Abstract Introduction Convex probe endobronchial ultrasound with transbronchial needle aspiration (EBUS-TBNA), offers a safe and minimally invasive alternative for the evaluation of mediastinal adenopathy. However, it is challenged in children by the relatively small trachea to accommodate the 6.9 mm outer diameter of the EBUS scope. This can be overcome by introducing the EBUS scope through the esophagus, a technique called EUS-B. Here, we present a case of 10-year-old child with mediastinal and hilar lymphadenopathy, who underwent EUS-B. Case description A 10-year-old male who was referred to our tertiary center with one year history of cough and intermittent fever accompanied by decreased appetite and easy fatigability with brief resolution of symptoms while on inhaled steroids and few intermittent weeks of oral steroids. CXR showed multiple small nodular opacities bilaterally. Extensive workup was ordered to rule out autoimmune vasculitis, immunodeficiency, fungal, parasitic and atypical infections. He had elevated angiotensin converting enzyme (ACE) level of 167 and soluble ILR2 of 3264. Chest CT showed multiple perihilar, mediastinal and perivascular lymphadenopathy (Figure 1A). Flow cytometry of the bronchoalveolar lavage showed CD4/CD8 ratio of 1.7 with negative lymphoma panel. He had a left inguinal excisional lymph node biopsy which showed non-necrotizing granuloma without evidence of lymphoma. He was initially treated with systemic steroids for presumed sarcoidosis but was transitioned to methotrexate due to side effects from systemic steroids. His respiratory symptoms resolved with reassuring pulmonary function testing. However, the fatigue/decreased energy has recently returned in addition to an elevation of ACE and ongoing lesions on CXR. A decision was made to proceed with a transbronchial lymph node biopsy prior to escalating treatment for steroid resistant sarcoidosis. Given his relatively small trachea to accommodate the EBUS scope, EUS-B was done, and station 7 (subcarinal) lymph node was targeted via EUS (Figure 1B). He tolerated the procedure well without any complication. The lymph node biopsy result showed non-caseating granuloma consistent with sarcoidosis. He was started on infliximab for refractory sarcoidosis. Discussion EUS-B is a safe and efficacious diagnostic modality for sampling the mediastinal lymph nodes especially in pediatric population when the EBUS-TBNA is challenged by the relatively small airway size. This abstract is funded by: None
Rashed et al. (Fri,) studied this question.