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CASE LETTER
Year : 2019  |  Volume : 36  |  Issue : 5  |  Page : 457-458  

Endoscopic ultrasound fine-needle aspiration with an echobronchoscope (EUS-B-FNA) from a difficult-to-access paraspinal lesion


Department of Medicine, All India Institute of Medical Sciences, New Delhi, India

Date of Web Publication23-Aug-2019

Correspondence Address:
Animesh Ray
Department of Medicine, All India Institute of Medical Sciences, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/lungindia.lungindia_226_19

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How to cite this article:
Ray A, Jain SR, Narwal A, Sinha S. Endoscopic ultrasound fine-needle aspiration with an echobronchoscope (EUS-B-FNA) from a difficult-to-access paraspinal lesion. Lung India 2019;36:457-8

How to cite this URL:
Ray A, Jain SR, Narwal A, Sinha S. Endoscopic ultrasound fine-needle aspiration with an echobronchoscope (EUS-B-FNA) from a difficult-to-access paraspinal lesion. Lung India [serial online] 2019 [cited 2019 Sep 21];36:457-8. Available from: http://www.lungindia.com/text.asp?2019/36/5/457/265166



Sir,

The main indications of endobronchial ultrasound (EBUS) include staging of lung cancer patients and diagnosis of enlarged mediastinal lymph nodes or lesions. It can usually be done as a day care procedure under conscious anesthesia. This modality has largely replaced the use of gold standard surgical mediastinoscopy for diagnosis because of its high efficacy, safety, low cost, and wider availability. As Guarize et al.[1] showed, EBUS had a sensitivity and specificity of 91.7% and 93.6%, respectively, and there were no major complications related to the procedure. With the increasing expertise in and availability of EBUS, clinicians are now exploring its use for sampling substernal goiter lesions, posteriorly located pericardial effusion, paraspinal lesions as well as difficult to access lesions.[2] Sinha et al.[3] had reported EBUS-guided paraspinal sampling (from the tracheobronchial tree) after failing to obtain tissue via computed tomography (CT)-guided approach and bone marrow aspirate and biopsy from the spine. We report a similar case which was approached by endoscopic ultrasound fine-needle aspiration with an echobronchoscope (EUS-B-FNA).

Our patient is a 21-year-old male who had been diagnosed as a case of chronic granulomatous disease (CGD) at the age of 17 years, when he developed lower respiratory tract disease, pyomyositis, and multiple abscesses over his back. He had responded to treatment with intravenous antibiotics, and subsequently, reactive oxygen species stimulation index was found to be low suggestive of CGD.

Now, he presented with complaints of mid-back ache and significant loss of weight and appetite for the last 6 months. However, there was no fever. On examination, he had a few subcentimetric cervical lymph nodes. The rest of the systemic examination was within normal limits.

His routine blood investigations were normal. Chest X-ray showed T7 vertebral body collapse. Contrast-enhanced CT chest revealed a prevertebral heterogeneously enhancing lesion, suggestive of partially organized collection extending from T5 to T9 vertebrae [Figure 1]. The radiological picture was suggestive of a chronic infective process like tuberculosis. For determining the exact etiology, sampling and microbiological investigati ons were planned. The position of the lesion made it difficult for a transthoracic approach. As the lesion abutted the tracheobronchial tree and the esophagus around the carina, a decision was made to approach with the help of EBUS. However, the lesion could only be partially visualized at the carina, and on rapid on-site evaluation (ROSE), the sample was deemed unsatisfactory. Hence, endoscopic ultrasound with echobronchoscope (EUS-B) approach was used, and after identifying the usual landmarks of liver and heart, the scope was positioned to clearly visualize the lesion [Figure 2] and aspirate was taken. Two passes were taken and ROSE showed lymphoid tissue with necrotic background [Figure 3]. Cartridge-based nucleic acid amplification test from aspirate showed Mycobacterium tuberculosis sensitive to rifampicin and cytology showed abundant necrosis and stained positive for acid-fast bacilli [Figure 4].
Figure 1: Computed tomography scan of the spine showing collection at T6–T7 level

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Figure 2: Echobronchoscope-B picture of the paraspinal lesionHowever

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Figure 3: Cytological examination of the aspirate showing abundant necrosis

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Figure 4: Cytological examination of the aspirate showing acid-fast bacilli

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Based on the above reports, the patient was diagnosed as a case of tuberculosis of the spine. He was started on antitubercular therapy with isoniazid, rifampicin, pyrazinamide, and ethambutol. The patient now has improved weight and appetite, and back pain has resolved.

In our case, the paraspinal collection could not be visualized properly with EBUS approach, so next EUS-B was done and the lesion could be successfully visualized and sampled. Dhooria et al.[4] and Oki et al.[5] had showed efficacy and safety of EUS-B where EBUS approach failed or was contraindicated. This case highlights the utility of the EUS-B approach in sampling mediastinal lesions not accessible by transthoracic or transbronchial route.

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.



 
   References Top

1.
Guarize J, Casiraghi M, Donghi S, Diotti C, Vanoni N, Romano R, et al. Endobronchial ultrasound transbronchial needle aspiration in thoracic diseases: Much more than mediastinal staging. Can Respir J 2018;2018:4269798.  Back to cited text no. 1
    
2.
Ray A, Kalum SJ, Sinha S. Ambidexterity: A useful addition to the skillset of an endobronchial ultrasound operator?. Lung India 2018;35:539-40  Back to cited text no. 2
    
3.
Sinha N, Padegal V, Jermely D, Satyanarayana S, Santosh HK. Endobronchial ultrasound guided needle aspiration of a paraspinal mass with prior failed multiple diagnostic interventions: A case report and literature review. Lung India 2014;31:401-3.  Back to cited text no. 3
[PUBMED]  [Full text]  
4.
Dhooria S, Aggarwal AN, Singh N, Gupta D, Behera D, Gupta N, et al. Endoscopic ultrasound-guided fine-needle aspiration with an echobronchoscope in undiagnosed mediastinal lymphadenopathy:First experience from India. Lung India 2015;32:6-10.  Back to cited text no. 4
[PUBMED]  [Full text]  
5.
Oki M, Saka H, Ando M, Kitagawa C, Kogure Y, Seki Y. Endoscopic ultrasound-guided fine needle aspiration and endobronchial ultrasound-guided transbronchial needle aspiration: Are two better than one in mediastinal staging of non–small cell lung cancer? J Thorac Cardiovasc Surg. 2014; 148:1169-77.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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