Key Clinical Message
- EP after TEE represents a medico-surgical emergency.
- Given the high rate of asymptomatic patients with COVID 19, the risk
of contamination and the frailty of esophageal tissues, we should check
coronavirus infection in every patient before TEE.
Background
Transesophageal echocardiography (TEE) is a very reliable method
increasingly used in cardiology. TEE is nevertheless a semi-invasive
method which does have some risks. Esophageal perforation (EP) is a rare
with an extremely low incidence (0.02 to 0.09%)[1,2] but serious
risk. We present the case of a patient with Coronavirus disease who
developed EP after TEE and we discuss if this complication is favorited
by COVID-19 infection .
Case presentation
Our patient was a 67-year-old woman with a medical history of
hypertension and atrial fibrillation. She was admitted in our department
because of one-week fever (38.3℃). She had no respiratory symptoms or
history of gastro-esophageal disease. Physical examination revealed good
general condition, with the blood pressure of 120/80 mm Hg, and a pulse
rate of 80 beats/min. Her oxygen saturation was 92% in ambient air.
Pulmonary auscultation was normal. Cardiac auscultation showed normal
heart sounds and a 3/6 systolic murmur to the mitral focus. The
electrocardiogram was in sinus rhythm.
A transthoracic and then transesophageal ultrasound were performed,
finding a slightly dilated left ventricle with preserved systolic
function, severe mitral regurgitation by prolapse of the large mitral
valve (A2 prolapse) and rupture of the cord. There is moderate tricuspid
regurgitation. Laboratory studies showed hemoglobin of 15.7 g/L and
normal leukocyte count. There were elevated blood levels for C-reactive
protein (150 mg/L; normal range, 0–10 mg/L).
Given the high probability of infectious endocarditis (IE) , we
performed TEE which didn’t show any signs if IE. The introduction of the
probe was uneventful and the patient tolerated well the exam.
Immediately after the TEE, the patient reported severe neck pain and
cervical swelling. Examination of the cervical region found a swelling 5
cm in diameter consistent with a hematoma and subcutaneous emphysema(figure 1) . The oropharyngeal exam was without abnormalities.
A cervico-thoracic computed tomography (CT) scan after oral contrast
administration was performed showing a perforation in the cervical
esophagus, a hematoma of the visceral space of the neck and an emphysema
of the retropharyngeal space (figure 2) .
Intravenous antibiotics and parenteral nutrition were initiated. As a
part of preoperative assessment, we performed a Real-time polymerase
chain reaction \sout(PCR) of nasopharyngeal swabs which was positive
for SARS-CoV-2. The patient underwent an emergent surgery, allowing the
closure of the perforation ,drainage of the collection and feeding
jejunostomy. Unfortunately, our patient died tens days later due to an
acute respiratory distress syndrome related to COVID-19.
Discussion
Here we reported the first case of EP in our department during a TEE
exam; more than 6000 exam have been performed until now, the fact that
patient had COVID-19 seems to increase the risk of this complication. In
fact, EP is a rare condition, the incidence is estimated at 3 cases per
million inhabitants per year [3], but it remains a serious
complication, associated with high mortality, mainly due to septic
complications such as mediastinitis [4] . The main causes are
increased intraesophageal pressure (spontaneous or Boerhaave’s
syndrome), iatrogenic damage due to instrumentation, physical or
chemical trauma, or diseases of the esophagus[3].
EP after TEE is extremely rare and commonly occurs in the cervical
esophagus [1,2,5,6] . Although the incidence of perforation is low,
esophageal mucosal injuries during TEE are common (up to 60%)[7].
However, only 2% of those injuries are recognized clinically. A review
of the literature found 35 reported cases of EP secondary to a TEE
[8] . These were most often elderly women and TEE performed
intraoperatively, without any particular difficulty during the
procedure. EP during intraoperative TEE is caused primarily by direct
trauma related to probe introduction and manipulation. Prolonged,
continuous pressure and thermal energy from a probe can also damage
esophageal tissue, resulting in indirect mechanical trauma [9].
At the cervical level, the esophageal wall showed weakness caused by the
crossing of fibers from the constrictor of the pharynx muscle and the
crico-pharyngeal muscle[7]. This zone projects in regard of the
cervico-thoracic junction (C5–C6 vertebrae). Perforation risk at this
level is increased during passing of the probe by upper extension of the
neck .Flexion of the neck enables opening the cervico-thoracic junction
and decreases the risk of perforation[7].
Identification of risk factors and gentle probe manipulation may prevent
this complication[10,11]. Risk factors for perforation during
instrumentation of the esophagus appear to be spasm or hypertrophy of
the cricopharyngeal sphincter and intrinsic esophageal disease (e.g.,
inflammation). In these instances, increased mucosal friability and
decreased esophageal compliance may increase the risk of perforation
during passing of the probe. In a patient with COVID-19 , weakening of
the esophageal wall may result from thrombotic and septic phenomena
related to viral infection [12,13]. Additionally, the coronavirus
has an extensive tissue distribution, causing microthrombosis and
generalized small vessel vasculitis [13,14] . These phenomena,
associated with patient comorbidities, such as hypertension and heart
disease, are associated with high mortality rates. In our patient, EP
may have been caused by be a direct damage of the esophagus wall by the
extremity of the probe into an esophageal mucosal disturbance.
The presenting clinical signs are variable, including pain, hypotension,
shock, fever, dyspnea, pneumomediastinum and biological inflammatory
syndrome [8,15,16]. Subcutaneous emphysema confirms the diagnosis,
but it is quite common with perforation of the cervical esophagus (60%
of cases) [17].
Cervico-thoracic CT scan after oral contrast administration is the gold
standard investigation to confirm the diagnosis by detecting the
presence of air in the mediastinum and visualizing of the perforation
[18]. It makes it possible to assess the perforation to guide
treatment by determining the site of the perforation, its extent, the
presence of abscesses, collections, pleural effusions.
When minor rupture is evident, medical therapy consisting of
board-spectrum antibiotics and total parenteral nutrition may be
attempted. Endoscopic treatment is also possible for small uncomplicated
perforations diagnosed early. In more extensive cases, surgical
treatment is performed, justified by the severe prognosis of this
affection. Jones and Ginsberg [16]reported mortality rates of 6, 34
and 29%, respectively for cervical, thoracic and abdominal esophageal
perforation in a collected review. Surgical technique depends on the
location of the perforation, its size, the viability of the esophageal
wall, the extent of local sepsis, and the presence of an underlying
esophageal lesion [19]. Conservative surgical treatment involves
debriding infected and necrotic tissue, suturing the puncture, and
draining on contact. A feeding jejunostomy is placed at the same time.
Conclusion
In conclusion, we presented an unusual case of iatrogenic esophageal
perforation in a patient with COVID-19. Force applied during the
intubation into an esophageal mucosal disturbance cause by COVID-19
probably represented the underlying condition that contributed to the
damage caused by the probe. We should avoid TEE in patients with
COVID-19, not only because of risk of contamination but also an eventual
frail esophagus and high risk of perforation.