Transbronchial Needle Aspiration Cytology and Purulent Pericarditis

Abstract

Endobronchial ultrasound with transbronchial needle aspiration (TBNA) is commonly performed for the evaluation of mediastinal lymphadenopathy. Purulent pericarditis is a rare, yet potentially fatal complication of TBNA. It commonly presents with nonspecific symptoms such as chest pain, shortness of breath, palpitations, or vague abdominal discomfort. Additionally, more severe symptoms such as cardiac tamponade and even death have been reported. In this article, we present the case of a 58-year-old male who developed purulent pericardial effusion with tamponade thought to be caused by TBNA cytology. This case raises an important question regarding the current guidelines for prophylactic antibiotic treatment for patients at high risk of developing purulent pericarditis as a complication of TBNA.

EBUS-TBNA-induced Purulent Pericarditis: A Rare Complication of a Common Procedure

“…Although the cytology and biochemical analysis of the pericardial fluid collected were compatible with empyema, the culture was negative, most likely due to the antibiotic course administered before pericardiocentesis. This fact renders the connection between the procedure and the infection more difficult, but not impossible, since a similar case was documented previously [6] . No clinical trials are described in the literature that identify the risk factors for the development of infection related to EBUS-TBNA.…”

A Rare Case of Primary Purulent Pericarditis Caused by Streptococcus constellatus

“…Though SAG can cause infection in any part of the body, more commonly they are isolated from skin and soft tissue lesions, peritonsillar, appendiceal, liver, brain, and lung abscesses [ 8 , 9 ]. From a search of the PubMed database, we identified 13 reports of purulent pericarditis caused by SAG [ 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 ]. Out of these, only two cases were caused by Streptococcus constellatus [ 16 , 17 ].…”

“…The most common complications are cardiac tamponade and transformation to pericardial constrictions [ 4 , 27 ]. In 13 reviewed cases of SAG-caused pericarditis, 9 patients developed cardiac tamponade and 3 progressed to constrictive pericarditis [ 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 21 , 22 ]. Purulent pericarditis tends to have acute or subacute progression to constriction, and, usually, pericardiectomy is required 6 months from the onset of the disease.…”

Mediastinal Infection After Endobronchial Ultrasound-guided Transbronchial Needle Aspiration

“…However, patient 3 presented with pericarditis over 2 months after the index procedure, whereas previous reports have shown patient presentation usually occurs within the first few weeks after EBUS-TBNA. 7,8 This difference is potentially explained by the patient's use of oral antibiotics for an unrelated indication between EBUS-TBNA and presentation, which may have initially suppressed his infection. Although it is difficult to state with certainty what the etiology, investigations for esophageal and dental source of bacterial inoculation were unrevealing, suggesting that these oropharyngeal florae were translocated during EBUS-TBNA.…”

“…A list of all patients underwent EBUS-TBNA in the study period was obtained from the electronic medical record. These patients were screened for a hospital admission within 90 days after EBUS-TBNA, as most patients with mediastinitis require inpatient care and previous literature suggests that mediastinal infections would present during this time period 4–8 . Patients meeting these criteria were then manually screened for the development of mediastinal infection after their procedure (Fig.…”