Baylor Scott and White Hospital, Temple, TX
Copyright 2016, American College of Chest Physicians. All Rights Reserved.
SESSION TITLE: Student/Resident Case Report Poster - Procedures
SESSION TYPE: Student/Resident Case Report Poster
PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM
INTRODUCTION: Endobronchial ultrasound (EBUS)-guided transbronchial needle aspiration (TBNA) has a low incidence of hemomediastinum in patients with normal coagulation but can result in protracted bleeding in a patient with coagulopathy. We present the case of a patient with no prior history of coagulopathy in whom EBUS-guided TBNA resulted in hemomediastinum despite a careful hematologic workup.
CASE PRESENTATION: A 62 year-old male had TBNA of R4 and R10 at an outside facility for enlarging mediastinal adenopathy on serial CT Chest. He presented the next day to the outside hospital with massive hemoptysis resulting in acute respiratory failure requiring intubation and was transferred to our facility on mechanical ventilation. Review of outside hospital records revealed the patient was referred to Hematology prior to EBUS by the Pulmonologist; he had normal PT/INR but prolonged PTT (101 seconds) concerning for coagulopathy. Workup revealed positive screen for lupus anticoagulant and he was deemed a low bleeding risk by the Hematologist after which he underwent EBUS. CT Chest on admission to our hospital was concerning for hemomediastinum due to mediastinal widening compared to CT Chest obtained prior to bronchoscopy. Coagulation studies repeated at our facility showed prolonged PTT and positive screen for lupus anticoagulant. A mixing study did not correct upon mixing the patient's PTT sample and a normal PTT sample. Factor VIII and IX levels were measured; of significance, Factor VIII activity was 12% while Factor VIII inhibitor level was 1024 Bethesda units (BU), suggestive of acquired Factor VIII deficiency. Hemostasis was achieved with several doses of activated prothrombin complex concentrate (PCC). He was given prednisone 1 mg/kg, Rituximab and Cyclophosphamide to eradicate Factor VIII inhibitor. Bleeding was controlled with a decline in Factor VIII inhibitor level to 870 BU. He was extubated on day nine with discharge home on day 19. Tissue pathology obtained during EBUS was non-diagnostic and he was deemed a poor candidate for repeat TBNA. He later enrolled in hospice and passed.
DISCUSSION: While the rate of hemorrhagic complications from EBUS remains low1, this case emphasizes cautious assessment of coagulation studies in patients undergoing EBUS-TBNA. Appropriate precautions were taken prior to EBUS in this patient but an unanticipated acquired hemophilia led to hemomediastinum with subsequent respiratory failure; the delay in diagnosis resulted in near-fatal consequences for the patient2.
CONCLUSIONS: This case highlights the need for Pulmonologists to recognize and promptly diagnose coagulation abnormalities prior to EBUS.
Reference #1: Agli, L. L. (2002). Mediastinal Hematoma Following Transbronchial Needle Aspiration. Chest, 122(3), 1106-1107
Reference #2: Shander, A., Walsh, C. E., & Cromwell, C. (2011). Acquired hemophilia: A rare but life-threatening potential cause of bleeding in the intensive care unit. Intensive Care Med Intensive Care Medicine, 37(8), 1240-1249.
DISCLOSURE: The following authors have nothing to disclose: Tasnim Lat, Kirill Lipatov, Thomas Delmas, Shekhar Ghamande, Robert Long
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