A 68-year-old woman was referred to our hospital due to a growing shadow in the right paratracheal and hilar area on the chest X-ray performed during the medical examination. She was a non-smoker and had a history of tuberculosis (TB) 40 years ago. A CT scan revealed two lobulated masses with homogeneous contrast enhancement in the right paratracheal and hilar area; however, no lung lesions were observed. EBUS-TBNA of the lesion was performed under deep sedation by a well-trained bronchoscopist. The patient was discharged without complications 1 day after the procedure. The amount of specimen was sufficient to analyze histological results, and no evidence of malignancy was found.
Eight days after the EBUS-TBNA, the patient was admitted to our emergency room due to chest discomfort and high fever. The vital signs were: systolic blood pressure (BP) 100 mm Hg, diastolic BP 60 mm Hg, heart rate 82/min, respiratory rate 16/min, and peak fever 38.4  C. The blood test results revealed a white blood cell count of 12110/muL and C-reactive protein of 25.3 mg/dL.
On a chest X-ray, pleural effusion of both lung fields and enlarged heart margin were revealed, in addition to a previously observed shadow in the right hilar area that had increased in size (Fig. 1A). A portable cardiac echocardiogram was performed. Although the ejection fraction of the left ventricle was within the normal range, a large pericardial effusion was observed. Pig tail catheter was inserted through percutaneous pericardiocentesis and 400 mL of fluid was drained, and symptoms were slightly improved. On a chest CT, enlargement of the right lower paratracheal lymph nodes and a multiloculated mediastinal abscess with gas formation (Fig. 1B, C) were observed. The patient underwent surgery for debridement and drainage along with lymph node dissection on the same day.
The operation was initiated with VATS under general anesthesia; adhesion of the whole lung and severe adhesion of the target lesion to surrounding structures were revealed; therefore, we converted to thoracotomy. Purulent fluid was contained in the thoracic cavity when we approached the target lesion, and a thick layer was found around the swollen lymph node; therefore, dissection was performed using surgical electrocautery and energy devices. Upon detachment, a large amount of pus-like fluid was secreted, and cytologic examination and culture were performed. Conglomerated and necrotic lesions seen on the CT were removed as much as possible, and biopsy was performed to confirm the pathology. The surgery was completed after massive saline irrigation, a 28-French chest tube was inserted into the thoracic cavity, and a 28-French right-angled chest tube was inserted into the pericardial space for effective drainage of the pericardial effusion. After the operation, the patient had stable vital signs without fever and gradually recovered. The pathological examination of the biopsy obtained during the surgery revealed inflammation, without other abnormal findings. During the hospitalization period, additional CT performed to check the changes of lesion revealed reduction in size, and the blood test results were within the normal range. The patient was discharged without any complications.