A 69-year-old man with preexisting hypertension and severe emphysema had experienced right-sided chest pain for several months. He had smoked a pack of cigarettes per day for 44 years. Chest computed tomography (CT) showed a tumor in the upper lobe of the right lung, and enlargement of multiple mediastinal and right hilar lymph nodes (Fig. 1A and B). Endobronchial lung biopsy was performed under ultrasonographic guidance, using a guide sheath; no malignant cells were found using rapid on-site cytologic evaluation. EBUS-TBNA was performed using the UC260FW (Olympus, Tokyo, Japan) bronchoscope to obtain tissue. A single-use 22-G needle was used for needle aspiration. The needle aspirate was obtained using the stylet push out method. The lung tumor and mediastinal lymph nodes were found to be necrotic (Fig. 1B); the necrotic areas were avoided under ultrasonographic guidance during aspiration. Three and two needle aspirates were obtained from the 4R and 11i lymph nodes, respectively. The histologic diagnosis was that of non-small cell lung cancer with neuroendocrine differentiation and considerable necrosis. Microbiological examination of the samples revealed no clinically significant bacteria.
Thirty days after the procedure, the patient was admitted to our hospital with loss of appetite and general fatigue, without fever. The chest CT scan revealed further enlargement of the lymph nodes with pericardial effusion (Fig. 1D and E). Six days before admission, a CT scan for planning radiation therapy revealed no complications from EBUS-TBNA (Fig. 1C). Although tazobactam/piperacillin was empirically administered to treat the mediastinitis and pericarditis, cardiac tamponade developed on the third hospital day. Pericardial fenestration and drainage were accordingly performed. The pericardial fluid obtained appeared yellow and turbid; Gram-positive cocci were identified on examination. We therefore diagnosed an infection in the mediastinal lymph nodes and pericardium, consequent to EBUS-TBNA. Intravenous vancomycin was added to the tazobactam/piperacillin regimen. Five days after pericardial fenestration, the antibiotic regimen was de-escalated to intravenous ampicillin/sulbactam; at 28 days after pericardial fenestration, the antibiotic regimen was de-escalated to oral amoxicillin hydrate for 4 weeks. Chemoradiation therapy for lung cancer was initiated 25 days after pericardial fenestration, without further complications. On anaerobic culture, the pericardial effusion demonstrated the growth of colonies, which were identified on subculture. Gemella sanguinis was eventually identified using the MALDI biotyper@ ver.3.1 (Bruker Daltonics) microbial identification system.