Severe Infectious Complications after Endoscopic Ultrasound-Guided Fine Needle Aspiration of Suspected Mediastinal Duplication Cysts: A Case Series

Esophageal duplication cysts: a clinical practice review

Esophageal duplication represents one of the most common types of bronchopulmonary foregut malformations. These rare congenital anomalies occur secondary to embryological aberrations between the 4th and 8th weeks of gestation. In order to be classified as an esophageal cyst a mediastinal cyst must have a close proximity with the esophagus, be lined by alimentary (squamous epithelium) or tracheobronchial mucosa and covered by two smooth muscle layers. These rare anomalies are often asymptomatic during adulthood. However, they can cause symptoms in early childhood, generally during the first 2 years of life. Variations in location, size, presence or absence of heterotopic mucosa, will dictate the clinical presentation. Dysphagia, food impaction, persistent cough and chest pain are common clinical presentations. Imaging studies including esophagram, computed tomography (CT) and magnetic resonance imaging (MRI) can provide key findings to reach the diagnosis. Nonetheless, endoscopic evaluation, particularly endoscopic ultrasound (EUS) is the most valuable tool to determine whether this lesion is cystic versus solid and or if there are abnormal mucosal findings. Needle biopsies are controversial but can help with drainage and to rule out malignant transformation. Therapeutic options include endoluminal drainage. However, more definitive therapies include surgical excision. Open and minimally invasive (laparoscopic and thoracoscopic) techniques have been demonstrated to be safe and effective at completely removing these lesions. Recently, robotic-assisted resections have gained more attention with case reports and series reporting excellent outcomes.

Gastric duplication cyst: a challenging EUS differential diagnosis between subepithelial gastric lesion and exophytic pancreatic cystic neoplasm-a case report and a literature review

Gastric duplication cysts are rare congenital malformation with a potential neoplastic progression and they may represent a challenge in differential diagnosis with exophytic pancreatic cyst neoplasm. We describe a case of a 38-year old man, complaining of recurrent epigastric pain due to a large abdominal mass, referred to our Hospital for EUS evaluation. Differential diagnosis was between gastric duplication cyst and exophytic pancreatic cyst because of FNA pointed out amylase 1280 UI/L and CEA 593.33 ng/mL. Despite antibiotic prophylaxis, an overinfection of the lesion occurred after the FNA, likely due to the technical failure to drain the cyst completely. Afterwards, the patient was referred to surgery and the pathologist confirmed the diagnosis of gastric duplication cyst. In this setting, EUS procedure has gained a leading play, complementary to traditional imaging tests, although its role has been not yet standardized in the reported literature. Here, we describe and discuss our demanding case, and we propose an algorithm to simplify and standardize the diagnostic workup.

A rare case of perforated gastric duplication cyst associated with gastric diverticulum

A 50-year-old man presented to the emergency department with a 1-day history of severe epigastric pain, vomiting and fever. He had a background of alcohol excess and smoking. The patient was tachycardic and febrile with an elevated white blood cell count and C reactive protein. CT demonstrated extensive upper abdominal free fluid, without free air, with a large cystic lesion arising from the greater curvature of the stomach, and a second smaller cystic lesion arising from the posterior aspect of the gastric fundus. The patient was managed with nasogastric drainage, parenteral nutrition, intravenous antibiotics and proton pump inhibitors, and CT-guided abdominal drainage, with resolution of sepsis, and further outpatient care was transferred to our unit. Follow-up endoscopy demonstrated a diverticulum arising from the posterior aspect of the gastric fundus, with normal mucosa throughout the remaining stomach, while CT showed an additional cystic lesion arising from the greater curvature, with thickening of the adjacent gastric wall consistent with a gastric duplication cyst (GDC). Laparoscopy confirmed a small diverticulum at the fundus, and a large GDC anteriorly with associated omental adhesions consistent with prior perforation-two wedge resections were performed. Histology demonstrated no evidence of malignancy or ectopic mucosa. The patient recovered uneventfully and remained free from recurrent symptoms at 6 weeks postoperatively. GDC is a rare entity, which may be associated with ectopic mucosa, malignant transformation and upper gastrointestinal perforation. No previous report describes the coexistence of a GDC and gastric diverticulum. Herein we describe the investigation and management of this condition, and review the associated peer-reviewed literature.

Septic shock due to Granulicatella adiacens after endoscopic ultrasound-guided biopsy of a splenic mass: A case report

BACKGROUND

Endoscopic ultrasound-guided fine needle aspiration or biopsy (EUS-FNA or FNB) has become a popular method for diagnosing various lesions of the gastrointestinal tract and surrounding tissue due to the accuracy and safety. To the best of our knowledge, no case report of severe infection after EUS-FNB of a solid lesion in the spleen has been described. Herein, we report a rare case of septic shock after EUS-FNB of a splenic mass.

CASE SUMMARY

A 45-year-old male patient presented to the outpatient clinic due to an incidentally detected splenic mass. A definitive diagnosis could not be established based on the abdominal magnetic resonance imaging. EUS of the spleen showed a 6 cm-sized, relatively well-demarcated, heterogeneous mass, and EUS-FNB with a 22G needle was performed. Ten days after the procedure patient developed septic shock and a splenic abscess was identified. Blood culture revealed growth of Granulicatella adiacens. After the treatment with antibiotics the patient underwent surgical resection, and the pathological examination showed diffuse large B-cell lymphoma. The patient received chemotherapy and he is in complete remission.

CONCLUSION

Infection of a splenic mass after EUS-FNB is a rare complication and prophylactic antibiotics might be considered.

The Endoscopy Patient as a Vector and Victim

Patient and procedural factors can increase the risk of infectious adverse events during endoscopy. Prophylactic antibiotic use must be judicious and individualized in the era of antibiotic resistance. New and emerging procedures require high-quality studies to elucidate appropriate risk profiles.