Endoscopy 2007; 39: E123-E124
DOI: 10.1055/s-2007-966157
Unusual cases and technical notes

© Georg Thieme Verlag KG Stuttgart · New York

Gemella morbillorum mediastinitis and osteomyelitis following transesophageal endoscopic ultrasound-guided fine-needle aspiration of a posterior mediastinal lymph node

T.  J.  Savides1 , D.  Margolis2 , K.  M.  Richman3 , V.  Singh1
  • 1Division of Gastroenterology, University of California, San Diego, California, USA
  • 2Division of Infectious Diseases, University of California, San Diego, California, USA
  • 3Department of Radiology, University of California, San Diego, California, USA
Further Information

T. J. Savides, MD

UCSD Gastroenterology

9500 Gilman Drive
Mail Code 0063
La Jolla
California 92093-0063
USA

Fax: +1-858-792-9267

Email: tsavides@ucsd.edu

Publication History

Publication Date:
18 April 2007 (online)

Table of Contents

A 78-year-old-man with a history of colon cancer was found on follow-up examinations (abdominal computed tomography and positron-emission tomography scans) to have an 8-mm posterior aortopulmonary-window lymph node that was suspected to be malignant ([Figure 1], [Figure 2]). Radial endoscopic ultrasound (EUS) revealed a 10-mm lymph node in the posterior aortopulmonary window ([Figure 3]). Transesophageal EUS-guided fine-needle aspiration (FNA) was performed with five passes, using a 22-gauge needle ([Figure 4]). No antibiotic prophylaxis was given. There were no immediate complications. Cytological examination subsequently revealed this to be benign lymphoid tissue.

Zoom Image

Figure 1 Positron-emission tomographic (PET) scan showing increased activity in the left mediastinum.

Zoom Image

Figure 2 Computed tomographic scan showing an 8.4-mm-diameter lymph node in the posterior aortopulmonary window, corresponding to the region of increased PET activity.

Zoom Image

Figure 3 Radial endoscopic ultrasound view showing a left posterior aortopulmonary-window lymph node measuring 10 mm in diameter and located 28 cm from the incisors.

Zoom Image

Figure 4 Transesophageal endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) of the posterior aortopulmonary lymph node.

Five days later, the patient developed chest pain, fevers, and an elevated white blood cell count. Chest computed tomography revealed inflammatory changes in the posterior mediastinal fat abutting the T5 - T7 vertebral bodies ([Figure 5]). Four sets of blood cultures grew Gemella morbillorum. Thoracic spine magnetic resonance imaging 6 weeks after the EUS-FNA revealed diskitis and osteomyelitis at T5/6 ([Figure 6]). The patient was successfully treated with intravenous ceftriaxone for a total of 12 weeks, and then with oral amoxicillin for several months until all the symptoms and radiographic changes had resolved.

Zoom Image

Figure 5 Computed tomographic scan showing posterior mediastinal inflammatory changes extending from the posterior aortopulmonary lymph node (arrow), which had undergone EUS-FNA, to the vertebral bodies at the same level. Note the new inflammatory changes anterior to the vertebral body, which has displaced the aorta to the left.

Zoom Image

Figure 6 Magnetic resonance imaging scan showing vertebral disk destruction at level T5/6. There is also increased signal in T5 and T6, consistent with osteomyelitis.

This is the first reported case of transesophageal EUS-FNA of a posterior mediastinal lymph node causing mediastinitis and osteomyelitis. The mediastinitis was probably caused by seeding of the target lymph node by an FNA needle contaminated by G. morbillorum, a facultative, anaerobic, aerotolerant, Gram-positive coccus which is a natural inhabitant of the human oropharynx [1].

[Table 1] summarizes the clinical details of the seven previously reported cases of mediastinitis caused by transesophageal EUS-FNA, as well as this present case [2] [3] [4] [5] [6] [7] [8]. Five of these were mediastinal cysts, and this has led to the recommendation that EUS-FNA should be avoided in cases where there is clearly a posterior mediastinal cyst, and that antibiotics should be given if an unsuspected cyst is aspirated. Two of these cases reported mediastinitis after EUS-FNA of mediastinal lymph nodes.

Table 1 Reported cases of mediastinitis as a complication of transesophageal endoscopic ultrasound-guided fine-needle aspiration (FNA)
Author(s) [ref. no.]YearLesion biopsiedFNA or TrucutAntibioticsComplicationsManagement
Ryan et al. [2] 2002CystFNAYesIncidental Candida organisms found at resectionThoracotomy
Wildi et al. [3] 2003Cyst (solid-appearing)FNA and TrucutNoMediastinitis and sepsisThoracotomy
Annema et al. [4] 2003CystFNANoMediastinitis (Streptococcus pneumoniae)Thoracotomy
Westerterp et al. [5] 2004Cyst (solid-appearing)FNANoMediastinitisEndoscopic fenestration
Varadarajulu et al. [6] 2004CystTrucutNoMediastinitisThoracotomy
Pai & Page [7] 2005Mass (teratoma)FNANoMediastinitisThoracotomy
Will et al. [8] 2005Lymph node (malignant)FNANoMediastinitis and esophagomediastinal fistulaEndoscopic treatment and antibiotics
Savides et al.2006Lymph node (benign)FNANoMediastinitis and osteomyelitis (Gemella morbillorum)Antibiotics

Endosonographers should be aware that mediastinitis can occur after transesophageal EUS-FNA of any solid posterior mediastinal lesion, and not only where the lesion is cystic.

#

Acknowlegdment

This abstract was presented in part as a poster at EUS 2006 in Amsterdam, 30 June 2006.

Endoscopy_UCTN_Code_CPL_1AL_2AF

#

References

T. J. Savides, MD

UCSD Gastroenterology

9500 Gilman Drive
Mail Code 0063
La Jolla
California 92093-0063
USA

Fax: +1-858-792-9267

Email: tsavides@ucsd.edu

#

References

T. J. Savides, MD

UCSD Gastroenterology

9500 Gilman Drive
Mail Code 0063
La Jolla
California 92093-0063
USA

Fax: +1-858-792-9267

Email: tsavides@ucsd.edu

Zoom Image

Figure 1 Positron-emission tomographic (PET) scan showing increased activity in the left mediastinum.

Zoom Image

Figure 2 Computed tomographic scan showing an 8.4-mm-diameter lymph node in the posterior aortopulmonary window, corresponding to the region of increased PET activity.

Zoom Image

Figure 3 Radial endoscopic ultrasound view showing a left posterior aortopulmonary-window lymph node measuring 10 mm in diameter and located 28 cm from the incisors.

Zoom Image

Figure 4 Transesophageal endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) of the posterior aortopulmonary lymph node.

Zoom Image

Figure 5 Computed tomographic scan showing posterior mediastinal inflammatory changes extending from the posterior aortopulmonary lymph node (arrow), which had undergone EUS-FNA, to the vertebral bodies at the same level. Note the new inflammatory changes anterior to the vertebral body, which has displaced the aorta to the left.

Zoom Image

Figure 6 Magnetic resonance imaging scan showing vertebral disk destruction at level T5/6. There is also increased signal in T5 and T6, consistent with osteomyelitis.