SESSION TITLE: Surgery Student/Resident Case Report Posters
SESSION TYPE: Medical Student/Resident Case Report
PRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PM
INTRODUCTION: Bronchogenic cysts are benign congenital lesions of the respiratory tract which are often asymptomatic in adults. We report a case of a bronchogenic cyst resulting in abscess formation and rapid enlargement with compression of surrounding structures after transbronchial needle aspiration.
CASE PRESENTATION: A51 year-old male with a 23 pack-year smoking history presented to the ED complaining of pleuritic chest pain, shortness of breath, fevers, and diaphoresis for 5 days. Pain was insidious, substernal, and without radiation. He denied cough, production of sputum, or symptoms consistent with heart failure. Of note, the patient had been followed for a mediastinal mass which was identified on an x-ray during a routine physical. Two months prior to presentation, it was 3.9 x 5.2 x 7.1 cm by CT. 15 days prior to presentation, the patient had bronchoscopy with TBNA of the mass which was non-diagnostic. At presentation, the patient had a heart rate of 150, but physical exam was otherwise normal. Chest x-ray revealed right hilar fullness. Labs showed a WBC of 15K. The patient was admitted to the ICU for possible sepsis. He was placed on vancomycin and piperacillin-tazobactam. CT angiography of the chest showed the mass had grown to 8 x 8.4 x 8.8 cm and compressrf the right pulmonary artery. He was taken by thoracic surgery for VATS with incision and drainage of his mass which revealed pus. Due to the proximity of the remaining cyst to his right pulmonary artery, it was not excised. Post-procedure, his chest pain resolved. Cultures were negative, and he completed ten days of antibiotics.
DISCUSSION: Bronchogenic cysts are the most common cystic lesion of the mediastinum. They are mucous-filled cysts lined by respiratory epithelium, smooth muscle, and cartilage, and arise as out-pouches of embryonic ventral foregut. Up to 1/3 of adult patients are asymptomatic. Detection is typically by XRAY or CT, but diagnosis requires biopsy. Complications of bronchogenic cysts include compression of surrounding structures, infection, and in rare cases, malignant transformation. This patient’s bronchogenic cyst appears to have become infected after a diagnostic TBNA was performed. The cyst became a mediastinal abscess, rapidly grew, and started to compress vital structures in the patient’s mediastinum. He underwent incision and drainage which showed pus and thus confirmed an abscess. Though cultures were negative, after drainage of the pus and a 10 day antibiotic course, this patient had no further problems.
CONCLUSIONS: Bronchogenic cysts which have developed an abscess can cause severe complications due to their proximity to vital structures. Treatment involves supportive care and empiric antibiotic therapy until emergent surgical intervention can provide definitive treatment..
Reference #1: Chung, Dai. “Pediatric Surgery.” In: Townsend C, Beauchamp R, Evers B, Mattox K, eds. Townsend: Sabiston Textbook of Surgery, 19th Ed. Elsevier; 2012; 1829-1871.
DISCLOSURE: The following authors have nothing to disclose: Jeffrey Shehane, Bimaje Akpa, Monique Bennerman, Richard Fremont
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