When eating becomes a real nightmare

Area of Science:

• Gastroenterology and Interventional Endoscopy
• Thoracic Surgery and Critical Care
• Oncology and Hematology

Background:

• Esophageal fistulas and mediastinal abscesses are severe complications that can arise from iatrogenic injury during endoscopic procedures.
• Castleman's disease is a rare lymphoproliferative disorder that can present with diverse clinical manifestations, including systemic inflammation and lymphadenopathy.

Observation:

• A 46-year-old female presented with dysphagia and retrosternal pain following an endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA).
• Gastroscopy revealed multiple esophageal fistulous orifices with purulent discharge, and CT scans showed communicating mediastinal abscesses.
• Histopathological analysis confirmed Castleman's disease as the underlying diagnosis.

Findings:

• The patient's esophageal fistulas and mediastinal abscesses were attributed to complications from EBUS-TBNA, potentially exacerbated by the underlying Castleman's disease.
• Successful management involved intravenous antibiotics and endoscopic nasogastric tube placement, leading to clinical and imagological improvement.
• Histological diagnosis of Castleman's disease was established.

Implications:

• This case highlights the importance of considering iatrogenic esophageal injury during EBUS-TBNA, especially in patients with pre-existing conditions like Castleman's disease.
• Prompt diagnosis and multidisciplinary management, including antibiotics and endoscopic interventions, are crucial for favorable outcomes in such complex cases.
• The complete closure of fistulas post-treatment suggests the potential for conservative and endoscopic management in selected patients.