Prisma Health-Midlands/ University of South Carolina Lexington, SC
Introduction: Esophageal malignancy is the most common cause of tracheoesophageal fistula (TEF) in adults. TEFs develops in 5-15% of patients with esophageal malignancy, often being found late in the disease course. TEFs are often a result of cellular damage from radiation therapy. Patients often present with symptoms including coughing, pneumonia, hemoptysis, hypoxic respiratory distress, and aspiration. The symptoms of cough, aspiration, and pneumonia remain consistent with expected symptoms of esophageal radiation, and thus, can lead to delay in diagnosis of tracheoesophageal fistula.
Case Description/Methods: The patient was a 75 year old male with a history of non-Hodgkin’s lymphoma status post radiation, and chronic dysphagia was admitted to the medical intensive care unit for acute hypoxic respiratory failure requiring non-invasive mechanical ventilation. Labs were remarkable for white blood cell count of 17.9, hemoglobin 10.5, platelets 400, and all electrolytes were within normal limits. Total bilirubin, transaminases, alkaline phosphatase, and lipase were unremarkable. Computed tomography (CT) chest w/o contrast noted multifocal aspiration pneumonia, most severe at the left lung base. CT abdomen w/o contrast showed irregular thickening of the mid to distal esophagus suspicious for a neoplastic etiology, for which GI was consulted for an esophagogastroduodenoscopy (EGD). Subsequently he developed pulseless electrical activity-arrest requiring intubation. At this point, it was conducive for the patient to undergo EGD, which found invasive squamous cell carcinoma of the esophagus with tracheal fistulation. Due to poor prognosis, the palliative care team was consulted at which point the patient elected for hospice with comfort measures only.
Discussion: Despite improvement in detection techniques, the incidence of esophageal malignancy in the United States continues to rise. Esophageal cancer is the 6th leading cause of cancer related death in men with a 5 year survival rate of 15-25%. It is important that these patients are diagnosed early in the disease course. Unfortunately, due to the rapidly progressive nature of the disease and the frequent lack of clinical symptoms during early stages, esophageal carcinoma is especially difficult to detect. Although TEFs are typically found late in the disease course, it is critical to recognize that complications associated with esophageal fistulas can be the presenting findings of esophageal malignancy.
