Meningo-encephalitis as initial manifestation of a fatal atrio-oesophageal fistula after atrial fibrillation ablation

OBJECTIVE: Meningo-encephalitis as a complication of an atrio-oesophageal fistula (AEF) after left atrial radiofrequency ablation (RFA) has been only rarely reported. CASE REPORT: A 49-year-old man with persisting atrial fibrillation and oral anticoagulation underwent RFA without initial complication. Four weeks after the procedure, however, fever, emesis, and confusion occurred. Clinical neurologic examination revealed somnolence, partial disorientation, psychomotor agitation, and athetotic movements of the upper limbs. CSF-investigations revealed 100/3 granulocytes and MR meningeal enhancement and multiple parenchymal enhancing spots. After haematemesis, seizure, and resuscitation, an AEF was detected by the third gastroscopy and confirmed by thoracic CT. Because of the septic state surgeons refused to close the fistula. The patient died 10 days after the clinical onset of meningo-encephalitis from cerebral oedema despite adequate antibiotic treatment. CONCLUSIONS: An AEF after RFA may initially manifest as septic meningo-encephalitis, even after a four-week symptom-free interval. Manipulations within the oesophagus after diagnosis of an AEF are contraindicated. The procedure of choice to diagnose an AEF is thoracic CT with contrast medium. Surgical closure of the fistula should be tried immediately after diagnosis despite sepsis.