Esophageal Perforation, Mediastinitis, and Retropharyngeal Abscess After Eel Intrusion

Abstract

To the Editors: Foreign body ingestion is an uncommon but important complaint. Ingestion of a living animal is rare. We report a girl who had esophageal perforation with retropharyngeal abscess and mediastinitis after intrusion of a living eel. This 2-year-old girl was brought to our clinic owing to fever and odynophagia for 1 day. No respiratory or gastrointestinal symptoms were associated, however a special history was noted, that her mouth had been intruded by a living eel. Several living eels (scientific name Anguilla japonica) caught by her neighbor had been placed on a short table. An eel jumped into her mouth while several children stood together by the table. The depth of eel into her oral cavity was about 15 cm, and the body length of the eel was around 47 cm. Although the eel was pulled out by her aunt immediately, fever and odynophagia developed. She was brought to our hospital because of her refusal to eat a solid diet, swelling, and anterior bending of her neck. Swelling over the neck was detected, but no stridor or wheeze was noted. Laryngoscopy revealed bulging of the posterior pharyngeal wall, while the neck lateral view and chest radiograph showed air accumulation and widening of the retropharyngeal space. Retropharyngeal abscess and mediastinitis were confirmed by chest computed tomography (CT). Emergent transcervical and transthoracic thoracoscopic drainage was performed. The esophagoscopy showed the discharge of pus from a 10-cm depth below the incisors. Oxacillin, cefotaxime, and clindamycin were administered initially and the pus culture yielded Pseudomonas aeruginosa. Therapy was shifted to ceftazidime according to the susceptibility tests. The patient’s fever flared up on day 6 after surgery and a second chest CT revealed right empyema. Furthermore, esophageal perforation was diagnosed when the esophagogram showed the leakage of contrast medium. During the clinical course, 5 surgical interventions were conducted, and the overall hospital stay was 47 days. The patient was doing well after discharge. The management of foreign body ingestion differs.1 We had no experience of the intrusion of a living creature into the esophagus. What should we do at that moment? The intruded eel had been removed by patient’s aunt, and further suffocation and gastrointestinal tract obstruction could be prevented. Because there were small teeth, scales and fins over the eel’s body, esophageal perforation secondary to laceration during the dragging out process was considered. Retropharyngeal abscess, mediastinitis, and empyema developed, and high mortality rate is noted in such cases.2 Faced with descending necrotizing mediastinitis,3 surgical drainage in addition to antibiotics is the treatment of choice, and repeated operations are usually needed. The most common pathogens in retropharyngeal abscess are Staphylococcus aureus and Streptococcus.4 Our special consideration was whether there were any special infectious pathogens in eels. Erickson et al5 reported several patients injured by moray eel bites and found Vibrio and Pseudomonas were predominant species. Chien-Yu Lin, MD Department of Pediatrics Mackay Memorial Hospital Taipei, Taiwan Chun-Chih Peng, MD Division of Neonatology and Pediatric Critical Care Department of Pediatrics Mackay Memorial Hospital Taipei, Taiwan Nan-Chang Chiu, MD Division of Infection and Neurology Department of Pediatrics Mackay Memorial Hospital Taipei, Taiwan Nein-Lu Wang, MD Department of Pediatric Surgery Mackay Memorial Hospital Taipei, Taiwan Kuo-Sheng Lee, MD Department of Otolaryngology Mackay Memorial Hospital Taipei, Taiwan