Acquired Tracheoesophageal Fistula in a Pregnant Patient with Coronavirus Disease 2019 (COVID 19) Pneumonia on Prolonged Invasive Ventilation

Abstract

Introduction.An acquired tracheoesophageal fistula (TEF), an abnormal communication between the trachea and esophagus, is most often caused by malignancies in adults. Occasionally, it may arise from benign causes, such as endoscopic intervention, trauma, and prolonged intubation. Case Presentation. A 24-year old previously healthy pregnant female was diagnosed with COVID-19 pneumonia and was intubated. Due to non-reassuring fetal status, an emergency cesarean section was performed at the 36th week of gestation;the baby tested negative for COVID-19 and was separated. Throughout her illness, the patient was treated for recurrent bouts of pneumonia, coupled with findings of pneumothorax and pneumomediastinum- all of which were attributed to pulmonary fibrosis from Acute Respiratory Distress Syndrome (ARDS). A chest and neck CT scan (figure 1), however, confirmed the presence of a tracheoesophageal fistula (TEF), along with a hyperinflated endotracheal (ET) cuff. A temporizing procedure, involving tracheostomy with an extended length tracheal tube, was performed. The long-term plan was to surgically correct the TEF after nutritional upbuilding and liberation from the ventilator, however the patient succumbed to her infections. Discussion.The findings of a communication between the trachea and the esophagus tie all of these events together: the pneumothorax and pneumomediastinum, as well as the recurrent bouts of pneumonia from recurrent aspiration through the fistula. Despite its rarity (0.3-3%), tracheoesophageal fistulas are a very real possibility in patients who require prolonged invasive ventilation. A retrospective study by Fiacchino et al. noted a significant increase in full thickness tracheal lesions in patients with COVID-19 pneumonia, which may be caused by several factors: the presence of an overinflated endotracheal (ET) cuff, prolonged steroid use, hypoxic injury, as well as possible direct injury of the tracheal mucosa from the Coronavirus itself [1]. This case highlights the importance of keeping a high index of suspicion for tracheal injury in patients who experience prolonged periods of intubation. It also underlies the high morbidity and mortality rate associated with TEF, albeit being a rare disease. Lastly, it highlights yet another possible long-term complication of COVID-19. Reference:[1]Fiacchini G, Tricò D, Ribechini A, et al. Evaluation of the Incidence and Potential Mechanisms of Tracheal Complications in Patients With COVID-19. JAMA Otolaryngol Head Neck Surg. Published online November 19, 2020. doi:10.1001/jamaoto.2020.4148 .