Scientific Letter
Focal Mediastinitis and Pulmonary Arterial Thrombosis after EBUS-TBNA
Mediastinitis focal con trombosis arterial pulmonar asociada tras EBUS-TBNA
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Se identifica una adenopatía patológica e hipercaptante en el hilio izquierdo (circunferencia blanca). B: TC de tórax en ventana de mediastino a la altura de la arteria pulmonar derecha. Arteria lingular permeable. C: TC de tórax en ventana de mediastino a la altura de la bifurcación bronquial, 34 días después de A. Se objetiva la aparición de un foco hipodenso (flecha blanca) en el seno de la adenopatía hiliar izquierda (circunferencia blanca). D: TC de tórax en ventana de mediastino a la altura de la arteria pulmonar derecha, 34 días después de B. Aparición de un trombo agudo de disposición central en la arteria lingular (flecha blanca) y un rodete inflamatorio que engloba las estructuras vasculares del hilio izquierdo (cabeza de flecha blanca). E: TC de tórax en ventana de mediastino a la altura de la bifurcación bronquial, 44 días después de A. La adenopatía hiliar izquierda persiste con mayor aumento de volumen (circunferencia blanca). F: TC de tórax en ventana de mediastino a la altura de la arteria pulmonar derecha, 44 días después de B. Resolución del trombo en el interior de la arteria lingular, pero con persistencia del rodete inflamatorio alrededor de los vasos hiliares izquierdos (cabeza de flecha blanca). G: TC de tórax en ventana de mediastino a la altura de la bifurcación bronquial. Recuperación de las características iniciales de la adenopatía hiliar izquierda, 69 días después de A. H: TC de tórax en ventana de mediastino a la altura de la arteria pulmonar derecha, 69 días después de B. Resolución del rodete inflamatorio que acompañaba a los vasos hiliares izquierdos.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Andrea Palomeque, Ivan Vollmer, Ainhoa Fontana, Carmen M. 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Subtotal atelectasis of the right lung, ECMO ejection cannula in the right jugular and suction cannula in the inferior vena cava. Contrast computed tomography (arterial phase, lung window). 1B) Predominantly central ground glass infiltrates (yellow arrows) observed in both lung fields. Consolidation in right lower lobe (red arrow). 1C) Permeability of the bronchial tree observed in the center of the consolidation focus (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Jorge Martínez-Solano, Iago Sousa-Casasnovas, Miriam Juárez Fernández, Carolina Devesa-Cordero, Francisco Fernández-Avilés, y Manuel Martínez-Sellés" "autores" => array:6 [ 0 => array:2 [ "nombre" => "Jorge" "apellidos" => "Martínez-Solano" ] 1 => array:2 [ "nombre" => "Iago" "apellidos" => "Sousa-Casasnovas" ] 2 => array:2 [ "nombre" => "Miriam Juárez" "apellidos" => "Fernández" ] 3 => array:2 [ "nombre" => "Carolina" "apellidos" => "Devesa-Cordero" ] 4 => array:2 [ "nombre" => "Francisco" "apellidos" => "Fernández-Avilés" ] 5 => array:2 [ "nombre" => "y Manuel" "apellidos" => "Martínez-Sellés" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0300289620302507" "doi" => "10.1016/j.arbres.2020.07.015" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0300289620302507?idApp=UINPBA00003Z" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1579212920303347?idApp=UINPBA00003Z" "url" => "/15792129/0000005700000001/v2_202102030751/S1579212920303347/v2_202102030751/en/main.assets" ] "en" => array:16 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Scientific Letter</span>" "titulo" => "Focal Mediastinitis and Pulmonary Arterial Thrombosis after EBUS-TBNA" "tieneTextoCompleto" => true "saludo" => "To the Editor:" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "74" "paginaFinal" => "75" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Andrea Palomeque, Ivan Vollmer, Ainhoa Fontana, Carmen M. Lucena, Carles Agustí" "autores" => array:5 [ 0 => array:4 [ "nombre" => "Andrea" "apellidos" => "Palomeque" "email" => array:1 [ 0 => "palomeque@clinic.cat" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Ivan" "apellidos" => "Vollmer" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "Ainhoa" "apellidos" => "Fontana" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "Carmen M." "apellidos" => "Lucena" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 4 => array:3 [ "nombre" => "Carles" "apellidos" => "Agustí" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Neumología y Alergia Respiratoria, Instituto Clínico Respiratorio, Hospital Clínic, Barcelona, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Radiodiagnóstico, Centro de Diagnóstico por la Imagen Clínic, Hospital Clínic, Barcelona, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Mediastinitis focal con trombosis arterial pulmonar asociada tras EBUS-TBNA" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2015 "Ancho" => 2917 "Tamanyo" => 509190 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A: Chest CT scan in mediastinum window at the level of the bronchial bifurcation. Pathological lymphadenopathy with enhanced uptake is identified in the left hilum (white circumference). B: Chest CT scan in mediastinum window at the level