDUCATION

EXPLANATIONTOPICTUREQUIZ020316SWELLINGOFBOTHPAROTIDGLANDS

Ans:B,giveprednisone.

DiagnosisHeerfordt'ssyndrome.Thisisarareformofsarcoidosisinwhichthecompressionofthefacialnerve
resultsinpalsy.

Thereisbilateralhilar(whitearrows)andrightparatrachealadenopathy(yellowarrow),acharacteristic
patternoflymphadenopathyforsarcoid.


CTshowsincreaseduniformcontrastenhancementofthebothparotidglands.

HEERFORDTSYNDROME
,oruveoparotidfever,isanuncommonacutepresentationofsarcoidosismanifesting
asfever,parotidandlacrimalglandenlargement,uveitis,bilateralhilaradenopathy,andoftencranial
neuropathies.Corticosteroids(prednisone)arethemainstayoftherapy.

Hilarand/ormediastinallymphadenopathyisfoundinthemajorityofpatientswithsarcoidosis;thisisthe
mostcommonfinding.Themostfrequentpresentationisbilateralhilarandrightparatracheal
lymphadenopathy.Leftparatrachealandaortopulmonarywindowlymphnodesarealsofrequentlyinvolved,
buttheymaybedifficulttodetectonastandardposteroanteriorchestradiograph.

Radiographicevidenceofanteriormediastinaladenopathyisseeninlessthan10%ofcases.Theposterior
mediastinumisleastcommonlyinvolved.Isolatedunilateralhilarlymphadenopathyisanunusual
manifestationofsarcoidosis,occurringinonly13%ofpatients.

HIVELISA

InpatientsinwhomHIVinfectionissuspected,thebestinitialtestisELISA(alsoreferredtoasenzyme
immunoassay).ELISAtestsarescoredaspositive(highlyreactive),negative(nonreactive),orindeterminate
(partiallyreactive).WhiletheEIAisanextremelysensitivetest,itisnotoptimalwithregardtospecificity.This
isparticularlytrueinstudiesoflowriskindividuals.Inthelowriskpopulation,only10%ofEIApositive
individualsaresubsequentlyconfirmedtohaveHIVinfection.

IftheELISAisindeterminateorpositive,repeatthetest.Iftherepeattestisnegativeontwooccasions,HIV
infectionisruledout.Iftheresultisnegative,thediagnosisisruledoutunlessearlyHIVinfection(withinthe
previous3months)issuspected.Then,performretestingasclinicallyindicated.

MEDIASTINAL(THYMIC)LARGEBCELLLYMPHOMA

Thisisadiseasethatcanbebulkyinsizebutusuallyremainsconfinedtothemediastinum.Itcanpresentwith
arapidgrowingmediastinalmasscausingdifficultybreathing,aswellaspleuraland/orpericardialeffusions,or
superiorvenacavasyndrome.Aboutonethirdofpatientsdeveloppleuraleffusions,and510%can
disseminatewidelytokidney,adrenal,liver,skin,andevenbrain.

Thefirststepinevaluatingamediastinalmassistoplaceitinoneofthethreemediastinalcompartments,
sinceeachhasdifferentcharacteristiclesions.Themostcommonlesionsintheanteriormediastinumare
thymomas,lymphomas,teratomatousneoplasms,andthyroidmasses.Themostcommonmassesinthe
middlemediastinumarevascularmasses,lymphnodeenlargementfrommetastasesorgranulomatous
disease,andpleuropericardialandbronchogeniccysts.Intheposteriormediastinum,neurogenictumors,
meningoceles,meningomyeloceles,gastroentericcysts,andesophagealdiverticulaarecommonlyfound.See
tablebelow.

TheThreeCompartmentsoftheMediastinum

Anatomical
boundaries

Contents

Anterior
Compartment
Manubriumandsternum
anteriorly,pericardium,
aorta,and
brachiocephalicvessels
posteriorly

Thymusgland,anterior
mediastinallymph

MiddleCompartment
Anteriormediastinumanteriorly,
posteriormediastinum
posteriorly

Posterior
Compartment
Pericardiumandtrachea
anteriorlyvertebral
columnposteriorly

Pericardium,heart,ascending
andtransversearchofaorta,

Descendingthoracic
aorta,esophagus,

nodes,internal
mammaryarteriesand
veins

Common
abnormalitie
s

Thymoma,lymphomas,
teratomatousneoplasms,
thyroidmasses,
parathyroidmasses,
mesenchymaltumors,
giantlymphnode
hyperplasia,hernia
throughforamenof
Morgagni

superiorandinferiorvenacavae,
brachiocephalicarteriesand
veins,phrenicnerves,trachea,
andmainbronchiandtheir
contiguouslymphnodes,
pulmonaryarteries,andveins

Metastaticlymphnode
enlargement,granulomatous
lymphnodeenlargement,
pleuropericardialcysts,
bronchogeniccysts,massesof
vascularorigin

thoracicduct,azygos
andhemiazygosveins,
sympatheticchains,and
theposteriorgroupof
mediastinallymphnodes

Neurogenictumors,
meningocele,
meningomyelocele,
gastroentericcysts,
esophagealdiverticula,
herniathroughforamen
ofBochdalek,
extramedullary
hematopoiesis

Erythemanodosum
(EN)isanacute,nodular,erythematouseruptionthatusuallyislimitedtotheextensor
aspectsofthelowerlegs.Erythemanodosumisahypersensitivityreactionandmayoccurinassociationwith
severalsystemicdiseasesordrugtherapies,oritmaybeidiopathic.Hilaradenopathymaydevelopaspartof
thehypersensitivityreactionoferythemanodosum.Bilateralhilarlymphadenopathyisassociatedwith
sarcoidosis,whileunilateralchangesmayoccurwithinfectionsandmalignancy.