Esophagomediastinal and esophagobronchial fistulas associated with invasive aspergillosis

A 67-year-old woman was diagnosed as having esophageal cancer. She was given neoadjuvant chemoradiotherapy and esophagectomy was carried out. Reconstruction was accomplished with a gastric pull-up through the posterior mediastinal route. After 6 years of the treatment, the patient had high grade fever, which was refractory to treatment with antibiotics. A chest computed tomography (CT) scan demonstrated mixed fluid and soft tissue density in the posterior mediastinum, partially within the wall of the esophagus ([Fig. 1]). A Gastrografin esophagogram confirmed the existence of esophagomediastinal and esophagobronchial fistulas ([Fig. 2]). We considered these fistulas as the cause of the fever, and carried out percutaneous drainage. Gastrointestinal endoscopy revealed an esophagomediastinal fistula with necrotic tissues ([Fig. 3]). Although both sputum and blood cultures did not reveal the causative organism, high levels of serum galactomannan (whose production is proportional to the Aspergillus fungal load in tissue) were demonstrated (> 5.0 ng/mL; cut-off value < 0.5 ng/mL). On the basis of this finding, along with the persistent fever and CT appearances, a diagnosis of probable invasive aspergillosis was made in accordance with the European Organisation for the Research and Treatment of Cancer/Mycoses Study Group (EORTC/MSG) consensus criteria [1]. Treatment with antifungal agents led to a fall in the temperature, reduction in the hematological parameters, including galactomannan, and resolution of the radiological findings. At 1 month, endoscopy revealed healing of the fistula ([Fig. 4]).

Fig. 1 A fluid and soft tissue density seen in the posterior mediastinum, which was not separable from the reconstructed esophagus.

Fig. 2 Gastrografin esophagogram showing perforation of the reconstructed esophagus with contrast flowing into the mediastinum and into the bronchial tree in the upper lobe of the right lung.

Fig. 3 Gastrointestinal endoscopy showing an esophagomediastinal fistula surrounded by necrotic tissue. A drainage tube was inserted into the fistula via the percutaneous route.

Fig. 4 At 1 month after treatment with antifungal agents and percutaneous drainage, endoscopy showed healing of the fistula.

Aspergillus is a common airborne organism that can be highly pathogenic under immunocompromised conditions such as prolonged neutropenia after chemotherapy or organ transplantation [2]. Mediastinitis caused by Aspergillus infection usually occurs by airborne contamination of the cardiothoracic surgical field in the months following the surgery [3]. Invasive aspergillosis is a fairly rare condition, but can be devastating if there is a delay in diagnosis [4]. This diagnosis needs to be considered in a patient with antibiotic-refractory infection in the presence of local immunocompromising factors such as irradiation-induced lung injury.

Endoscopy_UCTN_Code_CCL_1AB_2AC_3AZ

References

• 1 Ascioglu S, Rex J H, de Pauw B. et al . Defining opportunistic invasive fungal infections in immunocompromised patients with cancer and hematopoietic stem cell transplants: an international consensus.  Clin Infec Dis. 2002;  34 7-14
• 2 Latge J P. Aspergillus fumigatus and aspergillosis.  Clin Microbiol Rev. 1999;  12 310-350
• 3 Levin T, Suh B, Beltramo D. et al . Aspergillus mediastinitis following orthotopic heart transplantation: case report and review of the literature.  Trans Infec Dis. 2004;  6 129-131
• 4 Hope W W, Waish T J, Denning D W. Laboratory diagnosis of invasive aspergillosis.  Lancet Infect Dis. 2005;  5 609-622