St. Louis University School of Medicine St. Louis, MO, United States
Eugene C. Nwankwo, MD, MS1, Jennifer M. Ray, MD2, Antonio R. Cheesman, MD2 1St. Louis University School of Medicine, St. Louis, MO; 2St. Louis University Hospital, St. Louis, MO
Introduction: Acquired tracheoesophageal fistula (TEF) is rare and commonly occurs due to tracheal or esophageal trauma, malignancy, infection, and as sequelae of intubation. Symptoms typically involve aspiration. We present an elderly patient with relapsed Diffuse Large B-Cell Lymphoma (DLBCL) complicated by persistent COVID-19 infection who develops acute onset aspiration and productive cough. After workup, she is found to have an acquired TEF.
Case Description/Methods: Our patient is a 76-year-old woman who presents with acute onset cough and recurrent aspiration of solids and liquids. Past medical history includes COVID-19 infection diagnosed 2-3 months prior, and relapsed DLBCL undergoing chemotherapy with Monjuvi/Revlimid (held for 4 months due to COVID-19 infection). She denies prior dysphagia, odynophagia, intubation, or endoscopy. Physical exam is notable for expiratory wheeze. Chest X-Ray shows diffuse interstitial opacities bilaterally. Barium esophagram shows contrast extravasation into the left bronchus (Figures 1 & 2). Esophagogastroduodenoscopy (EGD) shows 30 mm fistula in the proximal esophagus (Figure 2A). A 20 mm x 100 mm through-the-scope esophageal stent was placed over the fistula site and anchored with endo sutures (Figure 2B). The patient had persistent aspiration and was found to have left vocal cord paralysis likely from recurrent laryngeal nerve damage. Her course was complicated by respiratory failure and she was transitioned to comfort measures.
Discussion: Acquired TEF is a rare finding with several different etiologies. Diagnosis is made via esophagram and treatment is typically esophageal stenting. Large TEFs serve as incubators for recurrent respiratory infections. There are no known cases of persistent COVID pneumonia due to TEF. Therefore, TEF should be considered in any immunosuppressed patient with history of persistent pneumonia and aspiration of unexplained cause.
Figure: Figure 1: X-Ray Esophagram. Red arrowhead shows extravasation of contrast into the left bronchus.
Figure 2A: A 30mm Tracheoesophageal Fistula in the proximal esophagus
Figure 2B: A 20mm x 100mm mesh through-the-scope stent (arrowhead) with endo-sutures (yellow arrows)
Disclosures: Eugene Nwankwo indicated no relevant financial relationships. Jennifer Ray indicated no relevant financial relationships. Antonio Cheesman indicated no relevant financial relationships.
Eugene C. Nwankwo, MD, MS1, Jennifer M. Ray, MD2, Antonio R. Cheesman, MD2. P1406 - Acquired Tracheoesophageal Fistula in Diffuse B Cell Lymphoma Associated With Persistent COVID-19, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.