of the right pulmonary artery. Patent lingular artery. C: Chest CT scan in mediastinal window at the level of the bronchial bifurcation, 34 days after A. The appearance of a hypodense focus (white arrow) in the center of the left hilar lymphadenopathy (white circumference) was observed. D: Chest CT scan in mediastinum window at level of the right pulmonary artery, 34 days after B. Appearance of a centrally located acute thrombus in the lingular artery (white arrow) and band of inflammation that encompasses the vascular structures of the left hilum (white arrowhead). E: Chest CT scan in mediastinal window at the level of the bronchial bifurcation, 44 days after A. Persistent left hilar lymphadenopathy and increased volume (white circumference) are observed. F: Chest CT scan in mediastinum window at level of the right pulmonary artery, 44 days after B. Resolution of acute thrombus located in the lingular artery but persistent band of inflammation surrounding the left hilar vessels (tip of white arrow). G: Chest CT scan in mediastinum window at the level of the bronchial bifurcation. Recovery of initial characteristics of left hilar lymphadenopathy, 69 days after A. H: Chest CT scan in mediastinum window at the level of the right pulmonary artery, 69 days after B. Resolution of band of inflammation that surrounded the left hilar vessels.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">In recent years, there has been a progressive increase in the use of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA), and it is currently the technique of choice for cytological analysis of mediastinal and hilar nodes in lung cancer and other diseases affecting this anatomical region. It is a very safe, minimally invasive technique.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> We report an unusual complication of EBUS-TBNA not described in the literature, involving pulmonary arterial thrombosis associated with intrapulmonary adenitis.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Our patient was a 71-year-old man, diagnosed 7 years previously with stage <span class="elsevierStyleSmallCaps">I</span> clear cell renal carcinoma who required left radical nephrectomy and, 3 years later, atypical segmentectomy in the right upper lobe for single lung metastases. During follow-up, a chest computed tomography (CT) was performed, showing a left interlobar lymphadenopathy measuring 12 mm in its smallest diameter, with central necrosis. EBUS-TBNA identified and aspirated a left interlobar lymphadenopathy (nodal station 11) measuring 15 mm in its smallest diameter, determined on cytological analysis to be clear cell renal carcinoma metastasis. Six days after EBUS-TBNA, the patient presented in the emergency room for general malaise, 38−40 °C fever, dyspnea, and non-specific chest pain. Blood tests showed C-reactive protein 16 mg/dl, leukocytosis 14.96 × 10^9/l, with neutrophilia 13.6 × 10^9/l. Chest X-ray was normal. Empirical antibiotic treatment began with ceftriaxone and azithromycin, but the patient remained febrile, so we requested a chest computed tomography (CT) that confirmed the persistence of left interlobar lymphadenopathy surrounded by an image of soft tissue density adjacent to the enlarged lymph node, particularly in its upper margin, possibly corresponding to the needle path, that also included the left lower lobar artery. An image of acute thrombus was also observed at the point where the lingular branch of the pulmonary artery emerges (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). A diagnosis of intrapulmonary adenitis with associated arterial thrombosis was given, and antibiotic coverage was changed to piperacillin/tazobactam and linezolid. Anticoagulant treatment started with enoxaparin 1 mg/kg every 12 h. The patient’s progress was favorable, with resolution of fever and normalization of inflammatory parameters. A chest CT scan 1 month after discharge showed resolution of the intrapulmonary adenitis and thrombosis of the lingular artery.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Discussion</span><p id="par0015" class="elsevierStylePara elsevierViewall">This is the first reported case of arterial thrombosis caused by EBUS-TBNA. Since its introduction in 2000, EBUS-TBNA has become an essential tool for investigating hilar and mediastinal lymphadenopathies in lung cancer, extrathoracic carcinomas, and various granulomatous conditions such as sarcoidosis or tuberculosis.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Complications of EBUS-TBNA are rare but can be serious. In a national Japanese survey evaluating a total of 7345 procedures, the percentage of complications was 1%, the most frequent being hemorrhage (0.6%), followed by infectious complications (0.1%), such as mediastinitis, pneumonia, pericarditis, or cystic lesion infection.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Similarly, a meta-analysis involving a total of 16,181 cases reported a frequency of serious adverse events of 0.1%, more than half of which were of infectious origin.