A 60-year-old man visited our hospital for further evaluation of an abnormal chest radiograph obtained on a health examination. He had a history of foot drop due to cervical spine injury and prostatic hyperplasia, which was treated with naftopidil. He had a 15-pack-year history of smoking. He did not report any symptoms and his physical examination was unremarkable. Computed tomography (CT) revealed multiple lung nodules and mediastinal and hilar adenopathy (Fig. 1). Mediastinum demonstrated the accumulation of gallium-67. EBUS-TBNA (BF-UC260FW, Olympus, Tokyo, Japan) was performed in the lymph node station 4R using 21 gauge needle (NA-201SX-4021, Olympus, Tokyo, Japan) and a transbronchial lung biopsy (TBLB) was performed for multiple lung nodules. On EBUS-TBNA, echographic images suggested an isoechoic texture. 3 passes were made with 21 gauge needle without any event during the procedure and the patient was discharged the following day.
Although only tracheal cartilage was detected from the EBUS-TBNA sample, a non-caseating granuloma was seen in the TBLB samples and he was diagnosed with sarcoidosis. Klebsiella pneumoniae was detected from TBNA needle washing culture but he had no symptom up to two weeks during follow-up and the culture result was considered as contamination during the procedure.
Six weeks after the EBUS-TBNA, the patient developed a fever, chills, and fatigue and presented to the emergency department next day. On arrival, his vital signs were as follows: body temperature, 40.7  C; blood pressure, 104/43 mmHg; pulse rate, 123 beats/min; SpO2, 97% in ambient air. On physical examination, his extremities were cold but other than that, the remainder of the examination was unremarkable.
Results from blood tests revealed white blood cell count of 3.8 x 109 cells/L, C-reactive protein level of 193.6 mg/L, and procalcitonin level of 42.51 mug/L (Table 1). A widened mediastinum was detected by a chest radiograph and an enhanced CT revealed swelling of station 4R lymph node where the EBUS-TBNA was performed six weeks ago. The lesion had a hypodense center suggestive of an abscess. Severe sepsis due to infectious mediastinal adenitis was suspected and treatment consisting of 1g of doripenem was administered every 8 hours and vasopressor was initiated. Klebsiella pneumoniae, the same species that was identified from TBNA needle washing culture, was detected in a blood and sputum culture. The patient started recovering and the vasopressor was tapered off on day 6. The fever lasted till day 21 and antibiotics were continued for one month.
CT on day 28 revealed a shrinkage of the hypodense region in the lymph node and the patient was discharged on day 34 (Fig. 2).