Mediastinitis after EUS-FNA in a Patient with Sarcoidosis-Case Report with Endosonographic Features and Review of the Literature

Background: EUS-FNA of lymph nodes is believed to harbour no risk of serious complications. However, recently, a case series of mediastinal abscess formation after EUS-FNA in patients with sarcoidosis has been published. Here, we describe a patient with sarcoidosis and mediastinitis after EUS-FNA. Case Report: Two years before EUS-FNA, the patient with a history of sarcoidosis, was operated because of esophageal adenocarcinoma. Due to progredient mediastinal lymphoma, we performed EUS-FNA to exclude tumor recurrence. 30 hours later, the patient developed general weakness, musculoskeletal pain, non-productive cough, andmild dysphagia. Ten days later, the patient was admitted with fever and thrombocytopenia. A CT scan showed a mediastinal mass without liquid areas, but small deposits of air. Meropenem, steroid, and low-dose heparin were started. The fever resolved after 24 hours, CRP, as well as coagulatory parameters returned to normal levels after 5 days. Endoscopic ultrasound revealed an inhomogeneous, slightly hyperechoic, mediastinal mass. The lymph nodes were partly dislodged, and partly embedded into this mass with a rounded shape and large hyperechoic center. Vascularization was not increased, liquid areas, or inclusions of gas were not present. A follow-up examination 6 weeks later revealed complete resolution of the mass. Conclusion: EUS-FNA, but not EBUS-FNA, seems to be associated with an increased infectious risk in patients with sarcoidosis. Endosonographic features include inhomogeneous, mass-forming mediastinal infiltration, and swelling of lymph nodes with hyperechoic central parts. In cases of suspected sarcoidosis, EBUS-FNA should be preferred. EUS-FNA, probably with antibiotic prophylaxis, should only be done after a non-diagnostic bronchoscopic work-up.