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.