70-year-old man with a personal history of prostate adenocarcinoma 7 years ago (T2a-b N0 M0), treated with androgen blockade, radiotherapy and brachytherapy. Surgical intervention of appendectomy and tonsillectomy. He did not take any regular medication and had a sister with breast cancer and a brother with lung cancer as relevant family history.
She attended the emergency department for sudden onset of transphyxial chest pain associated with vegetative crust while doing farm work. During his stay in the emergency department he remained asymptomatic and haemodynamically stable with BP 133/74 and HR 64 bpm. On examination he presented mucocutaneous pallor, cardiac auscultation with rhythmic muffled tones and no murmurs, with the rest of the examination being normal. Initial blood tests showed a normal haemogram with normal biochemistry and coagulation parameters, D-dimer 189 ng/ml (0-275), B-type natriuretic peptide 80 pg/ml (0-100), troponin 0.008 ng/ml (0-0.04). The initial chest X-ray (X-ray) showed mediastinal widening, so an urgent CT scan was performed, showing a prevertebral mass (Hounsfield Units/UH 38 - soft tissues), retrotracheal, encompassing the oesophagus and subsequently displacing the aorta, which had a normal morphology, with discrete bilateral pleural effusion, the rest of the structures being normal. Given the findings of the imaging test, the patient was initially admitted to the Digestive System Department where an endoscopic ultrasound was performed, visualising a heterogeneous lesion posterior to the oesophagus without depending on it, and a biopsy was taken with negative results for neoplastic cells with haemorrhagic cytology. A bronchoscopy was performed, describing extrinsic compression at the level of the posterior wall of the distal third of the trachea and main bronchi, performing 3 punctures with abundant haemorrhagic material coming out, with haemorrhagic cytology without neoplastic cells. A thoracotomy was proposed to obtain samples. In the absence of findings in the tests previously performed, prior to surgery, the Internal Medicine department was consulted, who, reviewing the clinical history from admission, noted anaemia in the first hours of admission (Hb 14.1 g/dl) and subsequently a Hb value of 11.2 g/dl, which remained stable. A new chest X-ray showed disappearance of the mediastinal widening with minimal persistence of pleural effusion. Diagnostic thoracentesis was performed with negative results for neoplasia with haemorrhagic cytology. Given the initial clinical picture and the results of the haemorrhagic cytology and given the high suspicion of a vascular complication at thoracic level, a new CT scan was requested and reported as a small image of hypodense and homogeneous appearance with an approximate calibre of 1.5 cm compatible with a haematoma in the posterior mediastinum in resolution. Angiography was performed, showing pseudoaneurysmal dilatation of the bronchial artery at its origin, and therapeutic embolisation was performed without incident.

