INTRODUCTION: Complications from transbronchial needle aspiration (TBNA) of lymph nodes are rare and can include minor bleeding, hypoxemia and bronchospasm. We report a case of endobronchial ultrasound (EBUS)-guided TBNA complicated by descending mediastinitis and purulent pericarditis.
CASE PRESENTATION: A 53-year-old female presented for outpatient consultation with symptoms of recurrent bronchitis and a long history of mediastinal lymphadenopathy. Thoracic CT revealed mediastinal and hilar lymph-adenopathy. The patient underwent EBUS-TBNA of the station 4R node to confirm a diagnosis of pulmonary sarcoidosis. Biopsy needle placement was confirmed using EBUS and four passes were made into the node. There were no immediate peri-procedural complications and pathology revealed only lymphoid elements. One week later, the patient presented to an outside pulmonologist with complaints of chest pain and high-grade fevers. A chest CT was obtained showing a new heterogeneous paratracheal mass at the level of the 4R lymph node and a small pericardial effusion. She was then transferred to our institution for treatment of mediastinitis. On mediastinoscopy, a large firm lymph node collection was discovered without suppuration or hematoma and biopsy revealed non-caseating granulomas with negative stains for fungal and acid fast organisms. She was hospitalized for three days and her fever resolved with vancomycin, gentamycin and piperacillin/tazobactam. Several days after discharge home without antibiotics, the patient again developed chest pain made worse when lying on her left side and deep inspiration, fevers, chills, joint pains and delirium. Her ECG showed low voltage with diffuse ST segment elevation and pulsus paradoxus was noted on exam. Echocardiography revealed a moderate circumferential pericardial effusion and mild hemodynamic compromise. She was promptly readmitted to our institution and treated with vancomycin, gentamycin and ceftriaxone. After catheter removal of 750 mL of purulent pericardial fluid with a white blood cell count of greater than 18,000 (98% polymorphonuclear cells) and no organisms on fluid culture, rapid clinical improvement ensued. Ceftriaxone was continued for 4 weeks. Follow-up transthoracic echocardiogram revealed improvement of the pericardial effusion.
DISCUSSIONS: Descending mediastinitis usually results from a complication of oropharyngeal infection or from extension of adjacent infection. Purulent pericarditis, equally rare and life threatening, usually results from contiguous pulmonary or chest wall infection such as pneumonia or empyema, hematogenous spread and direct infection from trauma or surgery. The most common organisms include S. aureus, other Gram positive organisms or fungal species. While others have reported mediastinitis through inoculation by infected transbronchial needles during TBNA and purulent pericarditis in the setting of gene therapy injection for treatment of lung cancer, none of these cases have involved standard EBUS-TBNA. The most likely mechanism for the spread of infection in this case would be translocation of airway bacteria into the pericardial space.
CONCLUSION: We report to our knowledge, the first case of mediastinitis and purulent pericarditis resulting from EBUS-TBNA lymph node biopsy illustrating the importance of considering this potential complication. Given the advantages and greater sampling accuracy of EBUS-TBNA, it will likely continue to be performed in much greater numbers which underscores the consideration of this rare complication.
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