Endobronchial spread of tuberculosis after endobronchial ultrasound-guided transbronchial needle aspiration and intranodal forceps biopsy

Sir, Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a minimally invasive procedure for accurate tissue sampling of mediastinal structures beyond the confines of airway walls. Endobronchial ultrasound-guided intranodal forceps biopsy (EBUS-IFB), a relatively novel technique, appears promising to improve the overall diagnostic yield of EBUS procedures when combined with TBNA.[1] Although EBUS-TBNA is considered to be a safe procedure, the data regarding the safety of EBUS-IFB are limited. We describe here a case of endobronchial spread of tuberculosis following EBUS-TBNA/IFB. A 35-year-old male patient presented with the only complaint of high-grade fever for 1 month. He neither had a personal history of smoking, alcohol, or substance abuse nor suffered from any co-morbid condition. His general and systemic physical examination was unremarkable. His routine laboratory investigations were within the normal range. The contrast-enhanced computer tomography (CECT) chest revealed enlarged right paratracheal (4R), subcarinal (7), and right hilar (10R) lymph node stations. The subcarinal lymph node (Station 7) was the largest, measuring 28.6 mm, and showed heterogeneous areas of contrast enhancement suggestive of necrosis [Figure 1a]. A few centrilobular nodules were also reported in the right upper (RUL) and middle (RML) lobes. Video flexible bronchoscopy showed normal-appearing airways without any endobronchial lesion. The bronchial alveolar lavage (BAL) was negative for acid fast bacilli (AFB) in Ziehl–Neelsen stain (ZN stain). EBUS-TBNA using a 22 G needle was performed in all three lymph node stations, which showed inconclusive results on rapid onsite cytology examination (ROSE). Hence, based on the CECT chest findings, EBUS-IFB of the largest and most pathological appearing lymph node station 7 was performed through the medial wall of the right main bronchus (RMB) at 9 0’ clock position [Figure 1b and c] after creating a track using a 19 G EBUS needle. The histopathological examination of biopsy specimens showed necrotizing granulomatous inflammation and a positive ZN stain for AFB, establishing a diagnosis of tubercular mediastinal lymphadenitis in this case. Antitubercular treatment (ATT) was advised with a combination of rifampicin, isoniazid, ethambutol, and pyrazinamide (RHEZ). The patient responded well initially, becoming afebrile after 1 week of starting ATT. He, however, presented with a recurrence of high-grade fever about a month later, whereas the ATT was continuing. A repeat CECT chest showed collapse-consolidation of the lateral segment of the RML [Figure 1d] despite a significant interval decrease in the size of enlarged mediastinal and hilar lymph nodes as compared to the previous CT scan. Repeat video flexible bronchoscopy showed the development of nodular lesions at the site of EBUS-TBNA and a sinus at the puncture site of EBUS-IFB in RMB [Figure 1e and Video 1]. An additional new finding was a nodular growth that was completely obstructing the lateral segment of the RML bronchus [Figure 1f and Video 1]. The endobronchial forceps biopsy of the nodular lesion in the RML bronchus showed a bronchial wall with intraluminal chronic inflammatory cell infiltration and epithelioid cell granulomas. The BAL from the RML was positive for AFB on the ZN stain. The Cartridge-based nucleic acid amplification test (CBNAAT, GeneXpert) in BAL detected Mycobacterium tuberculosis (MTB), but not rifampicin resistance. The Fluorometric BACTEC MGIT (liquid) culture of BAL after 6 weeks grew MTB, which was sensitive to RH. A diagnosis of tuberculosis of RML bronchus was made, possibly due to the endobronchial spread from the necrotic lymph node station 7 following EBUS-TBNA and IFB. The patient was advised to extend ATT with RHEZ for 3 months in the intensive phase, followed by RHE for 6 months in the continuation phase. The patient responded well to ATT with the subsequent radiological resolution of collapse-consolidation of RML.Figure 1: CECT chest (a) revealed a large subcarinal station 7 lymph node showing heterogenous areas of contrast enhancement suggestive of necrosis. EBUS-IFB (b) of the lymph node produced numerous biopsy specimens (c). Repeat CECT