MANAGEMENT OF MEDIASTINAL BRONCHOGENIC CYST WITH TRANSBRONCHIAL NEEDLE ASPIRATION

Abstract

INTRODUCTION: Bronchogenic cysts are rare congenital anomalies which present with a wide spectrum of clinical presentation from asymptomatic to acute respiratory distress. Radiographic manifestations are widely varied which sometimes make diagnosis difficult. We present a case where Endobronchial Ultrasound guided needle aspiration was both diagnostic and therapeutic. CASE PRESENTATION: 37 year old female with 25 pack year of tobacco use, history of intravenous drug use and previous tuberculosis exposure treated with 9 months of isoniazid presented with fever, chills, chest pain and cough to her physician. She was treated with antibiotics for possible pneumonia as evident on chest radiograph. A follow up Computed Tomography (CT) after her symptoms did not resolve showed a 4 x 5.6 cm right paratracheal mass extending from the apex of the lung to the carina. She continued to have pleuritic chest pain although fever was improved. A repeat chest CT after 3 weeks showed persistent right paratracheal mass. She underwent bronchoscopy with attempted transtracheal needle aspiration at a local hospital, which was unsuccessful. The patient was then referred for possible surgical resection and biopsy of the undiagnosed mass. However, it was decided to do an endobronchial ultrasound (EBUS) guided 22G needle aspiration. About 150 milliliters of straw colored fluid was aspirated. Post-procedure chest radiograph showed significant reduction of the mass. Cytologic evaluation of the fluid yielded no malignant cells. Routine cultures grew upper airway contaminants, there was no purulence, acid fast culture and stain was negative. DISCUSSIONS: Bronchogenic cyst in adults occasionally presents as an asymptomatic radiographic finding unlike our patient who had constitutional symptoms. Conservative management with radiologic follow-up is controversial, given higher morbidity and mortality related to surgical excision after cyst growth. Definitive treatment of bronchogenic cyst is surgical excision given its high rates of recurrence and possible complications. However few case reports have described conservative management with intermittent transbronchial needle aspiration in patients with minimal symptoms or those reluctant or unable to undergo surgery. Our patient did not have any old chest imaging to confirm whether the cyst was present since her childhood, however, we entertained an infectious etiology with her intravenous drug use history and associated fever. All cultures including Acid Fast Bacillus (AFB) from the aspirated fluid were negative ruling out an infectious cause. She remains asymptomatic and we plan to follow her with serial imaging and reserve surgical excision only if it becomes symptomatic or recurrent. Occasionally these cysts may be loculated and a blind needle aspiration may not be completely successful. However, with EBUS guidance we can aspirate loculations of sufficient size. CONCLUSION(S): EBUS guided real-time drainage of bronchogenic cysts can be both diagnostic and therapeutic. Bronchoscopic needle aspiration with appropriate follow-up is a viable alternative to surgery in patients with mediastinal bronchogenic cyst. Surgical resection may be reserved for those with recurrent symptoms or if needle aspiration is unsuccessful.