The patient, male, 75 years old, was admitted on April 16, 2020, mainly due to chest and back pain, choking on food for more than a year, worsening with dyspnea for a week. At the time of admission, the patient had obvious chest and back pain, with the right side being affected. He choked on food, accompanied by fever, cough, wheezing, palpitations, and other discomforts. He had no precordial pain, poor appetite, sleeplessness, and was able to urinate and dry stool. The previous diagnosis of esophageal squamous cell carcinoma in the lower thoracic segment was 6 months. The tumor size was about 2cm x 3cm x 2cm at the time of diagnosis. The clinical stage was cT3N2M0 Phase IIIb. Six cycles of chemotherapy with single drug tegeol 50mg po bid d1-14 q3w were performed. Traditional Chinese medicine and support treatment were used. No surgery, radiotherapy and immunotherapy were performed. The space occupying lesions in the anterior segment of the right upper lobe were diagnosed for 6 months. The history of hypertension, coronary heart disease, diabetes and other diseases was denied. The history of trauma and surgery was denied. The history of infectious diseases was denied. The family history of similar diseases was denied, A smoking history of 60 years, denied drinking history. Physical examination: temperature 38℃,pulse 105 times/min, respiratory rate 30 times/min,blood pressure 105/82mmHg, with painful expression, shortness of breath, cyanosis of the lips, thick respiratory sounds in both lungs, wet rales heard in the right lung, arrhythmia at 105 times/min, distant and low heart sounds, no murmurs heard in each valve, enlarged boundary of voiced heart, tenderness under the xiphoid process, and edema in both lower limbs. Auxiliary examination: Blood routine: White blood cell count 27.28 * 109/L, neutrophil percentage 93.7%, absolute value of neutrophils 25.56 * 109/L, absolute value of monocytes 0.81 * 109/L, hemoglobin 110 g/L, platelet count 473 * 109/L, urine analysis: urine protein (+), fecal routine: occult blood positive, B-type natriuretic peptide measurement 133.93 pg/mL, no significant abnormalities in electrolytes, liver and kidney function, and myocardial enzymes, tumor marker: ferritin 1416.0 ng/mL, Carbohydrate antigen 125 36.85 U/mL, cytokeratin 19 fragment 7.63 ng/mL, carcinoembryonic antigen, carbohydrate antigen 72 − 4, carbohydrate antigen 19 − 9, and carbohydrate antigen 24 − 2 showed no abnormalities. Electrocardiogram: Sinus tachycardia, atrial premature contractions, abnormal electrocardiogram (Fig. 1). Chest Computerized tomography(CT): 1, thickening of the esophageal wall in the middle and lower segments, and enlargement of surrounding lymph nodes in the cardia area, suggesting malignant mass. 2. Consider malignant mass in the upper lobe of the right lung, please consider clinical considerations. 3. Multiple enlarged lymph nodes in the hilum and mediastinum of the lungs. 4. Esophageal mediastinal fistula, pericardial effusion, communicating with the esophagus, esophageal pericardial fistula? (Figs. 2A and 2B), please combine with clinical practice.
Comprehensive analysis and admission diagnosis: 1. Esophageal malignant tumor lymph node metastasis invading surrounding tissues, esophageal mediastinal fistula, esophageal pericardial fistula? 2. Pulmonary space occupying lesions and pulmonary infections. 3. Pericardial effusion and gas accumulation 4. Mediastinal infection. Treatment includes oxygen inhalation, monitoring of electrocardiogram, blood pressure, and blood oxygen saturation, fasting of water, and comprehensive treatment including anti infection, nutritional support, pain relief, and symptomatic treatment. Please consult with the interventional department and cardiothoracic surgery department, and it is recommended to perform nasojejacual nutrition tube placement surgery in the catheterization room. On April 24, 2020, the above procedure was successfully performed. During the operation, a contrast agent (iodine alcohol injection) was found to be retained in the lower esophagus and pericardial cavity (Fig. 3A). During the catheterization process, the guide wire entered the pericardial cavity through the esophageal fistula (Fig. 3B), and the diagnosis of the esophageal pericardial fistula was confirmed.
After surgery, the patient's diet improved, but chest pain, wheezing, and palpitations did not improve. The vital signs were unstable. It was recommended to undergo pericardiocentesis and drainage, pericardial flushing, and transfer to the intensive medical department for further treatment. The patient's family refused and requested conservative treatment. The patient was discharged automatically the next day, and the follow-up patient died on the day of discharge.