Abstract Diagnosing mediastinal pathology in children is challenging. Many cases require invasive procedures such as mediastinoscopy or video-assisted thoracoscopic surgery (VATS). Traditional approaches - including endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) - are often limited by small sample volumes and inadequate preservation of tissue architecture, especially in suspected lymphoproliferative disorders. EBUS-guided transbronchial mediastinal cryobiopsy (EBUS-TMC) has emerged in adult practice as a minimally invasive technique that yields larger, architecturally intact tissue samples with higher diagnostic accuracy. However, its application in pediatric populations remains largely unreported. A previously healthy 14-year-old boy presented with two weeks of fever, headache, vomiting, and progressive lower extremity weakness. Initial laboratory evaluations and head CT were unrevealing. MRI brain showed leptomeningeal enhancement and a subtle linear filling defect in the superior sagittal sinus. Lumbar puncture revealed markedly increased opening pressure (51 cm H2O), elevated protein, low glucose, and lymphocytic-monocytic predominance. Extensive infectious, oncologic, and rheumatologic workup was negative. Presumed tuberculous meningitis was treated with multi-agent antimicrobials and corticosteroids. The patient improved and was discharged after normalization of CSF pressure. However, he was readmitted three weeks later with new rash, bilateral knee pain, and worsening lower extremity neuropathy. Repeat neuroimaging showed progressive leptomeningeal lesions and new dural-based nodules; PET/CT revealed diffuse osseous uptake and FDG-avid mediastinal and hilar lymphadenopathy. Multidisciplinary review led to diagnostic flexible bronchoscopy with BAL, EBUS-TBNA, and EBUS-TMC. Cytology from BAL and TBNA was non-diagnostic, while cryobiopsy from a subcarinal node yielded ALK-positive anaplastic large cell lymphoma (ALCL) confirmed by immunohistochemistry. The patient tolerated the EBUS-TMC procedure without complication and was started on chemotherapy. Imaging after three cycles showed notable clinical improvement. This case demonstrates the diagnostic value and safety of EBUS-TMC for pediatric mediastinal lymphadenopathy. Adult studies have shown EBUS-TMC provides superior tissue quality for comprehensive histopathologic and molecular testing with a low risk of serious adverse events. Our experience underscores that EBUS-TMC can bridge the diagnostic gap in children, potentially reducing the need for surgical biopsies and accelerating both diagnosis and therapy for challenging mediastinal cases. To our knowledge, this case represents the first reported use of EBUS-guided cryobiopsy in a child, providing early proof-of-concept for the technique’s feasibility and safety in pediatric patients. Given the increasing use in adults and non-diagnostic rates with TBNA in children, EBUS-TMC should be considered in select pediatric cases after multidisciplinary review, with further research needed to formalize its role in pediatric diagnostics. This abstract is funded by: None
Arora et al. (Fri,) studied this question.
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