BILATERAL PULMONARY EMBOLISM MASQUERADING AS MEDIASTINAL LYMPHADENOPATHY DIAGNOSED WITH ENDOBRONCHIAL ULTRASOUND

Abstract

SESSION TITLE: Variety in Risk Factors and Treatment of VTESESSION TYPE: Rapid Fire Case ReportsPRESENTED ON: 10/19/2022 12:45 pm - 1:45 pmINTRODUCTION: Pulmonary embolism is a life-threatening respiratory condition. It is often a diagnosis that is investigated for in patients presenting with acute onset dyspnea, hypoxemia and/or hypotension. Mediastinal lymphadenopathy begets a separate differential diagnosis in dyspneic patients. Lymphadenopathy can be evaluated and biopsied by endobronchial ultrasound. Here we present a case of a young female with weakness who was felt to have mediastinal lymphadenopathy on chest imaging and on EBUS was found to have pulmonary embolism.CASE PRESENTATION: A 38-year-old female with a history of iron deficiency anemia presented for acute right lower extremity weakness. MRI of the L spine was done with findings of abnormal signal of the conus medullaris. Further MRI of the brain and spine demonstrated diffuse enhancing lesions. Given the cranial nerve involvement and homogenous lesions, the diagnosis was felt to be neurosarcoid. Lumbar puncture was done to evaluate for multiple sclerosis and infection. CT chest without contrast demonstrating bilateral mediastinal lymphadenopathy. EBUS was pursued for tissue sampling. On EBUS, mediastinal lymph nodes appeared normal in size with a normal architecture. Incidentally, EBUS demonstrated large intraluminal floating homogenous material within the left and right pulmonary arteries concerning for pulmonary embolism. CT chest with contrast post procedure showed that the initial mediastinal lymphadenopathy was now revealed as bilateral central pulmonary emboli. Lower extremity dopplers revealed right peroneal vein thrombosis. Echocardiogram did not show RV dysfunction and the patient remained hemodynamically stable. The patient was started on therapeutic anticoagulation as further neurological work up was pursued for alternative diagnoses of acute right lower extremity weakness. The patient was treated with a course of steroids of presumed acute disseminated encephalomyelitis and discharged to acute rehab on anticoagulation.DISCUSSION: CT chest without contrast suspicious for mediastinal lymphadenopathy can be misleading. In this case, mediastinal lymphadenopathy was first reported due to an inherent bias of neurosarcoid being the presumptive diagnosis. Currently, the evaluation of pulmonary embolism involves CT angiography of the chest as the gold standard. While less cost efficient than a CT scan, EBUS can be a safe and reliable tool in the diagnosis of pulmonary embolism in the right patient population in whom a CT is unable to be obtained or is contraindicated. Further studies evaluating the procedural risk in patients unable to get CT imaging is warranted.CONCLUSIONS: It is important to be aware of the limitations of CT imaging without contrast in formulation of a differential diagnosis. The diagnosis of pulmonary embolism can be made from EBUS and may have a role in an appropriate subset of the patient population.Reference #1: Aumiller J, Herth FJ, Krasnik M, Eberhardt R. Endobronchial ultrasound for detecting central pulmonary emboli: a pilot study. Respiration. 2009;77(3):298-302. doi: 10.1159/000183197. Epub 2008 Dec 9. PMID: 19065053.DISCLOSURES: No relevant relationships by Vincent ChanNo relevant relationships by Prarthna KulandaisamyNo relevant relationships by Lindsey Morris SESSION TITLE: Variety in Risk Factors and Treatment of VTE SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 1:45 pm INTRODUCTION: Pulmonary embolism is a life-threatening respiratory condition. It is often a diagnosis that is investigated for in patients presenting with acute onset dyspnea, hypoxemia and/or hypotension. Mediastinal lymphadenopathy begets a separate differential diagnosis in dyspneic patients. Lymphadenopathy can be evaluated and biopsied by endobronchial ultrasound. Here we present a case of a young female with weakness who was felt to have mediastinal lymphadenopathy on chest imaging and on EBUS was found to have pulmonary embolism. CASE PRESENTATION: A 38-year-old female with a history of iron deficiency anemia presented for acute right lower extremity weakness. MRI of the L spine was done with findings of abnormal signal of the conus medullaris. Further MRI of the brain and spine demonstrated diffuse enhancing lesions. Given the cranial nerve involvement and homogenous lesions, the diagnosis was felt to be neurosarcoid. Lumbar puncture was done to evaluate for multiple sclerosis and infection. CT chest without contrast demonstrating bilateral mediastinal lymphadenopathy. EBUS was pursued for tissue sampling. On EBUS, mediastinal lymph nodes appeared normal in size with a normal architecture. Incidentally, EBUS demonstrated large intraluminal floating homogenous material within the left and right pulmonary arteries concerning for pulmonary embolism. CT chest with contrast post procedure showed that the initial mediastinal lymphadenopathy was now revealed as bilateral central pulmonary emboli. Lower extremity dopplers revealed right peroneal vein thrombosis. Echocardiogram did not show RV dysfunction and the patient remained hemodynamically stable. The patient was started on therapeutic anticoagulation as further neurological work up was pursued for alternative diagnoses of acute right lower extremity weakness. The patient was treated with a course of steroids of presumed acute disseminated encephalomyelitis and discharged to acute rehab on anticoagulation. DISCUSSION: CT chest without contrast suspicious for mediastinal lymphadenopathy can be misleading. In this case, mediastinal lymphadenopathy was first reported due to an inherent bias of neurosarcoid being the presumptive diagnosis. Currently, the evaluation of pulmonary embolism involves CT angiography of the chest as the gold standard. While less cost efficient than a CT scan, EBUS can be a safe and reliable tool in the diagnosis of pulmonary embolism in the right patient population in whom a CT is unable to be obtained or is contraindicated. Further studies evaluating the procedural risk in patients unable to get CT imaging is warranted. CONCLUSIONS: It is important to be aware of the limitations of CT imaging without contrast in formulation of a differential diagnosis. The diagnosis of pulmonary embolism can be made from EBUS and may have a role in an appropriate subset of the patient population. Reference #1: Aumiller J, Herth FJ, Krasnik M, Eberhardt R. Endobronchial ultrasound for detecting central pulmonary emboli: a pilot study. Respiration. 2009;77(3):298-302. doi: 10.1159/000183197. Epub 2008 Dec 9. PMID: 19065053. DISCLOSURES: No relevant relationships by Vincent Chan No relevant relationships by Prarthna Kulandaisamy No relevant relationships by Lindsey Morris