Howard University Hospital, Washington, DC
Copyright 2016, American College of Chest Physicians. All Rights Reserved.
SESSION TITLE: Student/Resident Case Report Poster - Disorders of the Pleura
SESSION TYPE: Student/Resident Case Report Poster
PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM
INTRODUCTION: We describe a case of esophageal pleural fistula which may have been present for several years prior to diagnosis. Esophageal pleural fistulas are very rare clinical findings. If not diagnosed promptly, they can have grave consequences including death.
CASE PRESENTATION: A 64 year old female presented with worsening cough and fever of 2 weeks. She had a history of right breast cancer status post lumpectomy and radiation. She also developed right lung cancer for which she underwent right bilobectomy followed by radiation. Three years later she was admitted for severe pneumonia after which she developed bronchiectasis. She had frequent exacerbations of bronchiectasis. In her current admission, bronchoscopy revealed collapsed lower right lung orifices with purulent discharge. She developed hematemesis and a rapid drop in her hemoglobin for which esophagodeodonoscopy was done which revealed an esophageal fistula with bleeding from the orifice. A subsequent CT scan of the chest revealed a communication between the esophagus and the right pleura with air fluid levels. A gastrografin swallow study demonstrated a tract coming from the esophagus directed to the right upper pleural space. Esophageal stenting was planned but the patient desaturated and sustained a cardiac arrest leading to anoxic brain injury. She subsequently died of septic shock while on a mechanical ventilator
DISCUSSION: Esophageal pleural fistulas are very rare. Major causes include esophageal tumores, post-surgical, irradiation, iatrogenic and corrosive substance injury. Our patient had at least two risk factors to develop an esophageal fistula. Multiple chest wall irradiation and a major thoracic surgery.Recurrent aspirations to the lung predisposed the patient to develop bronchiectasis. Esophageal pleural fistula was not suspected until she developed massive esophageal bleeding and esophagoscopy revealed a bleeding fistula. A thoracic CT with esophageal contrast will help to diagnose esophageal pleural fistulas. Our patient had a communication between the esophagus and the right pleural space on CT of the chest. Esophagogram also demonstrated a leakage of contrast in the esophagus directed to the right upper pleural space. A high index of suspicion is required to diagnose esophageal pleural fistulas in patients who had predesposing risk factors.
CONCLUSIONS: A high index of suspicion is important to diagnose esophageal pleural fistulas. Patients who had previous malignancies involving the thorax, surgeries to the lung and esophagus, and radiation therapy are at risk. Patients at risk who present with recurrent lower respiratory tract infections might warrant diagnostic work up for fistulas involving the respiratory and the gastrointestinal tracts.
Reference #1: Wechsler RJ. CT of esophageal-pleural fistulae. AJR Am J Roentgenol. 1986;147 (5): 907-9
Reference #2: Giménez A, Franquet T, Erasmus JJ et-al. Thoracic complications of esophageal disorders. Radiographics. 2002;22 Spec No (suppl 1): S247-58
DISCLOSURE: The following authors have nothing to disclose: Agazi Gebreselassie, Ronke Ajala, Yordanos Habtegebriel, Yewande Odeyemi, Vishal Poddar, Hasan Nabhani, Wayne Davis
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