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 Table of Contents  
CASE REPORT
Year : 2016  |  Volume : 4  |  Issue : 2  |  Page : 91-93

Pseudomonas species as an uncommon culprit in transbronchial needle aspiration of mediastinal lymph node


Department of Respiratory, Critical Care and Sleep Medicine, Indraprastha Apollo Hospitals, New Delhi, India

Date of Web Publication10-Jun-2016

Correspondence Address:
Trilok Chand
B-241, Department of Respiratory, Critical Care and Sleep Medicine, Sarita Vihar, New Delhi - 110 076
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2320-8775.159883

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  Abstract 

Mediastinal lymphadenopathy due to various infective agents such as Mycobacterium and fungus, due to sarcoidosis, lymphoma, and metastasis is often seen. Ordinary bacteria have rarely been reported to cause necrotizing, usually suppurative granulomatous reactions. We report a case of mediastinal lymphadenopathy due to Pseudomonas infection, in a patient of chronic kidney disease on maintenance hemodialysis, who presented with fever, breathlessness, and low blood pressure.

Keywords: Endobronchial ultrasound-guided transbronchial needle aspiration, mediastinal nodes, Pseudomonas species


How to cite this article:
Bansal A, Chand T, Kumar R. Pseudomonas species as an uncommon culprit in transbronchial needle aspiration of mediastinal lymph node. J Assoc Chest Physicians 2016;4:91-3

How to cite this URL:
Bansal A, Chand T, Kumar R. Pseudomonas species as an uncommon culprit in transbronchial needle aspiration of mediastinal lymph node. J Assoc Chest Physicians [serial online] 2016 [cited 2019 Aug 21];4:91-3. Available from: http://www.jacpjournal.org/text.asp?2016/4/2/91/159883


  Introduction Top


Pseudomonas is ubiquitous in nature and is an opportunistic pathogen that causes a wide range of infections.[1] Chronic kidney disease is an immunocompromised state and the chances of infection such as tuberculosis, fungal, and viral are common. The common risk factors for Pseudomonas species infection are immunocompromised state, recent surgery, hospital admission, and body wounds. According to the National Nosocomial Infection Surveillance System between 1992 and 1999 Pseudomonas was most common cause of pneumonia, fourth most common cause of urinary tract infection and sixth most common cause of bloodstream isolate in intensive care unit (ICU). Suppurative granulomatous reaction due to Pseudomonas infection has been rarely reported.[2] Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is now a common diagnostic procedure gaining popularity world-wide for the purpose of investigating mediastinal lymphadenopathy in both malignant as well as nonmalignant etiologies.[3],[4],[5]


  Case Report Top


A 65-year-old nonsmoker male presented with 10 days history of high-grade fever with chills, generalized weakness, and decreased appetite. He had nausea, vomiting, and episode of hypotension on the day of admission. He was a known hypertensive and had diabetic triopathy since last 5 years. He had chronic kidney disease and was on regular maintenance hemodialysis for last 2 years.

Two months back he had an acute coronary event for which percutaneous transluminal coronary angioplasty was done. At the same time he had lower limb weakness and edema for which venous Doppler study of both lower limb was done which was negative for deep vein thrombosis but bilateral varicose veins diagnosed for which radiofrequency ablation was done. Nerve conduction velocity of lower limb revealed severe sensory and motor neuropathy.

On examination, he was found to be obese, febrile, tachypneic, and hypotensive (blood pressure: 80/50 mmHg). Basal crepitations were heard both sides of the chest and bilateral lower limb edema and right foot ulcer were noted.

Patient's routine investigations revealed high total leukocyte counts (42,900/cmm) with neutrophilic predominance, low Hb (7.8 g%), deranged renal profile (serum urea - 130 mg/dl, creatinine - 9.2 mg/dl), high serum procalcitonin (30.1 ng/ml), liver functions were normal. Chest X-ray revealed cardiomegaly. Two sets of blood cultures and urine culture were sent and empirical intravenous antibiotics (meropenem and teicoplanin) were started along with noradrenalin infusion in view of septic shock. Patient was dialyzed routinely. Patient's blood and urine cultures were found to be sterile. Meanwhile, high-resolution computed tomography thorax was done which showed enlarged subcarinal and paratracheal lymph nodes [Figure 1] with normal parenchyma [Figure 2]. EBUS-TBNA [Figure 3] and bronchoalveolar lavage (BAL) was done to rule out tuberculosis or any fungal infection. Pus was aspirated from the right paratracheal node, which was sent for culture and cytology. BAL sample was also sent for microbiology and cytology.
Figure 1: Computed tomography-chest shows right paratracheal lymph node

