Abstract Endobronchial ultrasound-guided (EBUS) transbronchial biopsy (TBB) has demonstrated a high diagnostic yield and is a relatively safe procedure in children. EBUS facilitates diagnostic testing for infections, malignancies, and granulomatous diseases, allowing for microbiological and molecular testing from lymph node samples with high sensitivity and minimal complications. Compared to traditional surgical approaches, such as mediastinoscopy and thoracotomy, EBUS-guided biopsy is less invasive and reduces morbidity. The current literature suggests that this technique has been used in children as young as 1.5 years. We present an 11-year-old previously healthy female with recurrent pneumonia, referred to the pulmonary clinic for chronic fevers and pneumonia evident on chest x-ray (CXR). She had completed a 10-day course of cefdinir prior to her clinic visit. Her CXR revealed a round consolidation, and she exhibited a wet cough, a five-pound weight loss over the past month, and shortness of breath with activity. There was no history of recent travel outside California. Due to her progressive symptoms, she was admitted for further investigation. During her hospitalization, her workup was largely negative with an ESR of 50 but negative infectious work up. CT chest with contrast showed extensive heterogeneous lingular consolidation and satellite nodules in the lingula/left upper lobe. Bronchoscopy revealed near-complete collapse of the lingular bronchus due to external compression. She was discharged with a course of clindamycin. She was readmitted a week later due to difficulty swallowing. A repeat CT neck/chest showed unchanged paratracheal and subcarinal lymph nodes with mass effect on the esophagus. An EBUS-guided TBB was performed using a 3.1 mm scope and a 6.9 mm EBUS scope. The scope was advanced to the left mainstem but could not be advanced to the left upper lobe due to airway size and inflammation. Once in position, we performed 10-12 transbronchial needle aspirations and 4-5 cryobiopsies using a 1.1 mm cryoprobe, with minimal airway bleeding. Samples were sent for flow cytometry, tissue examination, and cultures. Pathological evaluation revealed necrotizing granulomas, with flow cytometry negative for lymphoblastic lymphoma and tuberculosis studies also negative. Fungal culture from the lymph node biopsy grew Coccidioides immitis, despite a negative fungal culture from the BAL.The patient was started on a six-month course of fluconazole, leading to a successful recovery. In children with mediastinal or hilar abnormalities and inconclusive prior evaluations, EBUS-guided transbronchial biopsy (TBB) should be considered the next diagnostic step. This abstract is funded by: None
Nachreiner et al. (Fri,) studied this question.