Mediastinitis as a complication of minimally invasive diagnostic and mediastinal staging techniques.

The introduction of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) and endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) has been a major advance in the diagnosis and staging of lung cancer, as well as in the study of other mediastinal lesions.1 Although they are safe techniques, complications have occurred, including pneumothorax, hemorrhage, infection, mediastinitis and mediastinal abscess, with a 50% mortality rate with the last two.2 We present two cases of mediastinitis that we have experienced recently in our hospital following these endoscopic examinations. A 42-year-old woman diagnosed with a grade 3 breast infiltrating ductal carcinoma (stage cT2N+), was initially treated with neoadjuvant chemotherapy, left mastectomy, and monthly trastuzumab. Recurrence was confirmed through biopsy of a solitary pulmonary nodule. Later on, a chest CT revealed a well-delimited and necrotic pretracheal mediastinal adenopathy (2R) (Fig. 1A), which was biopsied by EBUS-TBNA under sedation (midazolam, 6mg; Olympus needle, 21-gauge) and a total of 4 passes, without complications. Malignancy was confirmed. After 48 h, she started feeling general malaise, retrosternal pain radiating to the neck, odynophagia, dysphagia, fever, and erythematous, and pruriginous maculo-papular lesions in the trunk and upper limbs. In blood analysis, we noticed a significant presence of leukocytosis and elevation of C-reactive protein. Chest CT showed increased attenuation of mediastinal fat, well-defined wall collections in the left upper and lower paratracheal space (Fig. 1B and C). Treatment response with ceftriaxone and clindamycin was good and did not require surgical debridement. Blood cultures and punctured adenopathy were negative. The evolution was favorable and after 11 days she was discharged, continuing treatment at home. A 74-year-old woman was monitored in Pulmonology Clinic for presenting mediastinal lymphadenopathy (Fig. 1D). EUS-FNA (Cook needle, 22-gauge) was performed with a total of 4 passes (subcarinal adenopathy, 7), with no immediate complications. Tuberculosis was confirmed in anatomopathological samples. The next day she started having retrosternal pain not associated with any other symptomatology. After two weeks, she went to Emergency because of persistent pain and fever. As she was hemodynamically unstable she was admitted to the Intensive Care Unit. Blood tests revealed leukocytosis and hyperfibrinogenemia. The chest CT showed three