A 52-year-old woman with recurrent hemoptysis

A rare case of pulmonary mucormycosis and broncho-esophageal fistula in a patient with poorly controlled diabetes

Key Clinical Message

In patients with poorly controlled diabetes, early recognition of rare fungal infections like pulmonary mucormycosis, especially when presenting with unusual complications such as broncho-esophageal fistula, is critical. Prompt intervention with antifungal therapy and consideration for surgical debridement significantly impact outcomes. Multidisciplinary management is paramount for such complex cases.

Abstract

Mucormycosis is a rare fungal infection caused by the Mucorales. This infection is mostly observed among those with poorly controlled diabetes or immunodeficiency. The most common presentation of the infection among those with poorly controlled diabetes is rhino-orbit-cerebral involvement. In this case report, we provide the history and outcome of a rare case of pulmonary mucormycosis in a patient with poorly controlled diabetes who was simultaneously diagnosed with broncho-esophageal fistula. Our patient was a 32-year-old male with a history of poorly controlled diabetes. Over the months, he had complained of productive coughs and dyspnea, which had lately been joined by dysphagia. He also claimed to have lost considerable weight (10 kg) during the previous 3 months. Barium swallow showed an abnormal flow of contrast between the bronchus and esophagus, suggesting a broncho-esophageal fistula. Computed tomography of the thorax revealed a broncho-esophageal fistula between the left main bronchus (LMB) and esophagus. He had a bronchoscopy the next day, which revealed necrosis and a broncho-esophageal fistula in the LMB. A bronchial biopsy showed typical hyphae with necrotic tissue, indicating mucormycosis. The patient's antimycotic medication (liposomal amphotericin) was started and a prompt surgery consult was ordered. The patient, however, passed away from massive hemoptysis. We described a rare case of pulmonary mucormycosis with broncho-esophageal fistula in a patient with poorly controlled diabetes. The rarity of this combination highlights the associated diagnostic and treatment hurdles. Early detection, antifungal medication, as soon as possible surgical debridement of involved tissues, and a multidisciplinary approach could improve patient outcomes.

A Successful Treatment of Broncho-Esophageal Fistula with Esophageal Stenting Using Direct Endoscopic Visualization

Broncho-esophageal fistula (BEF) is a severe yet relatively rare connection between the bronchus and esophagus usually caused by esophageal and pulmonary malignancies. We present a case report of a 49-year-old man diagnosed with terminal lung carcinoma who developed a BEF. The thoracic computed tomography scan detected a mass in the left bronchi that partially covers and disrupts the bronchial contour in certain regions and extends to the esophageal wall. After thoroughly evaluating alternative treatment approaches, we opt for the stenting procedure due to the advanced stage of the tumor and the significantly diminished quality of life. The treatment involves the use of a partially covered metal stent that is known to exhibit lower potential to migrate. The treatment is highly successful, resulting in a significant enhancement of the patient's quality of life, a lengthening in his survival, and the ability to pursue additional palliative treatment options. In contrast to the typical prosthesis implantation, our procedure uses a direct endoscopic visualization for the proximal deployment of a partially covered stent, offering a cost-effective and radiation-free alternative that can be particularly beneficial for BEF patients in facilities without radiology services.

Over-the-scope-clip treatment of gastrobronchial fistula following minimally invasive oesophagectomy: a novel approach

Gastrobronchial fistulae (GBF) following minimally invasive oesophagectomy (MIO) is a rare entity, with an estimated incidence of 0.3–1.5% according to the published literature. It could present with persistent cough (Ohno’s sign), chest pain, haemoptysis and recurrent pneumonia. Barium swallow examination remains the most sensitive investigation in 78% of the cases; the main stay of management is surgical and in some cases endoscopic (stent insertion). We report a rare case of a GBF 1 month after two-stage MIO for cancer of the gastro-oesophageal junction, which was successfully treated for the first time with an over-the-scope-clip.

Bronchoesophageal fistula: a rare complication of aortic endograft infection

Endovascular aortic aneurysm repair is an increasingly common approach for aortic aneurysm repair. Infection of the prosthetic is a rare, but devastating complication which may result in the well-known aortoenteric or aortobronchial fistulae. Bronchoesophageal fistula resulting from an infected aortic endograft has not yet been reported in the literature. Early recognition of the symptoms and prompt imaging confirmation are essential for treating an otherwise highly morbid diagnosis.

