• Bronchoscopy
• Cough/Mechanisms/Pharmacology

A 78-year-old man was referred to our hospital to study a pulmonary nodule in the left lower lobe, suspicious for malignancy. An endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) was carried out for the study, during the procedure samples were taken from lymph node stations 4R (lower paratracheal right), 7 (subcarinal) and 11 L (interlobar left) using a 22-gauge needle. The histological results ruled out lymph node involvement. There were no immediate complications, however, the patient developed a dry cough 72 hours after the procedure.

After assessment by the multidisciplinary lung tumour committee, mediastinoscopy and excision of the lesion were decided, however, the patient rejected this treatment option, leaving radiotherapy as the only remaining therapeutic option.

During the follow-up period, the patient attended the emergency department twice for persistent cough. Before initiation of radiotherapy, and corresponding with 2 months after EBUS-TBNA, a positron emission tomography-CT was performed to complete the study. This detected hypermetabolic focal thickening of the distal trachea, reactive paratracheal adenopathy and trabeculation of the mediastinal fat (figure 1A,B).

Consequently, a flexible bronchoscopy was performed, which revealed a non-critical circular stenosis with an inflammatory appearance in the distal third of the trachea, corresponding to the puncture area of the 4R lymph node station (figure 1C). The lesion was biopsied and histopathology showed epithelioid granulomas and squamous metaplasia with no signs of malignancy.

• Download figure
• Open in new tab
• Download powerpoint

Figure 1

(A) Axial contrast-enhanced CT image showing focal thickening of the distal trachea (arrows), trabeculation of mediastinal fat and lymph node enlargement (arrowheads). (B) Axial positron emission tomography-CT fusion imaging showing hypermetabolic focal thickening of the distal trachea (arrows) and trabeculation of the mediastinal fat (arrowheads). (C) Flexible bronchoscopy showing a granulomatous lesion in the distal third of the trachea with non-critical stenosis. (D) Axial contrast-enhanced CT image after corticosteroid treatment demonstrating resolution of the focal tracheal thickening (arrow) and paratracheal inflammatory signs.

As a result of the biopsy results, methylprednisolone was started at a dose of 40 mg/day, later reduced via a tapering dose over the course of 1 month resulting in a rapid resolution of the patient’s symptoms. A CT scan was performed after treatment showing resolution of the focal tracheal thickening and paratracheal inflammatory (figure 1D).

In summary, EBUS-TBNA is a procedure with an excellent safety profile and a very low complication rate ranging from 1.23% to 1.44%.1 2 This case report highlights the importance of considering cough as a symptom of a very rare complication of this interventional technique, an inflammatory nodular reaction at the tracheobronchial puncture site. From the cases reported to date, it is a complication with a good prognosis which can be treated conservatively.3 Finally, it could be an underdiagnosed complication and should, therefore, be taken into account in those patients who present with respiratory symptoms a few days after EBUS-TBNA.