Interact CardioVasc Thorac Surg 2008;7:280-281. doi:10.1510/icvts.2007.170290
© 2008 European Association of Cardio-Thoracic Surgery
Negative results - Cardiac general |
Bronchopericardial fistula, an unusual complication of oxytetracycline sclerosis therapy
Adem Grbolarb,
Lawand Qaradaghia,*,
Yildirim Imrena,
Irfan Tasogluc,
Elif Coskuna and
Tugba Avc a
a Department of Cardiovascular Surgery, Gazi University Hospital, Besevler, Ankara, Turkey
b Department of Cardiovascular Surgery, Private Mesa Hospital, Ankara, Turkey
c Department of Cardiovascular Surgery, Yuksek Ihtisas Hospital, Ankara, Turkey
Received 17 October 2007;
received in revised form 23 November 2007;
accepted 24 November 2007
*Corresponding author. Tel.: +90 312 202 67 37; fax: +90 312 212 90 14.
E-mail address: lawand_mahmood{at}yahoo.com (L. Qaradaghi).
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Abstract
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Here we report a rare case of bronchopericardial fistula following intrapericardial instillation of oxytetracycline. A 63-year-old female patient was admitted for management of malignant pericardial effusion secondary to right-sided bronchogenic carcinoma. Medical therapy and recurrent percutaneous catheter drainage failed in resolving the problem, so subxiphoid pericardiostomy and drainage tube insertion was performed. There was no decrease in the drainage so we decided to perform pericardial sclerosis by intrapericardial tetracycline instillation. After the second time oxytetracycline instillation, the patient developed respiratory arrest with hemodynamic instability. A huge amount of yellow frothy secretion aspirated through the endotracheal tube. The presence of tetracycline in the bronchial secretion was proved by microbiological methods. The hemodynamic status of the patient deteriorated rapidly and despite all resuscitation measures we lost the patient within a few hours.
Key Words: Bronchopericardial fistula; Pericardial effusion; Tetracycline
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1. Introduction
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The involvement of the pericardium by metastatic tumors is not uncommon. Mostly the presenting finding is the development of malignant pericardial effusion [1]. Malignant pericardial effusions occur in up to 21% of cancer patients [2]. Pericardiocentesis, pericardial sclerosis, systemic chemotherapy, radiotherapy, and surgical treatment represent the therapeutic modalities of malignant pericardial effusion.
Despite the wide acceptance and considerable experience with sclerosing agents in the treatment of malignant pleural effusion [3], their use in patients with malignant pericardial effusion is much more limited. Many agents have been used for pericardial sclerosis including tetracycline, mechlorethamine hydrochloride, bleomycin sulfate, thiotepa and radioactive gold [4, 5].
To the best of our knowledge, this is the first reported case of bronchopericardial fistula following intrapericardial tetracycline instillation for a malignant pericardial effusion.
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2. Case report
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A 63-year-old female patient was referred to our clinic as a case of recurrent malignant pericardial effusion for pericardiostomy. The patient was a case of right-sided bronchogenic carcinoma (small cell carcinoma near the hilum) diagnosed five months previously. She was admitted to hospital with progressive shortness of breath and peripheral edema. Imaging methods (PA chest radiography, echocardiography and thoracic MRI) helped in establishing the diagnosis of malignant pericardial effusion. The patient did not respond to antifailure therapy and recurrent percutaneous catheter drainage. Subxiphoid pericardiostomy for pericardial sac draining, biopsy specimen and a 28 gauge drainage tube insertion was performed. On postoperative follow-up, there was no decrease in the drainage so we decided to perform pericardial sclerosis by intrapericardial tetracycline instillation.
We instilled 750 mg of oxytetracycline HCl mixed with 50 ml of normal saline solution via a drainage tube into the pericardial sac. We clamped the tube for 2 h following instillation, then allowed it to drain to an underwater seal system. The procedure was repeated after 24 h but this time, after 1 h from instillation, the breathing of the patient became shallow, followed by respiratory arrest. Resuscitation was started immediately; after intubation a huge amount of yellow frothy secretion aspirated through the endotracheal tube (the color of which mimicked that of oxytetracycline HCl) which continued for more than 1 h (Fig. 1). This raised the possibility of bronchopericardial fistula secondary to tetracycline instillation and the drainage tube was de-clamped. On comparison between the pre- and post-instillation chest radiography, there was an obvious increase in bilateral haziness (Fig. 2). During this period the blood gas analysis value was shifting toward acidosis and the hemodynamic status deteriorated rapidly. Despite medical interventions and resuscitation measures we lost the patient within a few hours. We confirmed the presence of fistula by biological analysis of endotracheal aspirate, but not by bronchoscopy or imaging methods.
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Fig. 2. Chest radiography: preinstillation (a) and postinstillation (b), showing the increase in the bilateral haziness after intrapericardial oxytetracycline instillation.
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3. Discussion
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In autopsy and clinical studies, malignant pericardial effusions occur in up to 21% of cancer patients [2]. Despite the wide acceptance and considerable experience with sclerosing agents in the treatment of malignant pleural effusion, their use in patients with malignant pericardial effusion is much more limited. The mechanism of action for sclerotic effect of tetracycline is still not completely understood [1]. The suggested mechanism is mesothelial cell destruction by high acidity of tetracycline which leads to an inflammatory process and pericardiodesis [6].
On admission, the thoracic MRI revealed no bronchopericardial fistula. The cell destruction effect of tetracycline leads to path formation within the necrotic malignant tissue. The end result was the formation of a bronchopericardial fistula. We depended on the biological estimation of endotracheal aspirate for confirmation of tetracycline presence, which was performed on the aspirated material from the endotracheal tube in the postmortem period. Oxytetracycline was estimated using the plate agar diffusion method using the staphylococcus. This proved the presence of a high concentration of oxytetracycline HCl in the bronchial secretions (the level after centrifugation was 68%). On the second time instillation of oxytetracycline, the solution tracts through the fistula to the bronchial tree caused flooding from inside which ended with respiratory arrest. We lost the patient before confirming the presence of fistula by bronchoscopy or imaging methods. The patient's relatives did not give permission for internal autopsy.
Here we have discussed the intrapericardial sclerosis with tetracycline which was instillated to the pericardial space involved with malignant effusion process, such a tissue being considered a weak barrier in front of sclerosing and eroding effect of oxytetracycline. We focused light on the intrapericardial sclerosis using tetracycline and on its effects that it is not a totally innocent procedure. This instillation procedure may predipose to bronchopericardial and possibly other types of fistula.
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References
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- Buzaid AC, Garewal HS, Greenberg BR. Managing malignant pericardial effusion. West J Med 1989 February;150:174–179.[Medline]
- Lam KY, Dickens P, Chan AC. Tumors of the heart. A 20-year experience with a review of 12,485 consecutive autopsies. Arch Pathol Lab Med 1993;117:1027–1031.[Medline]
- Hausher FH, Yarbro JW. Diagnosis and treatment of malignant pleural effusion. Semin Oncol 1985;12:54–75.[Medline]
- Shepherd FA, Ginsberg JS, Evans WK, Scott JG, Oleksiuk F. Tetracycline sclerosis in the management of malignant pericardial effusion. J Clin Oncol 1985;3:1678–1682.[Abstract/Free Full Text]
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- Sahn S, Good JT Jr. Experimental pleural symphysis: results of differing sclerosing agents. Clin Res 1980;28:83A.
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Abstract
1. Introduction