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Mediastinal Infection After Ultrasound-guided Needle Aspiration

Kouskov, Oleg S. MD*; Almeida, Francisco Aécio MD, MS, FCCP; Eapen, Georgie A. MD, FCCP; Uzbeck, Mateen MD; Deffebach, Mark MD

Journal of Bronchology & Interventional Pulmonology: October 2010 - Volume 17 - Issue 4 - p 338-341
doi: 10.1097/LBR.0b013e3181f30d74
Case Reports
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We describe 2 cases of mediastinal abscess developing after endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) in patients with thoracic malignancies. The first case was that of a 68-year-old male patient with a history of colon cancer presenting with new mediastinal adenopathy. EBUS-TBNA confirmed metastatic colon adenocarcinoma; however, he developed fever and atrial fibrillation 32 days after the procedure and was diagnosed with mediastinal abscess. The patient was successfully treated with antibiotics. The second case was that of a 66-year-old previously healthy male who presented for evaluation of cough. Imaging showed a right paratracheal mass and he underwent EBUS-TBNA sampling, which showed malignant cells. Eight days after the procedure the patient developed fever and was diagnosed with mediastinal abscess. The second patient was treated with antibiotics and several debridements; however, he was eventually transitioned to hospice care because of a continued spread of his cancer. Although rare, mediastinal infection is a complication of endoscopic mediastinal needle aspiration.

*Department of Pulmonary Medicine, Oregon Health and Science University

Department of Pulmonary Medicine, Portland VA Medical Center, Portland, OR

Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX

There was no financial support for any of the authors.

Reprints: Oleg S. Kouskov, MD, Department of Pulmonary Medicine, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, UHN 67, Portland, OR 97239 (e-mail: kouskovo@ohsu.edu; okuskov2001@yahoo.com).

Received for publication May 14, 2010; accepted July 12, 2010

There is no conflict of interest.

No other disclosures.

Case number 1 is from Portland VA Medical Center and case number 2 is from UT MD Anderson Cancer Center.

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a safe procedure with few reported complications.1 In comparison, mediastinoscopy has a complication rate of 0.6% to 1.07%.2,3 We share our experience from 2 institutions with cases of mediastinal infection after EBUS-TBNA.

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CASE 1

A 68-year-old man with a history of stage IIA colon cancer, treated with hemicolectomy, presented 5 months later for the evaluation of new right lower lobe mass and mediastinal adenopathy. After a nondiagnostic bronchoscopic transbronchial needle aspiration of an enlarged subcarinal lymph node, the patient underwent EBUS-TBNA 2 weeks later (CP-EBUS; BF-UC160F-OL8; Olympus; Tokyo, Japan). Metastatic colon adenocarcinoma was confirmed by sampling of the right pretracheal, hilar, and subcarinal lymph nodes. A total of 10 needle aspirations were performed. There were no immediate complications. Two weeks later a peripherally inserted central catheter was placed and chemotherapy was initiated. He felt well and denied any fever or chest pain at that time. Chest computed tomography (CT) 2 weeks after the EBUS-TBNA showed increasing size of the right lower lobe mass and mediastinal and right hilar adenopathy (Fig. 1). Nearly 5 weeks after the EBUS-TBNA, the patient was admitted to the intensive care unit with fever of up to 38°C and new atrial fibrillation. No obvious source of infection was identified on initial evaluation so no antibiotics were started. One of 4 blood culture bottles grew coagulase-negative Staphylococcus and the peripherally inserted central catheter line was removed. Chest CT scan was repeated almost 2 weeks later because of difficulties in controlling heart rate and a persistent fever of up to 38°C.

FIGURE 1.

FIGURE 1.

