Paratracheal Abscess: An Unusual Complication of Transtracheal Aspiration

PARATRACHEAL ABSCESS striction is believed to be a rare, if ever occurring, event in pyogenic pericarditis.7*'2 It is not clear whether this patient developed staphylococcal pericarditis as a complication of systemic lupus or whether preexistent purulent pericarditis triggered a severe exacerbation of systemic lupus. Since it is difficult to imagine the patient surviving eight weeks without antibiotics, the former postulate is probably correct. This raises the question of whether organisms may more readily seed a pericardium already diseased by lupus than a normal pericardium, especially as there were never any positive blood cultures or obvious sources of infection. The pericarditis of lupus is usually relatively benign and responds well to aspirin and steroids. Duboisz stated that, if a diagnosis of systemic lupus erythematosus is proved, there is no need to perform pericardiocentesis. In the absence of a typical response to therapy or in the presence of continued cardiac decompensation, a specific cause of pericarditis should be searched for and pericardiocentesis should be performed.

1 Keefer CS, Felty AR: Acute disseminated lupus erythe matosus: Report of three fatal cases. Bull Johns Hopkins Hosp 35:294-304, 1924 2 Dubois EL: Lupus Erythematosus. New York, McGrawHill Book Co., 1966 3 Harvey AM, Schulman LE, Turnulty PA, et al: Systemic lupus erythematosus: Review of the literature and clinical analysis of 138 cases. Medicine 33:291-437, 1954 4 Haserick JR: Modem concepts of systemic lupus erythematosus: Review of 126 cases. J Chron Dis 1:317-345, 1955 5 Klemperer P, Pollack AD, Baehr G: Pathology of disseminated lupus erythematosus. Arch Path01 32:569-631, 1941 6 Larson DL: Systemic Lupus Erythematosus. Boston, Little, Brown and Co, 1961 7 Bogle JD, Pearce ML, Guze LB: Purulent pericarditis: Review of literature and report of 11 cases. Medicine 40: 119-144, 1961 8 Schoenfeld MR, Messeloff CR: Cardiac tamponade in systemic lupus erythematosus. Circulation 27 :98-99, 1963 9 Taubenhaus M, Eisenstein B, Pick A: Cardiovascular manifestations of the collagen diseases. Circulation 12: 903-920, 1955 10 Yurchak PM, Levine SA, Gorlin R: Constrictive pericarditis complicating disseminated lupus erythematosus. Circulation 31: 113-118, 1965 11 Kaltman AJ, Schwedel JB, Straus B: Chronic constrictive pericarditis and rheumatic heart disease. Am Heart J 45:201-208, 1953 s 11: Factors in the 12 Deterling RA Jr, ~ - ~ h r e ~GH etiology of constrictive pericarditis. Circulation 1230-43, 1955

CHEST, VOL. 65, NO. 1, JANUARY, 1974

Paratracheal Abscess: An Unusual Complication of Transtracheal Thomas T . Yoshikawa, M.D.; Anthony W . Chow,M.D.; John Z . Montgomerie, M.D.; and Luden B. Guze, M.D.

Two patients with paratracheal abscesses following h.anstracheal aspiration are described. This eompUcation has been uncommonly reported in the literature. Catheter contaminstion of the punchwe site with tracheobronchial flora or local de oovo infection appear to be the pathogenic met-

T

ranstracheal aspiration has been widely utilized in determining the etiology of lower respiratory tract infections, and its efficacy has been well d o c ~ m e n t e d . l - ~ Despite its relative safety, transtracheal aspiration has occasionally been associated with complications such as localized subcutaneous emphysema, transient hemoptysis, bleeding at the puncture site, mediastinal emphysema and death.z-6 Infection at the puncture site, however, has been infrequently reported. This report describes two patients developing paratracheal abscesses following transtracheal aspiration.

A myear-old man with chronic obstructive pulmonary disease and myaxes fungoides was admitted to the hospital with dyspnea, productive cwgh and bilateral diffuse fibronodular infiltrates. He had previously received total body irradiation and was maintained on prednisone, 40 mg, and methotrexate, 5 mg a day. A culture of expectorated sputum taken on admission grew Klebsiella. The patient was treated with cephalothin and gentamicin, with no clinical improvement. A transtracheal aspiration performed on the ninth hospital day failed to yield any pathogens, including fungi and viruses. Nine days after transtracheal aspiration, a 3 cm by 3 cm mass was noted anterior to the trachea, encompassing the transtracheal puncture site and localized to the subcutaneous tisssue. Incision and drainage yielded purulent material consisting of thin filamentous mycelia, which were acid-fast. Culture demonstrated Nocardia brasilienris. Local care and initiation of appropriate antibiotic therapy resulted in resolution of the paratracheal abscess. An open lung biopsy performed four days later revealed only nonspecific fibrosis, with negative bacterial and fungal cultures. An 18-year-old boy was admitted to the hospital with complaints of fever, pleuritic chest pain and a right lower lung infiltrate. Expectorated sputum demonstrated Gram-positive diplococci on smear, but culture yielded normal flora. *From the Department of Medicine, Harbor General Hospital, Torrance, Calif., Research and Medical Services, Veterans Administration (Wadsworth) and the Department of Medicine, UCLA School of ~ A c i n eLos Angeles. Reprint requests: Dr. Yoshikawa, V A ~ o s p i t u i ,Los Angeles 90073

