Delayed Constrictive Pericarditis Following Presumed Esophagopericardial Communication After Esophageal Stenting

Esophagopericardial fistula is a rare but life-threatening complication of esophageal stenting and malignancy. Although acute purulent pericarditis is a well-recognized consequence, delayed presentation as constrictive pericarditis years after the initial insult is exceptionally uncommon. A 74-year-old woman presented with a two-month history of progressive dyspnea. She had undergone esophageal stent implantation for esophageal cancer two years earlier, followed by chemoradiotherapy. Transthoracic echocardiography demonstrated preserved biventricular systolic function and constrictive physiology without significant pericardial effusion. Chest computed tomography revealed dense pericardial fluid containing air bubbles, raising suspicion of an esophagopericardial communication. However, contrast-enhanced computed tomography with both oral and intravenous contrast failed to demonstrate an active fistulous tract. Cardiac magnetic resonance imaging confirmed constrictive physiology with septal bounce. The patient underwent surgical pericardiectomy, during which a large amount of firm, white, cheese-like purulent material was evacuated. Microbiological culture of the pericardial specimen grew Enterobacter cloacae, susceptible to piperacillin/tazobactam and meropenem. Histopathological examination demonstrated chronic inflammation, extensive fibrosis, and dystrophic calcification, confirming chronic constrictive pericarditis. Following surgical intervention and targeted antimicrobial therapy, inflammatory markers normalized, and the patient's heart failure symptoms resolved. Delayed constrictive pericarditis secondary to a presumed spontaneously sealed esophagopericardial fistula represents an extremely rare late complication of esophageal stenting. The presence of intrapericardial air should prompt suspicion for prior esophagopericardial communication even when contrast imaging fails to demonstrate an active fistula. Early multimodality imaging, surgical pericardiectomy, and targeted antimicrobial therapy are essential for successful management.