Case report
A 74-year-old man was admitted to our hospital for worsening dysphagia, fever, and intermittent retrosternal discomfort 7 days after he had eaten a meal containing fish. On the day of the meal, the patient had presented to the emergency department of a different hospital with dysphagia and odynophagia, and believed he had swallowed a fishbone. At that time, a laryngoscopy was performed but showed no evidence of foreign material, so the patient was discharged. He had a fever of 39.0°C, normotension of 133/68 mm Hg, and tachycardia of 108 bpm on admission to our hospital. Laboratory testing documented severe leukocytosis (WBC 19.1 × 103/uL) and an increased C-reactive protein concentration (16.47 mg/dL). A computed tomography (CT) scan showed a thin foreign body in the upper third of the esophagus, penetrating the wall and almost reaching the thoracic aorta (Fig. 1A), combined with mediastinitis that included free periesophageal air bubbles and fluid collection. No clinical or radiologic signs of active bleeding from the thoracic aorta were noted at that time. An emergent esophagogastroduodenoscopy (EGD) was performed, and the fishbone fragment was removed (Fig. 1B). While there was no active bleeding, deep ulceration of the esophagus was observed (Fig. 1C). The next day, follow-up enhanced chest CT revealed a tiny pseudoaneurysm of the thoracic aorta (Fig. 2A), which had increased at the subsequent CT angiogram on the third day (Fig. 2B). Immediately after the third CT scan, thoracic endovascular aortic stent-graft placement was performed to treat the pseudoaneurysm under local anesthesia through the femoral artery. The covered portion of the graft was placed just distal to the origin of the left common carotid artery. Two days after endovascular repair, the patient had approximately a half cup-amount of hematemesis. An EGD and CT angiogram were immediately performed. The CT scan showed a much larger saccular outpouching lesion of the thoracic aorta, indicating that the pseudoaneurysm was growing (Fig 2C). However, the patient’s vital signs were stable, and the pseudoaneurysm on the CT angiogram was lower contrast-enhanced than the aorta proper, so we decided to proceed with conservative treatment using the Sengstaken–Blakemore tube (SB tube). Four days after the procedure, we removed the SB tube and hematemesis did not reoccur. Upon admission, antibiotic treatment was administered according to the following regimen: IV cefepime [2.0 g] and metronidazole [0.5 g] thrice daily. Six days after the intervention, the patient’s temperature decreased to below 38°C. C-reactive protein concentration started to decrease 3 days after the intervention and normalized on the 12th day post-procedure. Follow-up CT angiography showed that the pseudoaneurysm had completely disappeared 14 days after the placement of the stent (Fig. 2D). Although the patient had undergone the McKeown procedure due to consistent esophageal perforation 2 months later, AEF and pseudoaneurysm did not reoccur.