New-Onset Malignant Pleural Effusion after Abscess Formation of a Subcarinal Lymph Node Associated with Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration

Abstract

We present a case of an unusual infectious complication of a ruptured mediastinal abscess after endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA), which led to malignant pleural effusion in a patient with stage IIIA non-small-cell lung cancer. EBUS-TBNA was performed in a 48-year-old previously healthy male, and a mediastinal abscess developed at 4 days post-procedure. Video-assisted thoracoscopic surgery was performed for debridement and drainage, and the intraoperative findings revealed a large volume pleural effusion that was not detected on the initial radiographic evaluation. Malignant cells were unexpectedly detected in the aspirated pleural fluid, which was possibly due to increased pleural permeability and transport of malignant cells originating in a ruptured subcarinal lymph node from the mediastinum to the pleural space. Hence, the patient was confirmed to have squamous cell lung carcinoma with malignant pleural effusion and his TNM staging was changed from stage IIIA to IV.

Endobronchial ultrasound‐guided transbronchial needle aspiration: Safe as it sounds

“…Development of malignant pleural effusion post‐EBUS‐TBNA for nodal staging of stage IIIA lung cancer has also been described . This patient also developed mediastinal abscess and the pleural effusion was noted during the video‐assisted thoracoscopic surgery.…”

“…antibiotics . There are eight case reports of mediastinitis post‐EBUS‐TBNA including five cases developing mediastinal abscess . Two of these patients with mediastinal abscess suffered sepsis syndrome and shock .…”

“…Two of these patients with mediastinal abscess suffered sepsis syndrome and shock . All the five patients with mediastinal abscess were treated with antibiotics and surgical debridement . The causative organisms could be isolated in three patients, and were alpha streptococcus, diphtheroids and Klebsiella pneumoniae .…”

“…This patient also developed mediastinal abscess and the pleural effusion was noted during the video‐assisted thoracoscopic surgery. The pleural fluid sample revealed malignant cells on cytology, thus worsening the existing stage IIIA lung cancer to stage IV . The Japanese survey reported life‐threatening consequences in four (5.3%) patients (mediastinitis in two patients, tumour rupture in one patient and aggravation of airway stenosis in one patient) .…”

“…Al Qadi and Maldonado 25 2014 Case report Tracheal stenosis 1 12 Jang et al 26 2014 Case report Malignant pleural effusion 1 13 Hata et al 27 2013 Case report Intrabronchial polyp; sputum positive for tuberculosis post-EBUS-TBNA 2 14 Lee et al 28 2013 Case report Endotracheal granuloma 1 15 Miller et al 29 2013 Letter to editor Fatal haemorrhage 1 16 Hong et al 30 2013 Case report Cyst rupture; pneumonia 1 17 Gochi et al 31 2013 Case report Mediastinitis 1 18 Dhillon and Yendamuri 32 2013 Case report Needle assembly malfunction 2 19 Huang et al 33 2011 Case report Mediastinitis, empyema, lung abscess 1 20 Gomez et al 34 2010 Case report Sputum positive for tuberculosis post-EBUS-TBNA 1 21 Gupta et al 35 2010 Case report Endobronchial polyp 1 22…”