SESSION TITLE: Infectious Disease Cases II
SESSION TYPE: Affiliate Case Report Slide
PRESENTED ON: Wednesday, October 29, 2014 at 11:00 AM - 12:15 PM
INTRODUCTION: Herpes simplex virus (HSV) can infect the squamous epithelium of the gastrointestinal tract in immunocompromised patients and is a common cause of esophageal ulcerations in patients with acquired immunodeficiency syndrome (AIDS). Rarely these ulcerations erode into adjacent airways and can result in a bronchoesophageal fistula (BEF).
CASE PRESENTATION: A 32-year-old woman with a history of AIDS and peptic ulcer disease presented to our emergency department with dysphagia and a cough for one month. On arrival she was febrile, tachycardic, and in mild distress requiring supplemental oxygen. Esophagogastroduodenoscopy (EGD) showed large ulcerations at the gastroesophageal junction with a small out-pouching of the lumen at 30cm. Bronchoscopy identified a left main-stem bronchus ulceration and an esophagram confirmed a bronchoesophageal fistula. Histopathology from endobronchial and esophageal biopsies showed cytopathic changes of herpes infection and HSV-1 was identified in the BAL fluid. Initial treatment was conservative with antibiotics, acyclovir, and PEG-tube insertion. On follow up the fistula appeared to be improving however, four weeks later the BEF was redemonstrated by esophagram after the patient resumed oral intake. A repeat EGD diagnosed candida esophagitis and an esophageal stent was placed with subsequent closure of the fistula.
DISCUSSION: BEFs can be congenital or acquired. The most common cause of acquired BEF is malignancy. Infectious BEFs occur more frequently in immunocompromised patients and tuberculosis is the most common culprit. Optimal treatment of infectious BEFs is unclear as this is an exceptionally rare condition and data regarding treatment strategies is limited to case reports. Successful closure of infectious BEFs have been reported with both conservative and invasive treatment strategies. However, both treatment modalities carry a high mortality rate of approximately 50%, mainly from sepsis.
CONCLUSIONS: This case is unique in that although conservative management failed because of both recurrent infection and noncompliance, the patient still demonstrated a favorable outcome with successful esophageal stenting. We propose that an initial invasive treatment strategy may be a better option for patients at risk for recurrent infections or noncompliance.
Reference #1: Wesselhoeft C, et al. Acquired Nonmalignant Esophagotracheal and Esophagobronchial Fistulas. AnnThoracSurg 1968;6:187-195.
Reference #2: Shin J, et al. Interventional Management of Esophagorespiratory Fistula. KoreanJRadiol 2010;11:133-140.
DISCLOSURE: The following authors have nothing to disclose: Kate Grossman, Glen Chun, Mary Beth Beasley, Timothy Harkin, Sakshi Dua, David Weir
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