Pneumonia, pleurisy, mediastinitis, and mediastinal cyst infection secondary to endobronchial ultrasound-guided transbronchial needle aspiration: A case report

Pyopericardium and extensive mediastinal abscess following EBUS-TBNA for mediastinal staging of NSCLC: a case report

Background

Based on the algorithm on preoperative mediastinal staging in patients with non-small cell lung cancer (NSCLC), endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is indicated in case of computed tomography (CT)-enlarged or positron emission tomography (PET)-positive mediastinal lymph nodes. It represents both a safe minimal invasive procedure with complication rates of less than 1.5% and a valid tool with a high sensitivity defining mediastinal nodal disease. However, infectious complications like mediastinitis or pyopericardium are most feared.

Case Description

A 54-year-old woman was admitted to our hospital for further investigation of a suspected NSCLC of the right upper lobe. EBUS-TBNA was performed to receive both diagnosis and samples of the mediastinal lymph nodes. Two weeks after EBUS-TBNA, the patient presented with symptoms of cardiogenic/septic shock: hypotension, tachycardia, chest pain and fever. Prompt diagnosis of concomitant infectious mediastinitis and extensive pyopericardium in consequence of EBUS-TBNA was obvious. Besides systemic antibiotics, bilateral thoracoscopic interventions finally made the breakthrough. The patient could be discharged roughly three weeks after emergent re-admittance. As being finally diagnosed with NSCLC (stage IIIA squamous cell carcinoma), the patient underwent-subsequent to induction chemotherapy-a definitive sequential chemoradiotherapy. Twelve-month follow-up confirmed stable disease.

Conclusions

It is to be expected that with increasing application of EBUS-TBNA as mediastinal staging tool, the number of serious infection-related complications will rise accordingly. The efficacy of antibiotic prophylaxis after EBUS-TBNA has not yet been proved and is therefore not included in any guideline. Our case gives an impression on the severity of delayed infectious complications after EBUS-TBNA and outlines up-front surgery as primary objective to broadly debride all contagious abscess-/empyema sites. With increased use of EBUS-TBNA as mediastinal staging tool, clinicians should be aware of this rare but highly critical peri-interventional complication in order to closely monitor endangered patients.

Mediastinal thymic cysts: a narrative review

Background and Objective

Mediastinal thymic cysts are a relatively rare pathology. With the expansion of eligible individuals screened with cross-sectional imaging for lung cancer, it is likely that there will be an increase in the number of individuals presenting with these cysts. Understanding this rare pathology will become more important when this incidental pathology is encountered.

Methods

Search of PubMed was undertaken using keywords "mediastinal", "mediastinum", "thymic", "thymus", "cyst". Relevant literature was reviewed and selected for this comprehensive narrative review, including case reports, case series, and retrospective reviews.

Key Content and Findings

Thymic cysts in the mediastinum can be classified into two broad categories, congenital and inflammatory. Accurate diagnosis by imaging is challenging and the majority of patients are asymptomatic. Literature suggests that the majority of cysts are benign, however an unknown percentage may harbor neoplastic processes and over time can cause significant compressive symptoms. Definitive treatment and diagnosis is surgical, with overall excellent outcomes. The decision to pursue surgical treatment versus surveillance requires a shared decision making approach with patients.

Conclusions

Given the scarcity of available high quality evidence regarding the management of mediastinal thymic cysts, this review provides practitioners a broad knowledge base to guide patients to make informed decisions.

Severe mediastinitis and pericarditis after endobronchial ultrasound-guided transbronchial needle aspiration: A case report

BACKGROUND

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a safe and minimally invasive diagnostic tool for mediastinal and hilum evaluation. However, infectious complications may occur after EBUS-TBNA. Among these, mediastinitis and pericarditis are rare.

CASE SUMMARY

A 67-year-old woman was referred to our hospital due to paratracheal lymph node enlargement on chest computed tomography (CT). EBUS-TBNA was performed on the lymph node lesions, and prophylactic oral antibiotics were administered. Seven days after EBUS-TBNA, the patient visited the emergency room with a high fever and chest pain. Laboratory test results revealed leukocytosis with a left shift and elevated C-reactive protein level (25.7 mg/dL). Chest CT revealed the formation of a mediastinal abscess in the right paratracheal lymph node and pericardial and bilateral pleural effusions. The patient received intravenous antibiotic treatment, cardiac drainage through pericardiocentesis, and surgical management. The patient recovered favorably and was discharged 31 d after the operation.

CONCLUSION

Mediastinitis and pericarditis after EBUS-TBNA are rare but should be considered even after the use of prophylactic antibiotics.