S3036 A Rare Case of Failure to Thrive and Malnutrition Caused by Dysphagia Lusoria

Abstract

INTRODUCTION: Dysphagia Lusoria is a rare cause of swallowing difficulties, malnutrition and failure to thrive. CASE DESCRIPTION/METHODS: 56-year-old Hispanic immigrant lady with a PMH of duodenal ulcers, failure to thrive, food impaction, shortness of breath for twenty years who presented to ER with chest pain and for two weeks. Chest pain is retrosternal, dull, six out of ten, no radiation associated with difficulty in breathing related to moderate exercise. As well she reports cough and fatigue. Physical examinations: vitals: BP 138/88 mmHg, HR 71 bpm. RR 18, Pulse oximetry 95 on 2L nasal cannula, BMI: 19 chest examination: clear to auscultation bilaterally, no wheezes or rales no stridor. Cardiovascular examination: S1, S2 within normal limits. No lower limb swelling, no distended jugular vein. Musculoskeletal examination: no deformities, no rash, no swollen joints, no telangiectasia or any abnormal skin changes. Laboratory investigations revealed BUN 8mg/dl (5–25mg/dl), serum creatinine 0.8 mg/dl (0.44–1.0mg/dl), Liver function tests were normal. WBC is 7.5 (4.0–11 0k/uL) hemoglobin is 13 mg/dl (12–16 mg/dl), and platelet is 277 (140–450 K/uL). Patient had a left heart catheterization which was normal for any coronary artery diseases. Anti-Nuclear antibody, antibody Jo-1, anti-centromere antibody, Scleroderma scl 70, RNP antibody were all negative. Patient had a barium swallow which came back 9 positives for esophageal stricture. CT angiography of the chest revealed an abnormal right subclavian artery around trachea and esophagus. DISCUSSION: Dysphagia Lusoria was first described by Bayford in 1794. It is dysphagia resulting from any anomalous or aberrant vascular anomaly commonly caused by Aberrant right subclavian artery. I It causes esophageal lumen obstruction resulting in severe malnutrition and ultimately death. The aberrant right subclavian artery (ARSA) is rare aberration with incidence of 0.16 in the general population. It is predominant in females. Most common clinical presentation is asymptomatic (60–80% of the patients). The 20–40% that are symptomatic classically present with nonprogressive mechanical dysphagia at around age 48–50. Retroesophageal course of ARSA is the most common (80–84%), followed by ARSA courses between trachea and esophagus (12.7–15%), and pretracheal route (4.2–5%) [7].Figure 1.: CT angiography shows absence of Right subclavian artery on the anterior slices.Figure 2.: CT angiography shows Right Aberrant Subclavian Artery course behind the esophagus.Figure 3.: Barium swallow shows stricture of the middle third of the esophagus.