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Pulmonary Procedures |

A Patient Presenting With Persistent Cough, Shortness of Breath, Fever, Dysphagia, and Weight Loss FREE TO VIEW

Ikrita Klair, MD; Jagpal Klair, MD; Monica Goswami, MD; Jaime Palomino, MD
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University of Arkansas for Medical Sciences, Little Rock, AR


Chest. 2015;148(4_MeetingAbstracts):842A. doi:10.1378/chest.2278947
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Abstract

SESSION TITLE: Procedures Student/Resident Case Report Posters

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 27, 2015 at 01:30 PM - 02:30 PM

INTRODUCTION: Broncho-esophageal fistula (BEF) is a rare entity. BEF is a communication between bronchus and esophagus. In adults, most BEFs occur in association with bronchogenic or esophageal malignancy, and present early after disease onset.1

CASE PRESENTATION: A 50-year-old male with HIV/AIDS presented with 2-month history of severe bouts of cough associated with eating and drinking, dysphagia and weight loss. He was febrile on admission. Lung examination was clear to auscultation bilaterally. Chest X-ray was unremarkable. Infectious disease workup was negative. Computed tomopraphy (CT) chest (Figure 1a) showed a suspected BEF to left lower lobe (LLL) and possible LLL aspiration pneumonia. CT chest findings prompted bronchoscopy (Figure 1b) which revealed a dark, spherical, free standing lesion in the LLL (Figure 1c). Histopathology (Figure 1c/d) showed vegetable matter (red arrows) with skeletal muscle fibers (black arrow), which were indicative of aspiration. Barium esophagogram (Figure 2a) was consistent with fistulous connection between esophagus and bronchus. Esophagogastroduodenoscopy (EGD) (Figure 2b - arrowhead: esophagus, down arrow: fistula, up arrow: false lumen) showed a fistulous tract 3 cm in length within esophagus with false lumen at 31-34 cm from entry site representing BEF. Patient has a history of chronic esophagitis diagnosed via barium swallow 4 years ago which is most likely explanation for his BEF. Patient was a poor surgical candidate was discharged to a nursing home with a jejunostomy tube in order to prevent further aspiration.

DISCUSSION: Benign BEFs have a slow insidious course and are usually diagnosed decades later.1 Barium esophagogram is the confirmative diagnostic modality.1-2 In a retrospective analysis of 368 patients with BEF, the sensitivity of CT chest, esophagogastroduodenoscopy , and bronchoscopy was found to be 89%, 94%, and 50%, respectively.2 In our patient, BEF was visualized on CT chest and EGD, but not on bronchoscopy. Treatment is surgical, endoscopic, or medical.1-2 Success rate of surgical intervention is very high. Closure is important to prevent chronic infection, and respiratory compromise. Endoscopic interventions are not suitable for benign BEF since there is no stricture to hold the stent in place.1 Medical treatment is usually aimed at underlying etiology (usually inflammatory or infectious). Prognosis is generally good and best after surgical intervention.1-2

CONCLUSIONS: BEF should be suspected in any patient presenting with persistent cough as in our patient. These patients present with non-specific symptoms though most of them most of these patients will endorse symptoms of cough and hemoptysis at the time of diagnosis, which is usually delayed due to rarity of this entity.

Reference #1: Mangi A, Gaissert HA, Wright CD, et. al. Benign Broncho-Esophageal Fistula in the Adult. Ann Thorac Surg 2002;73:911-5

Reference #2: Risher WH, Arensman RM, Ochsner JL. Congenital Bronchoesophageal Fistula. Ann Thorac Surg 1990;49:500-5

DISCLOSURE: The following authors have nothing to disclose: Ikrita Klair, Jagpal Klair, Monica Goswami, Jaime Palomino

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