A Lethal Illusion: T-Cell Lymphoma Masquerading as Aortic Dissection

Document Type

Conference Proceeding

Publication Date

10-2025

Publication Title

Chest

Abstract

INTRODUCTION: Aortic dissection(Type A) is a life-threatening condition requiring emergent surgical intervention. However, conditions that mimic dissection can lead to misdiagnosis and delayed appropriate management. We present a case of T-cell lymphoma initially misdiagnosed as an aortic dissection, highlighting the diagnostic challenges and the importance of review of imaging and thorough clinical evaluation. CASE PRESENTATION: A 64-year-old male with a history of hypertension was transferred from an outside hospital (OSH) for the evaluation of a suspected Type A aortic dissection and pericardial haemorrhage. He reported several months of intermittent chest pain, which had worsened prior to admission, along with significant shortness of breath and generalized abdominal pain. Initial imaging(CTA PE) at the OSH demonstrated mediastinal haemorrhage with concerns for aortic rupture, prompting transfer for surgical evaluation while patient was initiated on IV esmolol. Upon arrival, a repeat computed tomography angiography (CTA) of the chest, abdomen, and pelvis revealed extensive soft tissue thickening surrounding the ascending aorta, aortic arch, descending thoracic aorta, and mediastinum around the main pulmonary artery along with soft tissue masses encasing the entire right coronary artery with pericardial thickening. Differentials included vasculitis, infiltrative disease like IGG4, Erdheim Chester Disease(ECD), malignancy or an infectious aetiology given patient's significant travel history. The patient was admitted to the ICU and underwent pericardiocentesis with drainage of 400cc of hemorrhagic fluid. A pigtail catheter was placed for a large left pleural effusion, which drained 2240cc with persistent continuous drainage over several days. Infectious workup including fluid cultures, AFB smear, TB quantiferon, fungal cultures remained negative. The initial pleural fluid analysis and pericardial fluid was eventually found to be concerning for malignancy, with flow cytometery revealing an aberrant T-cell population suggestive of a T-cell neoplasm. Subsequent mediastinoscopy with biopsy confirmed the diagnosis of T-cell lymphoma with unremarkable cytogenetics. The patient was started on DA- EPOCH (etoposide, prednisone, vincristine sulfate, cyclophosphamide, doxorubicin) for chemotherapy. DISCUSSION: Our case emphasis the potential for thoracic lymphoma to mimic life-threatening vascular conditions such as aortic dissection. The initial presentation with hemorrhagic pericardial effusion, mediastinal hemorrhage, and imaging suggestive of aortic pathology contributed to the diagnostic challenge. The presence of soft tissue thickening around major vascular structures and encasement of the SMA prompted reconsideration of the diagnosis. Mediastinal lymphomas, particularly T-cell lymphomas, can present with vascular invasion and compression, mimicking dissection or vasculitis. Although T cell lymphomas are more common in young adults and immunocompromised host, they should be considered when evaluating similar cases. CONCLUSIONS: This case highlights the importance of maintaining a broad differential diagnosis when evaluating suspected aortic dissection, especially in the presence of atypical imaging findings. Awareness of this rare but serious mimic can prevent unnecessary surgical intervention and reduce potentially disastrous patient outcomes.

Volume

168

Issue

4S

First Page

3294A

Comments

American College of Chest Physicians CHEST Annual Meeting, October 19-22, 2025, Chicago, IL

Last Page

3295A

DOI

10.1016/j.chest.2025.07.1857

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