RARE COMPLICATION OF BILATERAL BRONCHOESOPHAGEAL FISTULAS DUE TO INVASIVE MUCORMYCOSIS AFTER RENAL TRANSPLANTATION

Abstract

SESSION TITLE: Fellows Chest Infections Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: October 18-21, 2020 INTRODUCTION: Bronchoesophageal fistula (BEF) is a rare pathological connection between the esophagus and bronchi. Most are acquired due to esophageal or lung cancer. A small subset is caused by opportunistic infections in the immunocompromised. To our knowledge, this is the first case of bilateral bronchoesophageal fistulas due to invasive mucormycosis in an immunocompromised patient. CASE PRESENTATION: 67 year old male with hypertension, diabetes, ESRD status post kidney transplant one month prior presents with two weeks of dysphagia, cough, and fatigue. Initial labs were significant for leukocytosis. Computed Tomography (CT) of the chest showed nonspecific pulmonary nodules and a mediastinal mass contiguous with the esophagus concerning for malignancy. EGD revealed an esophageal ulcer that was biopsied. Flexible bronchoscopy with bronchoalveolar lavage and EBUS of subcarinal lymph node was also obtained. Over the course of 72 hours, patient’s clinical status deteriorated. His oxygen requirements increased from nasal canula to high flow in a matter of hours and was ultimately intubated due to hypoxic respiratory failure. After intubation, patient had persistent air leak and remained hypoxic despite being on 100% FiO2. His ET tube was upsized from 7.5mm to 8.5mm due to concern for tracheomalacia. At this time, BAL cultures and esophageal cultures grew mucor. Amphotericin B was initiated. Repeat chest CT showed possible BEFs. Bedside bronchoscopy revealed bilateral white exudate at the level of the right and left mainstem bronchi. Gas bubbles from the esophagus were visible, confirming the bilateral BEFs. During this time patient developed septic shock requiring multiple pressors and persistent hypoxia despite maximal ventilatory settings. Cardiothoracic surgery team offered last-resort surgery including total esophagectomy and lobectomy with reconstruction of BEFs. However, given the extremely high mortality risk, the family declined. The patient passed away shortly after. DISCUSSION: Invasive mucormycosis is a rare, opportunistic fungal infection that presents in immunocompromised patients with underlying diabetes mellitus. Rhino-orbital-cerebral and pulmonary infections are the most common sources. Diagnosis can be made by tissue histopathology with culture confirmation. Due to its aggressive nature, local invasion often leads to multi-organ dysfunction. BEFs are extremely rare complications of invasive mucormycosis. Unfortunately, even with aggressive anti-fungal and surgical intervention, invasive mucormycosis carries extremely high mortality rate. CONCLUSIONS: To our knowledge, this is the first reported case of bilateral bronchoesophageal fistulas due to invasive mucormycosis in an immunocompromised patient. Our EGD and bronchoscopy images illustrate the aggressive nature of this fungi. Due to its high mortality rate, early detection, anti-fungal therapy, and surgical debridement are critical. Reference #1: Lee et al. Rare complication of bronchoesophageal fistula due to pulmonary mucormycosis after induction chemotherapy for acute myeloid leukemia: a case report. Journal of Medical Case Reports (2016) 10:195 DISCLOSURES: No relevant relationships by Dafang Chen, source=Web Response No relevant relationships by Keith Killu, source=Web Response No relevant relationships by Brett Lindgren, source=Web Response No relevant relationships by Neha Mehta, source=Web Response