PHILIPS, LIBANOFF Penicillin therapy was initiated. On the third hospital day, the patient was still febrile, and a transtracheal aspiration was performed. Gram-positive diplococci were again seen on smear, but subsequent aerobic and anaerobic cultures were both negative. Blood cultures taken on admission grew Bacteroides capillom. The patient responded well to four weeks' therapy of intravenous penicillin and clindamycin. Of interest was the appearance of a 2% cm by 2% cm subcutaneous, anterior cervical mass at the site of transtracheal aspiration four days after the procedure. Incision and drainage revealed purulent material with Gram-positive cocci seen on smear, but aerobic and anaerobic cultures again yielded no growth. The abscess responded to conservative local therapy. Local infection has been an uncommon occurrence with transtracheal a s p i r a t i ~ n .The ~ - ~ explanation for this is unclear, since many of the patients subjected to this procedure have significant bronchopulmonary infections. Contamination of the puncture site as the catheter is withdrawn from the tracheobronchial tree would seem very likely. However, Pecora and Kohl5 experienced only two instances of infection of the needle tract (with tubercle bacilli in patients with active tuberculosis) out of 400 transtracheal aspirations. Reams and Bosniak7 reported one case of localized cellulitis due to nonhemolytic Streptococcus at the site of cricothyroid membrane puncture. The same organism was also recovered from the tracheobronchial tree. Pathogens isolated from local paratracheal infections resulting from cricothyroid membrane puncture may not always be related, however, to the tracheobronchial flora. In our &st patient, the organism cultured from the abscess was not recovered from the lower respiratory tract. Standard aseptic procedures were observed, and the technique for transtracheal aspiration described by Kalinske and associates4 was used. It is possible therefore that de nooo infection may have occurred at the puncture site. In addition to determining the microbial flora of the lower respiratory tract, cricothyroid membrane puncture has been utilized for tracheal anesthesia in preparation for intubation and bronchos~opy.~ The procedure is the same as a transtracheal aspiration, except that a local anesthetic is instilled into the tracheobronchial tree instead of aspirating for a specimen. Adriani and ParmleyQ reported a case of diffuse cellulitis of the neck associated with an indurated mass (abscess?) in the region of the thyroid gland following transcricoid anesthesia. Similarly, Harken and SalzbergRreported three cases of superficial cellulitis of the soft tissues around the site of injection. One case resolved spontaneously, while the other two cases required incision and drainage. Except for the latter patients and our cases, the only other recorded instance of paratracheal abscess associated with cricothyroid membrane puncture was by Guy and Elder.lo Their patient developed an abscess anterior to the trachea following the usage of this procedure for bron~hograph~. Thus, it must be recognized that paratracheal abscess does occur after cricothyroid membrane puncture during transtracheal aspiration, but that it is uncommonly reported. Rigorous aseptic techniques, meticulous care of

the wound site and initiation of specific therapy following the results of the transtracheal aspirate are probably the reasons for the infrequency of this complication. Since the completion of this manuscript, the authors had the opportunity to see a third patient with a paratracheal abscess secondary to transtracheal aspiration. The abscess extended posterior to the esophagus, requiring wide incision and drainage. The organisms recovered were alpha-hemolytic streptococcus, two Bacteroides species and Staphybcoccus epidennfdis. Additional therapy with clindamycin and gentamicin resulted in complete resolution of the abscess. 1 Pecora DV: A comparison of transtracheal aspiration witb other methods of determining the bacterial flora of the lower respiratory tract. N Engl J Med 269:684668, 1963 2 Hahn HH, Beaty HN: Transtracheal aspiration in the evaluation of patients with pneumonia. Ann Intern Med 72: 183-187, 1970 3 Schreiner A, Digranes A, Myking 0:Transtracheal aspiration in the diagnosis of lower respiratory tract infections. Scand J Infed Dis 4:49-52, 1972 4 Kalinske RW, Parker RH, Brandt D, et al: Diagnostic usefulness and safety of transtracheal aspiration. N Engl J Med 276:604808, 1967 5 Pecora DV, Kohl M: Transtracheal aspiration in the diagnosis of acute lower respiratory tract infection. Am Rev Resp Dis 86:755-758, 1962 6 Spencer CD, Beaty HN: Complications of transtracheal aspiration. N Engl J Med 286:304-308, 1972 7 Reams GB, Bosniak MA: Bronchography through puncture of the cricothyroid membrane. J Thorac Cardiovasc Surg 40:117-124, 1960 8 Harken DE, Salzberg AM: Transtracheal anesthesia for bronchoscopy. N Engl J Med 239:383-385, 1948 9 Adriani J, P m l e y J: Complications following transtracheal anesthesia. Am J Surg 84: 11-12, 1952 10 Guy J, Elder HC: A preliminary report on the radiographic exploration of the bronchopulmonary system by means of lipiodd. Edinburgh Med J 30:269-273, 1926

Arteriovenous Communication Associated with Obstructive Arteriosclerotic Coronary Artery Disease and Myocardial infarction* Peter A. Phillips, M.D., F.C.C.P., and Albert 1. Libonoff, M.D.

An arteriovenous W l a from the anterior descending coronary artery to the great cardiac vein was detected by coronary cineangiography in a Sbyear-OMman. The fistula was believed acquired secondary to occlusive 'From the City of Hope National Medical Center, Duarte, Calif. Reprint requests: Dr. Philips, City of Hope National Medical Center, Duarte, California 91010

CHEST, VOL. 65, NO. 1, JANUARY, 1974