A 40-year-old obese man with a history of hypertension, methamphetamine use, and heart failure presented to an outside ED with chest discomfort and shortness of breath. A chest x-ray revealed a right paratracheal mass measuring 6 cm which was confirmed on follow-up CT. CT also showed a small right-sided pleural effusion and moderate hilar, mediastinal, mesenteric and pelvic lymphadenopathy (Fig. 1). The initial outside radiographic read considered these imaging findings concerning for lymphoma vs. metastatic primary lung malignancy. The Hounsfield Units of the initial scan were 17.8.
The patient was initially referred to thoracic surgery, but given the proximity of the lesion to the trachea, thoracic surgery referred the patient for consultation by interventional pulmonary with endobronchial ultrasound (EBUS) guided transbronchial needle aspiration (TBNA). Bronchoscopy with EBUS guided FNA was performed in the operating room under general anesthesia using a laryngeal mask airway (LMA). To our surprise, the mass was hypoechoic, yet Doppler US (Fig. 2a) did not suggest any blood flow through the lesion. A 22 gauge EBUS needle was inserted into the lesion under direct US guidance. On aspiration, the syringe filled with a serous fluid (Fig. 2b). Cytologic analysis of the sample showed a paucicellular proteinaceous fluid with occasional foamy macrophages and no evidence of malignancy.
Further review of the outside pulmonary embolism (PE) protocol CT taken in conjunction with the biopsy results confirmed the clinical picture was most consistent with a bronchogenic cyst. In addition, re-read of the outside CT suggested the presence of a PE, which helped explain the hilar and mediastinal adenopathy and pleural effusion. Due to concern for PE, a repeat PE protocol CT was performed showing no evidence of a current PE; furthermore, it showed resolution of the ipsilateral pleural effusion and hilar and mediastinal lymphadenopathy. The cyst was reduced to from 6 cm to 3 cm following drainage (Fig. 3). Since undergoing EBUS guided TBNA, our patient has reported a good functional outcome with total resolution of his symptoms and greatly improved exercise tolerance.