The impact of systemic fungal infection in patients with perforated oesophagus

INTRODUCTION

Perforated oesophagus is a surgical emergency with significant morbidity and mortality. Systemic fungal infection represents a poor response to the magnitude of the insult, which adds significantly to the risk of morbidity and mortality in these patients. We reviewed our experience with this group of patients over a six-year period in a tertiary referral centre.

METHODS

A retrospective clinical review was conducted of patients who were admitted following a ruptured oesophagus over a period of six years (January 2002 - January 2008).

RESULTS

We had 27 admissions (18 men and 9 women) following an isolated perforated oesophagus to our unit. The median patient age was 65 years (range: 22-87 years). The majority (n=24, 89%) presented with spontaneous perforations (Boerhaave's syndrome) and three (11%) were iatrogenic. Fungal organisms, predominantly Candida albicans, were positively cultured in pleural or blood samples in 16 (59%) of the 27 patients. Fourteen patients grew yeasts within the first seven days while two showed a delayed growth after ten days. Overall mortality was 5 out of 27 patients (19%). There was no mortality among the group that did not grow yeasts in their blood/pleural fluid while mortality was 31% (5/16) in the group with systemic fungal infection (p<0.001). A positive fungal culture was also associated with increase ventilation time, intensive care unit stay and inpatient hospital stay but not an increased rate of complications.

CONCLUSIONS

Systemic fungal infection in patients with a ruptured oesophagus affects a significant proportion of these patients and carries a poor prognosis despite advanced critical care interventions. It may represent a general marker of poor host response to a major insult but can add to mortality and morbidity. It is worth considering adding antifungal therapy empirically at an early stage to antimicrobials in patients with an established diagnosis of a perforated oesophagus.

[Mediastinitis]

Mediastinitis is defined as acute or chronic inflammation of the mediastinal structures and generally has a low incidence. The most frequent acute cause is sternotomy following cardiac revascularization surgery with both internal mammary arteries, with an incidence of 0.4% to 5% and a mortality of 16.5% to 47%. The most frequent vector is Staphylococcus aureus. Esophageal perforation, usually iatrogenic, is the second most frequent cause of acute mediastinitis, produced by common oropharyngeal flora, with a mortality rate of 20% to 60%, depending on the time of diagnosis. The third most frequent cause is descending necrotizing mediastinitis, the origin being an odontogenous focus in 60% and beta-hemolytic streptococcus the causative agent in 71.5% of cases. The most accurate diagnostic imaging technique is computed tomography. Treatment is almost always surgical and survival depends on its early performance. The worst postsurgical prognostic factor is septic shock.

[Complicated course of oesophageal perforations because of fungal infections]

Perforations of the oesophagus are characterized by a high mortality rate, varying between 7 and 49%. In the analyzed group of patients between the years 1986 and 2003, the mortality rate of 28% was caused by septic complications such as mediastinitis and pneumonia. Microbiological examinations of samples from different locations and various secretions, detected mycoses in 28% of the patients (n = 16). Compared with the total of mycoses, a higher mortality of 50% was calculated. The invasive Candida infection of the oesophagus itself can cause a perforation. In perforations of the oesophagus, simultaneous mycoses arise by fungi invading sterile compartments or by haematogenous and lymphogenous dissemination up to sepsis. Uncomplicated courses do not need antimycotic therapy. At the beginning of the treatment, a microbiological monitoring should be provided, particularly with regard to the intraoperative facts. In relation to the course and the risk factors of the patients, an antimycotic therapy is initiated. Surgical clearing and sufficient drainage of the collateral compartments such as pleural and mediastinal compartments is highly significant.

Esophageal perforation secondary to angio-invasive Candida glabrata following hemopoietic stem cell transplantation

Esophageal perforation due to Candida glabrata is a rare entity. This organism is uncommonly recognized to be angio-invasive and cause gastrointestinal tract perforation. Herein, we describe a case of invasive C. glabrata infection leading to esophageal perforation in a patient undergoing hemopoietic stem cell transplantation.

Invasive candidiasis complicating spontaneous esophageal perforation (Boerhaave syndrome)

Spontaneous esophageal perforation is a rare condition that frequently results in infectious complications. Empirical broad-spectrum antibacterial therapy is therefore part of the standard management. We describe two patients suffering from spontaneous esophageal perforation who developed invasive candidiasis with hematogenous dissemination. One patient died of multiple organ failure due to Candida sepsis. Preexistent Candida colonization, incomplete mediastinal drainage, broad-spectrum antibacterial therapy, and prolonged intensive care therapy place patients with esophageal perforation at high risk for secondary fungal infection. Intense microbiological searching is mandatory, but the distinction between colonization and infection may be impossible. Empirical antifungal treatment with imidazole derivatives, particularly in patients with potential risk factors, should be considered.

Sepsis syndrome induced by tuberculous perforation of the esophagus

Perforation of the esophagus induced by tuberculosis with no evidence of HIV infection is an extremely unusual presentation of the disease. We report on a 41-year-old man presenting with an esophageal perforation who developed a sepsis syndrome characterized by multiple organ dysfunction. The perforation was covered endoscopically with a tube, the patient recovered from cardiovascular, renal and pulmonary dysfunction under intensive care treatment, including antimycobacterial therapy. In response to endoscopic and medical treatment the size of the lesion decreased and disappeared 56 days after diagnosis. The patient could be discharged 2 months after admission and remained asymptomatic after a 12 month follow-up examination.