Osman Ali, MD1, Suryanarayana Challa, MBBS2, Sukaina Alikhan, BS2, Raymond Kim, MD3; 1University of Maryland School of Medicine, Baltimore, MD; 2University of Maryland Medical Center, Baltimore, MD; 3University of Maryland, Baltimore, MD
Introduction: Esophagopleural fistula (EPF), a subtype of esophagorespiratory fistulas (ERF), is an abnormal communication between the esophagus and the pleural cavity. It can occur due to congenital malformation or acquired from infections, trauma, malignancy, or iatrogenic treatments. Patients typically present with non-specific respiratory symptoms followed by life-threatening pulmonary complications and death, if not addressed immediately.
Methods: A 59-year-old man presented with shortness of breath, productive cough, and 21lb weight loss for two weeks. On examination he was afebrile, RR: 20, HR: 151, BP: 110/76 and O2 saturation 97% on room air. His medical history was significant for smoking-related lung disease complicated by pulmonary squamous cell carcinoma (SCC) s/p chemoradiation, in 2013. He had a recurrence of his SCC in 2018 for which he received intensity-modulated proton therapy (IMPT) followed by ongoing consolidation chemotherapy with Carboplatin and Abraxane. During current admission, CT angiogram ruled out pulmonary embolism but showed pleural effusion with consolidation for which he received antibiotics. However, the hospital course was complicated by worsening of effusion, therefore a repeat CT scan was performed which revealed EPF. Multiple attempts of EPF closure were made using endoscopic self-expandable metallic stents (SEMS) followed by placement of an esophageal vacuum-assisted closure device (EVAC). However, these measures ultimately failed and therefore he required surgical correction with ileocostalis muscle flap. Two week follow up with esophagogram and EGD were consistent with successful fistula closure. Discussion: Lung carcinomas have a potential for causing ERF in 0.2% of cases, among them, EPF accounts for 3-11% of ERF’s. IMPT as well as Chemotherapeutic agents like carboplatin, irinotecan, VEGF inhibitor-bevacizumab and radiation therapy have sparsely shown an association of ERF. However, a clear underlying mechanism of pathogenesis is still unknown. Videofluoroscopy is helpful initially but may be falsely negative, contrast enhanced CT is the most sensitive and noninvasive test. Spontaneous closure is relatively uncommon in adults and requires endoscopic repair with clipping, suturing, SEMS, or EVAC devices. Surgical flap closure is recommended if there is persistence of fistula. This case demonstrates the need for early recognition and further research in patients receiving IMPT and chemotherapy to prevent life threatening complications from ERF.
Disclosures: Osman Ali indicated no relevant financial relationships. Suryanarayana Challa indicated no relevant financial relationships. Sukaina Alikhan indicated no relevant financial relationships. Raymond Kim indicated no relevant financial relationships.