On the basis of a CT finding of a fluid density mass in the middle mediastinum, the patient was diagnosed with a mediastinal abscess and was placed on vancomycin and piperacillin/tazobactam. An EBUS-guided aspiration of the fluid collection was then performed. Cultures revealed a polymicrobial infection, including Candida albicans and γ-hemolytic Streptococcus. The patient's condition improved with the resolution of the fever and rate control of atrial fibrillation. Chest CT scan repeated 10 days after the start of antibiotics showed a decrease in the size of the lesion. Vancomycin and piperacillin/tazobactam were discontinued and the patient was discharged on ceftriaxone. A chest CT 5 weeks after the commencement of antibiotic (Fig. 1) therapy showed a further decrease in the size of the lesion. Ceftriaxone and fluconazole were discontinued and the patient received 7 days of outpatient amoxicillin clavulanate. Without signs or symptoms to suggest an active infection, chemotherapy was restarted approximately 2 weeks later.

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CASE 2

A 66-year-old man, who was healthy earlier, presented with a 1-month history of cough. Physical examination was unremarkable and he was afebrile. An initial chest x-ray showed a right suprahilar mass, and a subsequent chest CT confirmed a right paratracheal mass extending from the level of the aortic arch to the precarinal area (Fig. 2). He underwent EBUS-TBNA (CP-EBUS; BF-UC160F-OL8; Olympus) of this mass without any immediate complications. Cytologic analysis showed rare malignant cells in a background of extensive necrosis. A follow-up visit, 5 days later, was unremarkable except for a complaint of mild chest pain after the EBUS-TBNA. Eight days after the EBUS-TBNA he developed chills with fever of up to 38.3°C.

FIGURE 2.

FIGURE 2.

The peripheral white blood cell count was 22,000/mm3 with 13% bands. Levofloxacin was started for presumed pneumonia. Neck swelling was noted shortly after admission and a neck CT scan showed a low-density mass of up to 5.3 cm in longest diameter within the posterior oropharynx. Chest CT scan also showed a significant increase in the size of the mediastinal mass (Fig. 2). Levofloxacin was discontinued and linezolid, imipenem-cilastatin, and fluconazole were started, followed by oral intubation and surgical debridement of an oropharyngeal abscess. The patient failed extubation after the procedure because of presumed mucus plugging. At that time fluconazole was discontinued and amphotericin and sulfamethoxazole-trimethoprim were added. Next, the patient was taken for mediastinoscopy, which showed right paratracheal necrotic tissue and purulent material. Approximately 100 to 150 mL of pus was drained from this area and another 50 mL was drained from the retropharyngeal space. Two 15-French drains were placed, 1 in each space. Cultures from the material obtained at mediastinoscopy showed Propionibacterium acnes, Bacteroides, and Eubacterium species. The pathology was consistent with an undifferentiated, malignant, large-cell neoplasm with extensive necrosis. He was extubated 2 days later. However, 9 days after the mediastinoscopy, he had persistent 120 to 150 mL/d of turbid serosanguineous fluid draining from the retropharyngeal drain. He then underwent an exploratory right thoracotomy for the removal/drainage of the mass/abscess and percutaneous endoscopic gastrostomy placement. The final pathology was no different than that reported earlier. He then developed a loculated right pleural effusion and had to undergo another thoracotomy 12 days later for empyema drainage and right lung decortication. He was finally discharged approximately 2.5 months after his initial presentation with 1 chest drain in place and on oral ciprofloxacin and intravenous ertapenem. Definitive intensity-modulated radiation therapy to the mediastinal mass was started approximately 2 weeks later but he was readmitted shortly thereafter with disorientation. A new hemorrhagic mass within the left frontal lobe, in addition to a parasigmoid mass, was found. Both these lesions were biopsy-proven metastases. His clinical condition progressively deteriorated and he was transitioned to hospice care. The last chest CT scan performed approximately 3 months after the initial EBUS-TBNA showed a persistent complex-loculated right pleural effusion along the right paramediastinal region and posterior costophrenic angle.