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Figure 2: Computed tomography-chest shows normal parenchyma

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Figure 3: Endobronchial ultrasound shows large lymph node with needle puncturing the node

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All stains were negative, but TBNA pus culture grown Gram-negative bacilli, which was identified as pan-sensitive Pseudomonas species. Meropenem was continued fever settled and the patient improved clinically. Interestingly BAL culture did not reveal any growth.


  Discussion Top


Pulmonary infection due to various micro-organisms is not uncommon, and mediastinal lymphadenopathy due to Mycobacterium tuberculosis is frequently encountered in India, but mediastinal lymph node infiltration by Pseudomonas species is very unusual. The differential diagnosis of mediastinal lymphadenopathy includes tuberculosis, Mycobacterium avium complex, sarcoidosis, lung and esophageal cancer, lymphangitis carcinomatosis, hypersensitive pneumonitis, cystic fibrosis, histoplasmosis, acute lymphoblastic leukemia, coccidioidomycosis, lymphoma and Whipple's disease.[6] In a rare case report, mediastinal lymphadenopathy also reported as a pulmonary manifestation of rheumatoid arthritis.[7]

Pathogenesis of Pseudomonas infection is complex, the healthy host is rarely affected but is highly virulent for a person in whom the normal cutaneous or mucosal barrier have been breached. It is a particularly virulent pathogen that produces exotoxins and enzymes.[8] It also produces a biofilm that protects it from environmental elements and from host antibodies and phagocytes.[9] Both intrinsic and extrinsic virulence factors play a role in pathogenicity of Pseudomonas.

Isolated suppurative mediastinal lymphadenopathy due bacterial infection other than Mycobacterium is not reported. There is a case report, which revealed infective mediastinitis an infectious complication of endoscopic ultrasound-guided fine-needle aspiration that occurred after puncture of a large malignant necrotic mediastinal lymph node.[10]

It is possible that our patient acquired the infection as he had multiple risk factors in the form of chronic kidney disease, diabetes, and recent surgery and had a recent history of ICU stay. Possibility of Pseudomonas species being a laboratory contaminant was unlikely because there was no growth in BAL culture. Only pus, which was aspirated from enlarged lymph node grew Pseudomonas.

Mycobacterium and fungi are quite commonly isolated from TBNA aspirates but Pseudomonas has hardly been reported. Gram-negative bacilli are rarely reported for granulomas formation, but Burkholderia cepecia (formerly Pseudomonas cepecia), Burkholderia pseudomallei (formerly Pseudomonas pseudomallei), and Pseudomonas andersonii are reported for lung granulomas. In 2012 Okada et al. found only one patient (2.9%) had mediastinal lymph node enlargement in 35 patients of Pseudomonas aeroginosa pulmonary infection,[11] but Pseudomonas infection of lymph node was not microbiologically established in this patient.

As Han et al. in 2001 isolated Gram-negative bacillifrom surgically resected pulmonary granulomas in a 42-year-old nonimmunocompromised woman, which was closely resembled to Pseudomonas species identified as P. andersonii.[2] Similarly, Simmon et al. in 2011 also identified the Gram-negative bacilli causing granulomatous lung lesion in four case reports.[12]

Endoscopic ultrasound guided fine needle aspiration has been shown to be a safe, minimally invasive procedure for the diagnostic approach to mediastinal lymphadenopathy.[13] This technique is complementary to TBNA and mediastinoscopy as it allows sampling of nodal stations not accessible by the other two procedures.[14]


  Conclusion Top


Isolated suppurative mediastinal lymphadenopathy due to Pseudomonas infection is probably not reported yet, and it is our first experience of this kind. Hence, these results suggest that the differential diagnosis of mediastinal lymphadenopathy should also include Gram-negative bacteria as a potential causative agent in addition to more common infections such as acid-fast bacilli and fungi. We recommend that every patient of chronic kidney disease which has mediastinal lymphadenopathy, aspirate from lymph node should be sent for microbiological analysis along with cytology as well.