Bronchial-oesophageal fistula: a rare initial presentation of squamous cell carcinoma of the lung

A 61-year-old Caucasian man with hypertension and hepatitis C presented to the emergency department with 7 days of productive cough and low-grade fevers despite outpatient therapy with oral azithromycin. On initial evaluation, he was lethargic with peripheral cyanosis and oxygen saturation in the low 70 s on room air, necessitating endotracheal intubation. Chest imaging revealed diffuse bilateral infiltrates compatible with the diagnosis of acute respiratory distress syndrome. Patient subsequently developed profound hypoxaemia and on day 2 of admission, veno-veno extracorporeal membrane oxygenation (ECMO) was initiated. Bronchoscopy revealed a necrotic ulcer on the posterior wall of the left mainstem bronchus, compatible with a bronchial-oesophageal fistula, which was later confirmed by endoscopy, and stented. Histology revealed poorly differentiated squamous cell carcinoma of the lung. Despite stenting of the fistula and ECMO support, the patient expired 5 days after admission.

Broncho-esophageal fistula leading to lung abscess: A life-threatening emergency detected on FDG PET/CT in a case of carcinoma of middle third esophagus

Sinister undesirable pathologies often accompany malignancies. Though the entire emphasis is on cancer management, these benign conditions are more life-threatening than the primary malignancy itself. We report an interesting imaging finding of broncho-esophageal fistula leading to lung abscess on ¹⁸F– fluoro-deoxy-glucose positron emission tomography/computed tomography (FDG PET/CT) in large middle esophageal cancer, which due to early detection, was promptly managed.

Broncho-Oesophageal Fistula (BOF) Secondary to Missing Partial Denture in an Alcoholic in a Low Resource Country

The clinical course of a missing partial denture with secondary BOF in an alcoholic is presented. In the index case we report an exceptional clinical course of a patient who did not ascribe his symptoms to his ''missing'' dentures for several years, the odontologist who replaced an unrecovered denture, and the generalist who administered the barium swallow in an unsuspected BOF. Preoperative optimization of the patient was by blenderized local feeds through a feeding tube gastrostomy and by chest physiotherapy. Extraction of the denture and closure of fistula were done through a right thoracotomy. The importance of a high index of clinical suspicion of BOF in a low resource setting to avoid the morbidity and mortality associated with missing dentures is discussed. Odontologists, caregivers and clinicians must educate patients on the hazards of missing dentures and cases of missing / lost dentures should be adequately investigated / explored in the patient's history and clinical assessment before they are replaced.

Acquired bronchoesophageal fistula

Bronchoesophageal fistula in an adult is rarely encountered in clinical practice. Most commonly, they have malignant origin. We report a case of bronchoesophageal fistula secondary to trauma caused by upper gastrointestinal endoscopy. The patient presented with recurrent chest infections and dysphagia since he underwent endoscopic procedure for obstructed denture. Barium swallow study revealed fistulous connection between right lower lobe bronchus and esophagus.

First Use of Ventricular Septal Defect Occlusion Device for Endoscopic Closure of an Esophagorespiratory Fistula Using Bronchoscopy and Esophagoscopy

A 70-year-old woman presented with a persistent, nonmalignant esophagorespiratory fistula. Since other treatment options failed or were denied, an experimental nonsurgical therapy was performed. A self-expanding ventricular septal defect (VSD) occlusion device (Amplatzer; AGA Medical Corporation; Golden Valley, MN) was bronchoscopically introduced to close the fistula. The double umbrella-like occlusion device is made from nitinol mesh and closes luminal contact between the esophageal and bronchial walls, with its waist filling out the fistula itself. The geometry of the occluder system can in theory be designed according to individual purposes and needs. The performed treatment was safe and successful, and the patient remained asymptomatic for 1 year after the first presentation. The treatment of chronic nonmalignant esophagorespiratory fistulas can be difficult. The self-expanding VSD occluder system described in this case might be useful in patients who are not surgical candidates.