Introduction: Fibrosing mediastinitis (FM) is a rare, progressive condition often triggered by prior granulomatous infection, particularly Histoplasma capsulatum. It leads to dense fibrotic proliferation in the mediastinum, compressing pulmonary vasculature and causing pulmonary hypertension, perfusion defects, and right heart failure. While medical therapy—including corticosteroids, antifungals, and immunosuppressants—may stabilize inflammation, it rarely reverses structural stenosis. Percutaneous vascular intervention may offer symptomatic relief but carries significant procedural risk, especially in advanced disease.
Description: We retrospectively analyzed two patients with biopsy-confirmed histoplasmosis-associated FM and significant pulmonary vascular stenoses. Patient 1 We report two cases of histoplasmosis-associated FM with pulmonary vascular involvement. Patient 1: A 73-year-old woman with severe LUPV stenosis (mPAP ~50 mmHg) underwent stenting in 2023. In June 2024, during a staged intervention for residual RUPV and bilateral PA stenoses, she developed LUPV perforation with hemothorax and hemodynamic collapse, requiring VA-ECMO. Her course was complicated by stroke, Stenotrophomonas pneumonia, candidemia, and multiorgan failure, resulting in death. Patient 2: A 36-year-old man with severe RLPV and RLPA stenoses despite prior medical therapy underwent successful RLPV stenting (9×18 mm Omnilink) and RLPA angioplasty (6 mm Viatrac) in April 2024. He reported NYHA class I symptoms post-procedure and maintained vessel patency on follow-up imaging. He remains on aspirin and under annual surveillance
Discussion: These cases illustrate the variability in outcomes following percutaneous intervention for FM-related vascular stenosis. In younger, medically optimized patients, targeted intervention may restore perfusion and significantly improve symptoms. In contrast, intervention in advanced FM with friable vasculature and severe pulmonary hypertension carries a high risk of catastrophic complications. These findings underscore the need for individualized decision-making, multidisciplinary involvement, and careful procedural planning based on anatomic severity and functional status.
