UNUSUAL PRESENTATION OF PNEUMOMEDIASTINUM AND SUBCUTANEOUS EMPHYSEMA MIMICKING ANGIOEDEMA

Abstract

SESSION TITLE: Case Report Semifinalists 2 SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a relatively safe technique associated with a very low complication rate for the sampling of mediastinal and hilar lymph nodes. Here we report a rare case of pneumomediastinum and subcutaneous emphysema following EBUS-TBNA. CASE PRESENTATION: 72 years old female, past smoker with remote history of right breast cancer s/p lumpectomy, radiation and chemotherapy (20 years ago), referred for evaluation of a 2.2 cm left hilar mass. She underwent elective EBUS under deep sedation after uneventful placement of a laryngeal mask airway, with transbronchial needle aspiration in the subcarinal (7) and left hilar stations (10L). There were no immediate complication. Two hours post procedure she developed rapidly progressive facial and neck swelling without any stridor. She was initially thought to have angioedema, and was intubated for airway compromise after she received IV Methylprednisolone 125 mg, IV epinephrine 10 mcg and 30 mcg subcutaneous epinephrine without improvement. No laryngeal edema was seen during intubation. Chest X ray subsequently showed extensive pneumomediastinum and subcutaneous emphysema. The decision was made to extubate patient since there was a risk of developing pneumothorax because of positive pressure. Patient was found to have air leak prior to extubation and was extubated to nasal cannula. Patient was discharged the next day to follow up as an outpatient. DISCUSSION: EBUS-TBNA is a safe procedure and complications are minimal. There are only a few case reports of pneumomediastinum associated with airway trauma from EBUS-TBNA so far. Subcutaneous emphysema may be observed in association with pneumomediastinum once pressure gradients allow air to spread via the fascial planes to the surrounding soft tissues [1]. Subcutaneous emphysema can mimic angioedema, an often a relatively benign disorder. Clinical presentations may include dramatic swelling of the neck associated with chest pain, wheezing, dyspnea, and dysphagia. Sparing of lips and presence of crepitus can be an important clue to differentiate it from angioedema [2]. Management of pneumomediastinum and sub cutaneous emphysema depends upon the clinical severity. Most patients respond well to the conservative management,however surgery may be required in rare cases. Treatment should be aimed at decreasing intrathoracic pressure spikes by reducing coughing and straining. CONCLUSIONS: Although EBUS-TBNA is considered a safe procedure with rare complications, it is necessary to remember that serious complications such as pneumomediastinum can occur. Our patient’s unusual presentation led to initial misdiagnosis. Although rare, clinicians must remain mindful of the complication to avoid delay in treatment. Reference #1: Ortiz, R., Hayes, M., Arias, S., Lee, H., Feller-Kopman, D. and Yarmus, L. (2014). Pneumomediastinum and Pneumopericardium after Endobronchial Ultrasound–Guided Transbronchial Needle Aspiration. Annals of the American Thoracic Society, 11(4), pp.680-681. Reference #2: Dhawan, A., Singal, A., Bisherwal, K., & Pandhi, D. (2016). Subcutaneous emphysema mimicking angioedema. Indian Dermatology Online Journal, 7(1), 55. https://doi.org/10.4103/2229-5178.174304 DISCLOSURES: No relevant relationships by Kulothungan Gunasekaran, source=Web Response No relevant relationships by Gini Priyadharshini Jeyashanmugaraja, source=Web Response No relevant relationships by Min Qiao, source=Web Response No relevant relationships by Daniel Rudolph, source=Web Response No relevant relationships by Christopher Winterbottom, source=Web Response