CHYLOTHORAX AS A RARE COMPLICATION OF ENDOSCOPIC ULTRASOUND WITH FINE NEEDLE ASPIRATION

Abstract

TOPIC: Procedures TYPE: Medical Student/Resident Case Reports INTRODUCTION: Trans-esophageal endoscopic ultrasound with fine-needle aspiration (EUS-FNA) is a relatively safe and minimally invasive procedure used to diagnose and stage mediastinal masses. Chylothorax is an extremely rare complication of EUS-FNA which can be fatal without timely intervention. We present one such case of EUS-FNA of an anterior mediastinal mass, complicated by chylothorax. CASE PRESENTATION: A 60-year-old female with a past medical history significant for COPD, diabetes, depression,90 pack-years of smoking, and a history of stage IIA adenocarcinoma of the appendix treated with colon resection 11 years prior, presented with an enlarged spiculated nodule in the left upper lung lobe noted on an annual surveillance CT scan. She reported significant weight loss, dyspnea on exertion, malaise, and fatigue for over a year. A PET scan performed 1-year prior revealed stable bilateral lung nodules without any hypermetabolic activity. At presentation, she was afebrile, hemodynamically stable, and saturating above 90% on room air. Her physical exam and labs were unremarkable. The large spiculated left upper lobe nodule noted on the CT thorax was concerning for malignancy and a biopsy was recommended to further characterize the lesion. An EUS-FNA was performed, which confirmed a 13 x 10 mm irregular, homogenous mass & a tissue sample was obtained. The procedure was uneventful without any immediate peri-operative complications. Cytology from the aspirate was notable for primary adenocarcinoma of the lung. Two days after the procedure, the patient developed progressively worsening shortness of breath associated with diminished left-sided breath sounds. An immediate repeat CT scan of the chest identified a new left-sided pleural effusion. A thoracentesis with a chest tube insertion drained approximately 500 ml of milky fluid, diagnostic of a chylothorax. Even after three days of fat-free diet and intravenous antibiotics, she continued to have high output from the chest tube. A Left-sided thoracotomy with a mediastinal lymph node dissection, resection of the upper lobe of the left lung, and talc pleurodesis was performed. This led to improvement of the symptoms in the subsequent days, and the follow-up chest x-ray showed resolution of the effusion. The patient was discharged to follow up for treatment of the lung adenocarcinoma. DISCUSSION: EUS-FNA is a commonly used technique to investigate the mediastinal pathology. The complications rate is as low as 3%[1], and typically includes mediastinitis, pneumonia, pericarditis, sepsis, and hemorrhage [2,3]. Chylothorax is an infrequent complication, with only a handful of cases noted in the literature. CONCLUSIONS: This case highlights chylothorax as a rare and severe complication of EUS-FNA. This also emphasizes the need for meticulous attention to anatomical structures while performing the procedure and the significance of post-operative surveillance. REFERENCE #1: Polkowski M, Larghi A, Weynand B, Boustière C, Giovannini M, Pujol B, Dumonceau J-M: Learning, techniques, and complications of endoscopic ultrasound (EUS)-guided sampling in gastroenterology: European Society of Gastrointestinal Endoscopy (ESGE) Technical Guideline. Endoscopy. 2012, 44:190–206. 10.1055/s-0031-1291543 REFERENCE #2: Mongelli F, FitzGerald M, Cafarotti S, Inderbitzi R: Chylothorax after endoscopic ultrasound with fine-needle aspiration causing migrating appearance of a solitary fibrous tumor of the pleura. Ann. Thorac. Med. 2018, 13:114–6. 10.4103/atm.ATM_340_17 REFERENCE #3: Asano F, Aoe M, Ohsaki Y, et al.: Complications associated with endobronchial ultrasound-guided transbronchial needle aspiration: a nationwide survey by the Japan Society for Respiratory Endoscopy. Respir Res. 2013, 14:50. 10.1186/1465-9921-14-50 DISCLOSURES: No relevant relationships by Abdul Hamid Alraiyes, source=Web Response No relevant relationships by nitish singh nandu, source=Web Response No relevant relationships by Swetha Paduri, source=Web Response No relevant relationships by Preeti Vadlamani, source=Web Response