 
  References Top

1.
Richards MJ, Edwards JR, Culver DH, Gaynes RP. Nosocomial infections in combined medical-surgical intensive care units in the United States. Infect Control Hosp Epidemiol 2000;21:510-5.  Back to cited text no. 1
    
2.
Han XY, Pham AS, Nguyen KU, Smythe WR, Ordonez NG, Jacobson KL, et al. Pulmonary granuloma caused by Pseudomonas andersonii sp nov. Am J Clin Pathol 2001;116:347-53.  Back to cited text no. 2
    
3.
Natu S, Hoffman J, Siddiqui M, Hobday C, Shrimankar J, Harrison R. The role of endobronchial ultrasound guided transbronchial needle aspiration cytology in the investigation of mediastinal lymphadenopathy and masses, the North Tees experience. J Clin Pathol 2010;63:445-51.  Back to cited text no. 3
    
4.
Fielding D, Windsor M. Endobronchial ultrasound convex-probe transbronchial needle aspiration as the first diagnostic test in patients with pulmonary masses and associated hilar or mediastinal nodes. Intern Med J 2009;39:435-40.  Back to cited text no. 4
    
5.
Yasufuku K, Chiyo M, Sekine Y, Chhajed PN, Shibuya K, Iizasa T, et al. Real-time endobronchial ultrasound-guided transbronchial needle aspiration of mediastinal and hilar lymph nodes. Chest 2004;126:122-8.  Back to cited text no. 5
    
6.
Urbanski G, Rivereau P, Artru L, Fenollar F, Raoult D, Puéchal X. Whipple disease revealed by lung involvement: A case report and literature review. Chest 2012;141:1595-8.  Back to cited text no. 6
    
7.
Martinez FJ, Karlinsky JB, Gale ME, Jung-Legg Y, Benditt JO. Intrathoracic lymphadenopathy. A rare manifestation of rheumatoid pulmonary disease. Chest 1990;97:1010-2.  Back to cited text no. 7
    
8.
Sadikot RT, Blackwell TS, Christman JW, Prince AS. Pathogen-host interactions in Pseudomonas aeruginosa pneumonia. Am J Respir Crit Care Med 2005;171:1209-23.  Back to cited text no. 8
    
9.
Singh PK, Schaefer AL, Parsek MR, Moninger TO, Welsh MJ, Greenberg EP. Quorum-sensing signals indicate that cystic fibrosis lungs are infected with bacterial biofilms. Nature 2000;407:762-4.  Back to cited text no. 9
    
10.
Aerts JG, Kloover J, Los J, van der Heijden O, Janssens A, Tournoy KG. EUS-FNA of enlarged necrotic lymph nodes may cause infectious mediastinitis. J Thorac Oncol 2008;3:1191-3.  Back to cited text no. 10
    
11.
Okada F, Ono A, Ando Y, Nakayama T, Ishii R, Sato H, et al. Thin-section CT findings in Pseudomonas aeruginosa pulmonary infection. Br J Radiol 2012;85:1533-8.  Back to cited text no. 11
    
12.
Simmon KE, Fang DC, Tesic V, Khot PD, Giangeruso E, Bolesta ES, et al. Isolation and characterization of “Pseudomonas andersonii” from four cases of pulmonary granulomas and emended species description. J Clin Microbiol 2011;49:1518-23.  Back to cited text no. 12
    
13.
Khoo KL, Ho KY, Nilsson B, Lim TK. EUS-guided FNA immediately after unrevealing transbronchial needle aspiration in the evaluation of mediastinal lymphadenopathy: A prospective study. Gastrointest Endosc 2006;63:215-20.  Back to cited text no. 13
    
14.
Herth FJ, Lunn W, Eberhardt R, Becker HD, Ernst A. Transbronchial versus transesophageal ultrasound-guided aspiration of enlarged mediastinal lymph nodes. Am J Respir Crit Care Med 2005;171:1164-7.  Back to cited text no. 14
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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