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CASE REPORT
A 70 year old woman presented with acute onset of chest tightness and right shoulder discomfort. She had a history of essential hypertension. She was married, lived with her husband, had a 100 pack year smoking history, and a family history of lung cancer. There were no risk factors for HIV infection and no recent travel. Physical examination was normal. A diagnosis of myocardial infarction or aortic dissection was considered. The chest radiograph, electrocardiogram, and laboratory studies including cardiac enzymes were normal. Transoesophageal echocardiography revealed normal cardiac function and neither aortic dissection nor aneurysm formation. A chest MRI scan showed a diffuse, infiltrative, subaortic, extravascular mediastinal mass that displaced the trachea rightward (fig 1A, arrow). These findings were considered suggestive of malignancy. At fibreoptic bronchoscopy no endobronchial lesions were seen and no tumour cells or microorganisms were found in specimens of bronchial lavage fluid. The patient developed sudden massive haemoptysis and expired, despite aggressive resuscitative efforts. Necroscopic examination revealed an aneurysm of the ascending aorta that had ruptured into the right bronchus (fig 1B, arrow). "Tree barking" was evident in the aortic intima and suggested tertiary syphilis as the aetiology of the ruptured aneurysm.
(A) MRI scan...