741 ACUTE PURULENT MYOPERICARDITIS SECONDARY TO ULTRASOUND-GUIDED TRANSBRONCHIAL NEEDLE ASPIRATION CYTOLOGY

Abstract

Abstract Introduction Endobronchial ultrasound-guided transbronchial fine needle aspiration (EBUS-TBNA) is a minimally invasive diagnostic method to sample peritracheal and peribronchial le- sions under real-time ultrasound guidance. The most important use of TBNA is the diagnosis and staging of lung cancer and the evaluation of sarcoidosis. Although TBNA is considered generally safe, serious or even fatal complication may develop after the procedure. Here we present a case report of acute purulent myopericarditis complicated by cardiac tamponade occurred after EBUS-TBNA procedure. Case Report A 62-year-old man with preexisting hypertension and previous myocardial infarction and coronary angioplasty was admitted to our hospital for persistent, oppressive and worsening chest pain, which started a few days before admission. Of note, the patient underwent EBUS-TBNA 10 days before admission because he was found to have a tumor in the upper lobe of the left lung and enlargement of multiple mediastinal, right hilar, subcarinal and para-aortic lymph nodes. Two days after the procedure, one week before admission, he was treated with amoxicillin clavulanate and levofloxacin because of fever onset. At the ER, his vital signs showed a blood pressure of 80/60 mmHg and a heart rate of 115 bpm; O2 saturation on room-temperature air was 97%. The ECG at presentation showed concave ST segment elevation in anterolateral and inferior leads. The echocardiography revealed moderate circumferential pericardial effusion without clear tamponade signs. Emergency coronary angiography showed patent coronary arteries. The next morning, the patient developed persistent hypotension (BP 75/50 mmHg). A transthoracic echo showed moderate to large circumferential pericardial effusion with tamponade physiology. He therefore underwent subxiphoid pericardiotomy with drainage of 400 ml of frank pus. Cultures from pericardial fluid were negative for common germs. Cytology was negative for malignancy and acid-fast bacilli. Histological examination of the pericardial tissue was diagnostic for acute fibrinous-purulent pericarditis. The patient was started on broad spectrum antibiotics (piperacillin/tazobactam and ciprofloxacin) with subsequent decrease of inflammation markers and clinical improvement. Control contrast enhanced chest CT scan revealed persistency of a mediastinal pluri-concamerate fluid collection. After a collective discussion with cardiac surgeons, infectious disease specialists and oncologists, given the progressive clinical and instrumental improvement, we decided to discharge the patient with long term oral antibiotics plus colchicine and ibuprofen for pericarditis. Infectious disease and oncological follow up was planned before discharge. Conclusion Complications following TBNA are relatively low, typically around 1.2%-1.4%. To date, only few cases of purulent pericarditis secondary to EBUS-TBNA have been reported in literature. Our case report adds to the existing scant literature regarding cardiac infective bronchoscopic complications and emphasizes concern of weather antibiotic prophylaxis may be needed before respiratory tract invasive procedures. Further research is necessary to better understand the existence of risk factors that could increase the probability to develop such rare but potentially lethal complications.