Endobronchial Ultrasound Image of Lung Abscess with Bronchial Fistulisation

Abstract

A 79 year-old ex-smoker gentleman presented for a few months history of cough and dyspnoea on exertion. He was evaluated for persistent right lower lobe mass-like density with multiple chest-computed tomography (CT) scans (Figures 1a and 1b). He also received four courses of antibiotic and he underwent flexible bronchoscopy, which revealed swelling and narrowing of the right middle lobe with purulent discharge. Cytology and cultures were negative and the diagnosis remains uncertain. The patient was then referred for endobronchial ultrasound (EBUS) diagnostic procedure. Flexible bronchoscopy with EBUS showed mucosal oedema with erythema of the right hilar area and purulent discharge originating from the posterior wall of the proximal right middle lobe bronchus, which was consistent with bronchial fistulisation (Figures 1c and 1d). The EBUS scope, which was positioned in the right lower lobe revealed a heterogeneous mass posteromedially with multiple cystic-like large areas of hypoechogenicity most consistent with abscesses formation (Figure 1e). Endobronchial ultrasound transbronchial needle aspiration (EBUS-TBNA) of this mass revealed purulent discharge and grew streptococcus mitis/oralis. Six weeks of intravenous ertapenem treatment was ineffective