Pyothorax and Constrictive Pericarditis after Chemoradiotherapy for Esophageal Cancer

Figures

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  Figure 1.. Radiation plan for esophageal cancer. Radiation plan fused with computed tomography images (A, B: transverse section, C: coronal section). The patient with advanced mid-thoracic esophageal cancer received a total of 63 Gy/35 fr, 4-fold anterior-posterior oblique irradiation. The red and green areas indicate the 95% and 65% irradiated areas, respectively.

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  Figure 2.. Contrast-enhanced computed tomography at admission. Cross-section (A, B) and coronal section (C) of contrast-enhanced computed tomography. A large amount of left pleural effusion was observed, which came in contact with the lateral and posterior walls of the left ventricle. Pericardial fluid was also observed. The border between the pericardium and pleura is partially obscured (arrowheads).

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  Figure 3.. Electrocardiographic changes over time after chemoradiotherapy for esophageal cancer. An electrocardiogram obtained just after chemoradiotherapy showed low potentials in limb leads and nonspecific ST changes (A). Two years after chemoradiotherapy, at the time of myocardial infarction, mild ST elevation and small negative T waves were observed in the III and aVF leads (B), and almost the same results were observed four years after chemoradiotherapy (C). Eight years after chemoradiotherapy, the overall QRS potential had become even smaller (D), and nine years after chemoradiotherapy, at the time of this admission, low potentials and nonspecific ST changes were observed (E).

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  Figure 4.. Echocardiographic and cardiac catheterization findings. Transthoracic echocardiograms in the parasternal long-axis (A) and short-axis (B) showed a normal left ventricular ejection fraction and pericardial effusion but no evidence of myocardial hypertrophy or pericardial thickening. M-mode echocardiography in the short-axis image (C) showed the bounce of the ventricular septum (arrowheads) and deviation to the left ventricular side during inspiration. Pulsed wave Doppler of the trans-mitral flow showed an increase in the E wave during expiration. Cardiac catheterization revealed diastolic waveforms of left and right ventricular pressure with dip and plateau signs as well as high left and right ventricular end-diastolic pressures of 37 and 35 mmHg, respectively (D).

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  Figure 5.. Clinical course during hospitalization. The patient was admitted with a diagnosis of pyothorax exacerbation (day 1). Thoracic drainage and antibiotic therapy failed to improve his condition, so he underwent lung peeling surgery (day 15). The inflammation improved temporarily, but hypotension and marked edema gradually worsened, which necessitated catecholamine therapy. As the inflammatory reaction had worsened, window-opening surgery was performed (day 57). With the exacerbation of hypotension and edema, he experienced cardiopulmonary arrest (day 59). After resuscitation, cardiac catheterization led to a diagnosis of constrictive pericarditis and cardiogenic shock. Extracorporeal membrane oxygenation and intra-aortic balloon pumping were performed, but the patient died (day 73). ABPC/SBT: ampicillin/sulbactam, BNP: brain natriuretic peptide, CHDF: continuous hemodiafiltration, CP: constrictive pericarditis, CRP: C-reactive protein, CTRX: ceftriaxone, ECMO: extracorporeal membrane oxygenation, IABP: intra-aortic balloon pumping, MEPM: meropenem, PIPC/TAZ: piperacillin/tazobactam, VCM: vancomycin

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  Figure 6.. Autopsy findings. A macroscopic examination revealed significant adhesions between the pericardium and the left pleura, especially on the side of the pericardium in contact with the left thoracic cavity (A). In the cross-sectional view, the pericardium was extremely thickened (B). A microscopic examination showed fibrous thickening of the epicardium and fibrin precipitation in the epicardium at 20× Hematoxylin and Eosin (H&E) staining (C). Furthermore, H&E staining of the border between the pleura and pericardium at 20× showed adhesions between the pericardium in the upper portion and the pleura in the lower portion of the image (D). At 400× Grocott’s stain, fungal infection of the pleura and pericardium was observed (E). Fungal abscesses were observed within the myocardium at 200× Grocott’s stain (F).