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DISCUSSION

With widespread use of EBUS by diverse practitioners, rare complications are becoming apparent. Even though they are supplied sterile, the needles used in transbronchial aspirations are frequently contaminated by oropharyngeal secretions at a 35% to 100% rate,4,5 with a 7% chance of developing bacteremia.5,6 Multiple passes and reinsertions may increase the risk of contamination. After TBNA, malignant diagnoses are frequently established, leading to the initiation of immunosuppressing therapies shortly after the procedure.

In the cases reported here, EBUS-TBNA appears to have been the most likely cause of mediastinal infection.

In both cases, the symptoms manifested relatively late after the procedure, at 32 and 13 days, respectively, probably because of the small number of inoculating organisms.

Although there has been no prospective study of infectious complications of EBUS-TBNA, our experience suggests that infectious complications of EBUS TBNA are rare, but there may be a few patterns that can help guide future practice. First, infections seem to be more common when sampling cystic or necrotic structures. It might be prudent to avoid sampling foregut cysts if diagnosis is highly suggested by imaging.7 Second, an adequate visual control of the tip of the needle should be maintained at all times to avoid puncturing the pericardium.8 Third, presentation can be as early as 2 days,8–10 or as late as 32 days after the procedure. Clinical suspicion should be maintained over a prolonged period after the intervention. Fourth, many infected mediastinal lymph nodes can probably be managed conservatively with antibiotics,8,10 reserving surgical interventions for refractory cases. Fifth, although there is no evidence for routine use of antibiotic prophylaxis with EBUS, some researchers report the use of a 3-day course for patients with necrotic lymph nodes.10

In summary, infection of the mediastinal structures is a rare complication of mediastinal needle aspiration, which can present early or late after the procedure, and some lymph node abscesses can be managed conservatively with antibiotics.

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REFERENCES

1. Varela-Lema L, Fernandez-Villar A, Ruano-Ravina A. Effectiveness and safety of endobronchial ultrasound-transbronchial needle aspiration: a systematic review. Eur Respir J. 2009;33:1156–1164.
2. Hammoud ZT, Anderson RC, Meyers BF, et al. The current role of mediastinoscopy in the evaluation of thoracic disease. J Thorac Cardiovasc Surg. 1999;118:894–899.
3. Lemaire A, Nikolic I, Petersen T, et al. Nine-year single center experience with cervical mediastinoscopy: complications and false negative rate. Ann Thorac Surg. 2006;82:1185–1190.
4. Epstein SK, Winslow CJ, Brecher SM, et al. Polymicrobial bacterial pericarditis after transbronchial needle aspiration: case report with an investigation on the risk of bacterial contamination during fiberoptic bronchoscopy. Am Rev Respir Dis. 1992;146:523–525.
5. Steinfort DP, Johnson DF, Irving LB. Incidence of bacteraemia following endobronchial ultrasound-guided transbronchial needle aspiration. Eur Respir J. 2010;36:28–32.
6. Compere C, Duysinx B, Dediste A, et al. Prospective risk assessment of bacteremia and other infectious complications associated with real-time ultrasound-guided transbronchial needle aspiration (EBUS-TBNA). Chest. 2007;132:439.
7. Cheruvattath R, Go D, Diehl D. Endosonographic (EUS) diagnosis of foregut duplication cysts: just say NO to the needle! (Abstract 1299.) Am J Gastroenterol. 2008;103:S508.
8. Haas AR. Infectious complications from full extension endobronchial ultrasound transbronchial needle aspiration. Eur Respir J. 2009;33:935–938.
9. Steinfort DP, Johnson DF, Irving LB. Infective complications from endobronchial ultrasound-transbronchial needle aspiration. Eur Respir J. 2009;34:524–525.
10. Aerts JG, Kloover J, Los J, et al. EUS-FNA of enlarged necrotic lymph nodes may cause infectious mediastinitis. J Thorac Oncol. 2008;3:1191–1193.
Keywords:

endobronchial ultrasound; mediastinitis; infection; cancer staging

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