The association of reactive mediastinal and hilar lymphadenopathies with congestive heart failure.
Abu Sayf A, Digiovine B, Simoff MJ, Ray C, and Diaz-Mendoza J. The association of reactive mediastinal and hilar lymphadenopathies with congestive heart failure. Am J Respir Crit Care Med 2018; 197.
Am J Respir Crit Care Med
Mediastinal and hilar lymphadenopathy (MHLD) is a common reason for referral to bronchoscopy to assess for malignant, infectious and granulomatous inflammatory etiologies. The rise of Endobronchial ultrasound guided trans-bronchial needle aspiration (EBUS/TBNA) as an accurate, safe and coast effective modality have led to its widespread use in pulmonary medicine. Several etiologies have been reported to be associated with reactive MHLD, such as chronic obstructive pulmonary disease (COPD), pulmonary hypertension, interstitial lung disease and chronic kidney disease. Congestive heart failure (CHF) is considered one of the most common causes of reactive MHLD. The association between CT scan findings and MHLD in CHF is still not well understood. METHODS:We retrospectively reviewed all the patients who underwent EBUS-TBNA bronchoscopy at our tertiary referral center between January 2010 and December 2015. They were screened initially by computed tomography (CT) chest findings. We included patients with pure MHLD with or without CT findings suggestive of CHF. Patients with lung nodules and/or masses, mediastinal mass, parenchymal lung disease suggestive of granulomatous or infectious etiology and extrathoracic lymphadenopathy were excluded. Patients with history of malignancy within 5 years and/or active malignancy were also excluded. We collected clinical, radiological and pathological data, as well as follow up data after 1 year. We used clinical and echocardiographic criteria to diagnose CHF. Reactive lymphadenopathy was defined as EBUS/TBNA samples showing lymph node tissue with no other pathology and 1 year follow up revealing no alternative diagnosis. RESULTS: Out of 1,778 patients who underwent EBUS TBNA bronchoscopy, 46 patients had either pure MHLD (11 patients) and/or lung parenchymal abnormalities compatible with CHF (35 patients) seen in CT scan. There were 24 patients with clinical CHF of whom 21 (Sensitivity = 87.5%, Lr+ = 9.7) had reactive MHLD. Of the 22 patients without CHF, only 2 cases (9.1%) had reactive disease (Odds ratio = 70, P value <0.0001). None of the 23 patients with “reactive” MHLD was diagnosed with any alternative diagnosis after 1 year. CONCLUSION: There was a strong association between clinical diagnosis of CHF and a diagnosis of reactive MHLD. Diagnosis of malignancy has a negative correlation with CT findings compatible with pure MHLD with or without findings suggestive of CHF. Prospective studies performed on CHF patients could provide better understanding of the phenomenon of reactive MHLD and may minimize the number of invasive procedures patients might undergo. (Table Presented).