An 88 year-old gentleman with good performance status, presented to clinic with chronic cough. A computed tomography (CT) scan of his thorax revealed a 5.3 x 4.7 x 5.7 cm left lower lobe mass with abrupt cut off at the posterior-basal segment of the left lower lobe (Fig. 1). He underwent bronchoscopy with radial endobronchial ultrasound (EBUS)- guided TBLB via a transoral route under moderate sedation with intravenous midazolam and fentanyl. A concentric heterogenous lesion with hyperechoic dots was identified on radial EBUS in the posterior-basal segment of the left lower lobe (Fig. 2). No visible endobronchial lesions or stenosis were seen. Forcep biopsies were performed under fluoroscopy to obtain 8 tissue samples. Post-procedure chest radiograph did not reveal any pneumothorax and he was discharged home. Histology of his lung mass confirmed lung adenocarcinoma with epidermal growth factor receptor (EGFR) exon-19 mutation detected.
He was admitted 6 days after his procedure, with symptoms of fever and cough that started since his bronchoscopy. Chest radiograph showed a new left lower lobe lung collapse with left pleural effusion. He was commenced on empirical intravenous antibiotics. CT scan of his thorax, abdomen and pelvis revealed an interval development of a moderate left pleural effusion with abscess formation within the lung mass (Fig. 1). In addition, a liver lesion consistent with metastatic disease was seen. Bedside ultrasound confirmed a left loculated pleural effusion, which was drained. Pleural studies showed an exudative picture based on Light's criteria with no cell count predominance, and cytology did not reveal any malignant cells. Pleural fluid cultures grew Streptococcus anginosus. Peripheral blood cultures were negative for any bacterial growth. A dental review showed no signs of abscess or dental infections. Our patient subsequently opted for prolonged antibiotic therapy and pleural drainage, and declined intrapleural fibrinolysis or surgical decortication in view of his advanced age. He made a full recovery following a 6 week course of Augmentin. Erlotinib was commenced prior to discharge for stage 4 lung adenocarcinoma.
Coronal CT images of the left lower lobe lung mass pre-bronchoscopy , and.