Lethargy, Confusion, and a Mediastinal Abnormality in a 68-Year-Old Woman

Lethargy, Confusion, and a Mediastinal Abnormality in a 68-Year-Old WomanA 68-year-old woman was brought to the hospital because of increasing lethargy and confusion. She continued to breathe spontaneously but required intubation to protect her airway shortly after arrival. The patient had a past history of hypertension, asthma, cerebrovascular disease, and seizures.
Vital signs: temperature, 37.4°C; pulse, 110/min; respirations, 24/min; blood pressure, 170/70 mm Hg. Neck: estimated central venous pressure <5 cm H2O. Eyes: pupils equal and reactive. Chest: bilateral end-expiratory wheezes. Cardiac: normal Sj and S2, grade 3/6 nonradiating diastolic murmur at the lower left sternal border, grade 2/6 apical holosys-tolic murmur radiating to the axilla, bisferiens carotid pulses, pistol shot pulses of Traube, positive Duroziez’s sign. Neurologic: obtunded without focal findings.
ABC (room air): pH, 7.48; РаСОг, 32 mm Hg; РаОг, 74 mm Hg. Chest roentgenogram: presence of a left third mediastinal “mogul” (Fig 1). Head CT: old right occipital infarction.
During the CT examination, the patient developed Cheyne-Stokes respirations and a repeat ABG (FI02 40 percent) showed: pH, 7.10; РаСОг, 65 mm Hg; РаОг, 48 mm Hg. Mechanical ventilation was initiated.
What diagnosis is suggested by the patient’s clinical presentation and chest radiographP. Natural asthma treatment antimicrobialmed.com A sinus of Valsalva aneurysm most commonly develops as a congenital condition from the absence of aortic media in a region of the vascular wall behind the aortic sinus. This defect results from an incomplete fusion of the two halves of the distal bulbar septum and leads to aneurysmal dilatation of the sinus—most commonly in the right coronary cusp. Associated congenital cardiac lesions include ventricular septal defect, aortic insufficiency, patent ductus arteriosus, coarctation of the aorta, and pulmonic stenosis.


Figure 1. Patient’s presenting chest roentgenogram demonstrates a left third mediastinal “mogul” (arrow).

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