Complicated parapneumonic effusion due to esophagopulmonary fistula

ABSTRACT

INTRODUCTIONEsophagopulmonary fistula (EPF) is an improper communication between the esophagus and lung parenchyma. The the etiology of EPFs including esophageal malignancy with direct tumor invasion or post-radiation therapy (accounts for 50%), prolonged mechanical ventilation, infectious/inflammatory disease, caustic ingestion, trauma, or indwelling esophageal stent. Here we present a case of EPF complicated by parapneumonic effusion initially thought to be an empyema. CASE REPORTA 53-year-old male with past medical history of polysubstance abuse, HIV, perforated peptic ulcer s/p partial gastrectomy, and hypertension presented with productive cough, fever, unintentional weight loss, and non-bloody watery diarrhea for two days. He also reported difficulty swallowing liquids and occasionally solid foods for several months associated with cough during ingestion. Vital signs showed BP 116/74, HR 135, RR 29, temperature 102.1°F, and oxygen saturation 93% on room air. Physical exam revealed rales with decreased air entry of the right lung fields. Labs were significant for WBC 20,300, Hgb 7.9, Platelets 467,000, and procalcitonin 0.68. Urine drug screen and SARS-COV2 PCR were negative. ABG on room air with pH 7.369, pCO2 40.6, and pO2 65.1. Pleural fluid showed a WBC count 8375 and pH 7.0. CXR showed opacity in the right middle and lower lung. CT chest showed complex right pleural effusion with multiple areas of gas and atelectasis of right lower lobe with possible superimposed consolidation or areas of necrosis. Chest tube was placed with 600cc cloudy serous fluid determined to be exudative. Due to the clinical presentation, and signs of sepsis along with nature of pleural fluid, empyema was suspected. Pleural fluid culture was positive for gram negative rods, corynebacterium, and candida albicans. AFB culture and cytology were negative. However, due to nature of debris in esophagus and GI history, esophagram was performed which confirmed the presence of an EPF between the right distal esophagus and right lower lobe. The patient was initially treated with empiric antibiotics with de-escalation based on cultures. Unfortunately, after brief recovery, patient left the hospital against medical advice. DISCUSSIONThere are few cases reported involving a benign etiology being a cause of EPF as reported in this case. The patient had history of perforated peptic ulcer which is likely the underlying etiology. Due to this being a chronic issue, patient likely developed an infectious process which responded well to therapy. The relative uncertainty to the initial diagnosis and the underlying etiology behind this finding makes our case unique.