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> It is speculated that mediastinitis is one of the most common infectious complications. It is potentially serious, with a mortality of 12%–50%,<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,6</span></a> and is possibly caused by contamination of the working channel of the bronchoscope by oropharyngeal cavity secretions and consequent contamination of the needle and direct bacterial inoculation during the transbronchial mediastinal puncture.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> With regard to adenitis, 1 case of localized infection of subcarinal lymphadenopathy after EBUS-TBNA has been reported.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> No cases of arterial thrombosis associated with the procedure have been published in the literature. Several factors may have been involved in thrombus formation, including the proinflammatory status associated with focal mediastinitis and the capacity of tumor cells to induce the generation of thrombin, an enzyme involved in the pathogenesis of the hypercoagulable state accompanying cancer.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8,9</span></a> In our case, it seems most likely that lymph node infection occurred with secondary infectious thromboarteritis due to contiguity, as suggested by the inflammatory reaction.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Conclusion</span><p id="par0030" class="elsevierStylePara elsevierViewall">EBUS-TBNA is a very safe test, but occasionally potentially serious complications can occur. If chest symptoms or fever develop after the procedure, these events must be ruled out with a comprehensive evaluation of the patient.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Discussion" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Conclusion" ] 2 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Palomeque A, Vollmer I, Fontana A, Lucena CM, Agustí C. Mediastinitis focal con trombosis arterial pulmonar asociada tras EBUS-TBNA. Arch Bronconeumol. 2020;57:74–75.</p>" ] ] "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2015 "Ancho" => 2917 "Tamanyo" => 509190 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A: Chest CT scan in mediastinum window at the level of the bronchial bifurcation. Pathological lymphadenopathy with enhanced uptake is identified in the left hilum (white circumference). B: Chest CT scan in mediastinum window at the level of the right pulmonary artery. Patent lingular artery. C: Chest CT scan in mediastinal window at the level of the bronchial bifurcation, 34 days after A. The appearance of a hypodense focus (white arrow) in the center of the left hilar lymphadenopathy (white circumference) was observed. D: Chest CT scan in mediastinum window at level of the right pulmonary artery, 34 days after B. Appearance of a centrally located acute thrombus in the lingular artery (white arrow) and band of inflammation that encompasses the vascular structures of the left hilum (white arrowhead). E: Chest CT scan in mediastinal window at the level of the bronchial bifurcation, 44 days after A. Persistent left hilar lymphadenopathy and increased volume (white circumference) are observed. F: Chest CT scan in mediastinum window at level of the right pulmonary artery, 44 days after B. Resolution of acute thrombus located in the lingular artery but persistent band of inflammation surrounding the left hilar vessels (tip of white arrow). G: Chest CT scan in mediastinum window at the level of the bronchial bifurcation. Recovery of initial characteristics of left hilar lymphadenopathy, 69 days after A. H: Chest CT scan in mediastinum window at the level of the right pulmonary artery, 69 days after B. Resolution of band of inflammation that surrounded the left hilar vessels.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:9 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Severe mediastinitis over a month after endobronchial ultrasound-guided transbronchial needle aspiration" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "K. Kurokawa" 1 => "T. Asao" 2 => "R. Ko" 3 => "T. Nagaoka" 4 => "K. Suzuki" 5 => "K. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 5 | 6 | 11 |
| 2024 October | 40 | 13 | 53 |
| 2024 September | 44 | 14 | 58 |
| 2024 August | 53 | 42 | 95 |
| 2024 July | 37 | 19 | 56 |
| 2024 June | 56 | 25 | 81 |
| 2024 May | 62 | 19 | 81 |
| 2024 April | 36 | 24 | 60 |
| 2024 March | 47 | 19 | 66 |
| 2024 February | 41 | 26 | 67 |
| 2024 January | 24 | 28 | 52 |
| 2023 December | 30 | 20 | 50 |
| 2023 November | 37 | 19 | 56 |
| 2023 October | 49 | 29 | 78 |
| 2023 September | 34 | 30 | 64 |
| 2023 August | 58 | 31 | 89 |
| 2023 July | 62 | 25 | 87 |
| 2023 June | 23 | 13 | 36 |
| 2023 May | 27 | 21 | 48 |
| 2023 April | 32 | 38 | 70 |
| 2023 March | 44 | 42 | 86 |
| 2023 February | 32 | 17 | 49 |
| 2023 January | 19 | 27 | 46 |
| 2022 December | 37 | 26 | 63 |
| 2022 November | 44 | 28 | 72 |
| 2022 October | 52 | 36 | 88 |
| 2022 September | 33 | 27 | 60 |
| 2022 August | 34 | 36 | 70 |
| 2022 July | 29 | 42 | 71 |
| 2022 June | 35 | 29 | 64 |
| 2022 May | 33 | 26 | 59 |
| 2022 April | 89 | 40 | 129 |
| 2022 March | 79 | 40 | 119 |
| 2022 February | 17 | 18 | 35 |
| 2021 January | 1 | 0 | 1 |
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