A 54-year-old man was referred to the otorhinolaryngology department in our hospital for examination due to voice change that started 6 months ago. The patient had a history of TB 30 years ago and was taking medication for arterial hypertension and diabetes. CT scan of both sides confirmed multiple lymphadenopathies with calcific foci in the mediastinum, and EBUS-TBNA was performed for biopsy. Target lesions were the right paratracheal and subcarinal lymph nodes. The patient was discharged the day after the procedure without complications, and histological examination revealed few lymphoid cells with necrotic debris.
The patient was admitted to the emergency room of our hospital 21 days after the EBUS-TBNA due to general weakness, chills, and high fever of 39.3  C. Systolic BP was 107 mm Hg, diastolic BP was 67 mm Hg, heart rate was 82/min, and respiration rate was 18/min. The blood test results revealed a white blood cell count of 7720/muL, C-reactive protein of 26.4 mg/dL, and procalcitonin of 58.89 ng/dL.
On chest CT scan, enlargement of the lymph node accompanied by the intranodal necrotic portion was found (Fig. 2A, B). The patient underwent surgery for debridement on the same day.
The operation was performed with VATS under general anesthesia. A layer accompanied by calcification was formed around the swollen lymph node, and a small amount of fluid was observed during the dissection. Cytology, culture, and biopsy were performed, and the 28-French chest tube was inserted, and the operation was completed. After the operation, the patient had stable vital signs, with mild fever, and broad-spectrum antibiotics were administered intravenously.
On the 5th postoperative day, the fever persisted and the chest x-ray showed an increase in shadow around the surgical site; therefore, the chest CT scan was re-evaluated. A loculated effusion with newly generated gas formation was observed, and empyema was suspected; therefore, the patient underwent a reoperation (Fig. 2C). In the previous lymph node enlargement site, a space with a large amount of pus was found without inflammatory findings. All fluid was removed, and massive irrigation was performed using saline. After the operation, the patient had no additional fever and blood test results also normalized. The pathological examination of the biopsy obtained during the first surgery revealed mature adipose tissue with focal fat necrosis, without other malignant or abnormal findings. The patient was discharged 8 days after the second surgery without any clinical signs of fever or inflammation.