Summary

A 64-year-old woman presented with shortness of breath, right-sided pleuritic chest pain and dry cough. She was systemically anticoagulated with warfarin for a pulmonary embolism diagnosed 3 months previously, with an international normalised ratio (INR) of 3.0 on presentation. Chest radiograph demonstrated a new right paratracheal abnormality, and CT scan showed a large mediastinal mass not present 3 weeks earlier. MRI demonstrated an ovoid mass with a fluid/fluid level with high T2 and dark T1 signal consistent with a mediastinal haematoma. The patient's anticoagulation was emergently reversed and a temporary inferior vena cava filter was placed. The haematoma slowly resolved on serial follow-up with no additional intervention. Spontaneous mediastinal haematoma is a rare but life-threatening diagnosis that frequently presents with chest pain, dry cough and dysphagia. It is frequently associated with therapeutic anticoagulation and may potentially be caused by sudden, atraumatic rise in intrathoracic pressure (ie, cough or emesis).