S4470 Hemophilia Masquerading as Cancer: Extraluminal Esophageal Hematoma in a Young Man

Introduction: Acute Onset Dysphagia raises concerns of esophageal obstruction due to malignancy, strictures, or external compression. We presented a unique case of sudden onset dysphagia due to extraluminal compression of the esophagus, presumed to be caused by a spontaneous mediastinal hematoma in a patient with hemophilia B. Case Description/Methods: A 34-year-old man with a history of hemophilia on recombinant factor IX presented with complaints of acute dysphagia to both solids and liquids. The patient had a preceding 3-day history of respiratory illness with a productive cough and low-grade fever. Initial imaging was significant for right basilar opacity and was managed with antibiotics. During hospitalization, computed tomography imaging was significant for a posterior mediastinal mass causing esophageal compression and hepatic lesions. Upper endoscopy did not show any intraluminal mass in the esophagus, and an external compression with mucosal discoloration was noted in the mid-distal esophagus. Endoscopic ultrasound revealed multiple large hypoechoic posterior mediastinal lesions with necrosis. Fine needle aspiration biopsy showed hypercellular specimen with fibrosis/sclerosis and few atypical cells but no malignancy. Tumor markers (Alpha-Fetoprotein, beta-human chorionic gonadotropin) were normal. Magnetic resonance imaging reaffirmed the presence of a posterior mediastinal mass. Following discharge, the patient had spontaneous resolution of symptoms with radiological reduction in mass size on serial imaging. A thoracoscopic biopsy was planned but was deferred due to possible further contained mediastinal hematoma development. Spontaneous regression of mediastinal mass and absence of B symptoms suggested that the compression was likely due to hematoma, possibly triggered by vigorous cough-related vascular injury in the setting of hemophilia B rather than malignancy. The patient was managed and improved with supportive care and factor IX replacement. Discussion: This case highlights the importance of considering spontaneous mediastinal hematoma as a rare but significant cause of dysphagia, particularly in patients with underlying coagulopathies. Recognizing nonmalignant causes of extraluminal esophageal compression is crucial to prevent unnecessary invasive interventions, and ensure timely, etiology-specific management. Early identification through appropriate imaging and clinical correlation can facilitate conservative treatment and improve outcomes in this uncommon but clinically relevant scenario.