chest showed collapse-consolidation of the lateral segment of RML (d). Fresh bronchoscopy findings were the development of nodular lesions at the site of previous EBUS-TBNA, a sinus (arrow) at the site of EBUS-IFB in the right main bronchus (e) and a nodular growth (f) completely obstructing the lateral segment of RML bronchus {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Video Clip 1","caption":"","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_4q1nu48i"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]} One of the significant advantages of EBUS-TBNA is the low risk of complications. The infectious complications of EBUS-TBNA include mediastinitis, pneumonia, mediastinal abscess, bacteremia, and prolonged fever with an overall incidence ranging from 0.19% to 0.54%,[2] and have been described rarely as case reports or in small retrospective studies,[3] primarily due to bacterial infections. This case is the first Indian report of the endobronchial spread of tuberculosis following EBUS-TBNA/IFB. Mehta et al.,[4] in one of the largest series of EBUS-IFB from India, did not observe these complications in their study. Hata et al.[5] reported two cases of tuberculosis after EBUS-TBNA. One of them was complicated by the development of intrabronchial polypoid lesions at the puncture sites nearly 2 months after undergoing the EBUS-TBNA procedure at the hilar and subcarinal lymph nodes. Our case demonstrated the development of nodular lesions at the site of EBUS-TBNA and a sinus at the puncture site of EBUS-IFB. We believe that the endobronchial spread of tuberculosis to the RML bronchus occurred from the sinus formed after EBUS-IFB of the station 7 lymph node, which was also showing necrosis. The biopsy of necrotic structures has been considered a potential risk factor for post-procedural infection.[2] In this case, we tried to perform the EBUS-TBNA/IFB from the non-necrotic lymph node area to avoid the risk of infection. However, EBUS usually provides a limited window, and necrotic areas might be punctured inadvertently despite the EBUS guidance. It has been suggested that infectious complications occurring after EBUS-TBNA are due to seeding at the puncture site.[6] As a complementary procedure, EBUS-IFB does not seem to significantly affect the safety profile of bronchoscopy procedures with an overall complication rate of 1.5%, comparable with EBUS-TBNA.[7] However, this observation is based on reports of EBUS-IFB performed primarily in the lymph nodes caused by malignant pathology and sarcoidosis, whereas data on the safety of EBUS-IFB in tubercular lymphadenopathy is grossly lacking. We used a 22 G needle for EBUS-TBNA and a 19 G needle for creating a track for EBUS-IFB. It is likely that the sinus was formed by the track created by the large bore 19 G needle at the puncture site of EBUS-IFB. Although the appropriate number of passes is not yet defined with EBUS-IFB, we obtained eight biopsy specimens measuring up to 2 mm each to ensure adequate material for a histopathology examination. It is possible that the increasing number of biopsy attempts could be another contributing factor to the complication. The endobronchial spread of tuberculosis, in this case, resulted in clinical–radiological deterioration, needing extended ATT to achieve a good outcome. This case highlights that excessive puncturing should be avoided in patients with tuberculous mediastinal lymphadenitis,[4] and EBUS-IFB can cause the endobronchial spread of tuberculosis, especially if the target lesion appears necrotic on chest CT. This article refers to a complication of the EBUS-guided intranodal biopsy technique in a patient with a necrotic lymph node. This complication is intuitive and this procedure should be ideally avoided in such a situation. Indeed, there are data to suggest that this complication is observed even with EBUS-TBNA. However, with a plethora of techniques that are available for taking larger specimens from a mediastinal lymph node and great enthusiasm to use such techniques, this case report is a useful reminder to the proceduralists that discretion is important when nascent aggressive techniques are attempted. Therefore, EBUS-IFB must be performed only after careful selection of patients in a tuberculosis-endemic country such as India. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.