Meningitis: A Rare Complication of Esophageal Dilatation 2009 ACG/AstraZeneca Clinical Vignette Award, 2009 Presidential Poster

Abstract

Purpose: A 65 yr old white female developed esophageal stricture following radiation therapy for locally advanced squamous cell cancer of the upper esophagus. She underwent a series of esophageal dilatations with Savary dilators. The patient developed altered mental status a few hours after the index dilatation, followed by confusion and fever. A lumbar puncture was subsequently performed with CSF analysis suggestive of bacterial meningitis. No other sources of infection were identified. Patient responded well to intravenous antibiotics and was discharged home. Repeat esophageal dilatation was performed after four weeks for recurrent dysphagia. Two days later, patient was admitted with severe headache and neck pain. Lumbar puncture with CSF analysis was again suggestive of bacterial meningitis. MRI of the neck showed a small fistulous tract from the posterior wall of the proximal esophagus into the prevertebral soft tissue space at T1-T2 level, with pneumocephalus due to air tracking into the epidural space. A subsequent esophagogram did not show any contrast leak. A review of CT Chest performed during the previous admission showed the fistulous tract to be present at that time. Patient had significant clinical improvement with intravenous antibiotics and did not require surgical therapy. Discussion: Current literature review revealed only one prior case report of meningitis following esophageal dilatation without mention of esophagoepidural fistula. In our case it appears that meningitis was due to the esophago-epidural fistula with contiguous spread of infection. Although this is an extremely rare complication it should be considered in a patient with mental status changes following esophageal dilatation. A high index of suspicion should be maintained for possible esophageal perforation.