Presentations

Abstract

Introduction: Contrast-induced bronchospasm can be a rare and severe reaction to iodinated contrast media, comprising only 0.2% of total contrast related reactions. This outcome is most commonly associated with intravascular administration. We present a patient with a rare case secondary to orally administered contrast in a patient with bronchopleural-esophageal fistula (BEF) and chronic obstructive pulmonary disease (COPD) who underwent enteric contrast administration during esophagogastroduodenoscopy (EGD) with esophageal stent placement, leading to severe bronchospasm and failed extubation.

Case Information: A 66-year-old male with a history of esophageal squamous cell carcinoma (SCC), COPD, and chronic hypoxic respiratory failure presented to the hospital with a chief complaint of shortness of breath and significant respiratory secretions. Notably, the patient underwent an esophageal stent placement a month prior to the current admission for esophageal stenosis and had no documented history of allergy to iodinated contrast media. A CTA chest upon admission showed a BEF and a thick-walled collection containing gas along the adjacent right mediastinal pleura, concerning for a leak. The patient underwent stent replacement and EGD. Fluoroscopy with iodinated-contrast media was used to locate the fistula in the middle third of the esophagus. A covered stent was placed under fluoroscopic guidance. Upon initial extubation following stent placement and administration of contrast, the patient complained of dyspnea and chest tightness. His vitals were significant for hypotension, tachycardia, and tachypnea. Two doses of phenylephrine 100 mcg were administered. He was re-intubated due to worsening respiratory status and transferred to the intensive care unit. Review of procedural images, contrast was noted to have entered the main bronchi and extended into the subsegments bilaterally. The patient was started on methylprednisolone 40 mg IV, ipratropium-albuterol 3 mL and broad-spectrum antibiotics, resulting in clinical improvement and extubation the following day. Imaging (CT chest with IV contrast) three days later showed larger posterior basilar left lower lobe consolidation consistent with aspiration pneumonia. The patient expired later in hospitalization secondary to an aspiration event.

Discussion/Clinical Findings: This case presents an interesting etiology of contrast-induced bronchospasm. Anaphylactoid reactions, including bronchospasm, to enteric administration of contrast media as seen in this patient are rare in comparison to intravascular or direct injection. This patient underwent fluoroscopy accompanied by enteric contrast media which is useful for direct visualization of various pathologies of the gastrointestinal tract. Specifically, in our patient with a BEF, enteric contrast was utilized to guide esophageal stent placement to the area of contrast extravasation. Despite aiding in stent placement, the extravasation of the contrast into the airway via the fistula contributed to the development of adverse symptoms. This is likely not a true contrast related allergic reaction and more likely due to direct irritation of the airway tissue by the contrast. Additionally, the patient's history of COPD is independently associated with bronchospasm. When coupled with his BEF, the enteric contrast administration caused direct airway insult and bronchospasm that led to extubation failure and aspiration pneumonia.

Conclusion: Although fluoroscopy accompanied by enteric contrast media is highly useful for direct visualization of pathology in the GI tract, in patients with BEF, it may be important to consider potential preventative treatments, such as steroids and additional nebulizer treatments for possible respiratory complications in patients with COPD or asthma.