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A case of mediastinitis following botulinum toxin type A treatment for achalasia

Nature Clinical Practice Gastroenterology & Hepatology volume 4, pages 579–582 (2007)Cite this article

Abstract

Background A 62-year-old obese, diabetic female underwent endoscopic esophageal injection of botulinum toxin type A (Botox®; Allergan, Irvine, CA) for achalasia. The patient presented to her gastroenterologist with chest pain 4 days after the procedure, but no thoracic or gastrointestinal pathologies were identified and the patient was sent home. She presented again the next day with continuing chest pain and newly developed fever. Esophagoduodenoscopy revealed no esophageal leak and a CT scan revealed only mild paraesophageal inflammation. The patient was sent home the same day with antibiotics after a urinalysis suggested presence of a urinary tract infection. The patient presented again 9 days after the procedure with continuing chest pain and fever.

Investigations Chest radiography, electrocardiography, complete blood count, cardiac enzyme levels, basic metabolic panel, urinalysis, Gastrografin® (Bracco Diagnostics Inc, Princeton, New Jersey) and barium swallow study, endoscopy, abdominal and chest CT scans, blood culture and wound culture.

Diagnosis Ulceration without perforation of the esophageal mucosa in the area of Botox® injections. Unilateral pleural effusion and mediastinitis without abscess formation.

Management Pantoprazole and clonazepam for suspected gastroesophageal reflux and esophageal spasm. Levofloxacin for urinary tract infection. Intravenous antibiotic therapy and acute surgical exploration for possible esophageal rupture. Paraesophageal drain placement, nasogastric tube placement, and parenteral and enteral feeding.

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Figure 1: Chest CT scan taken 9 days after the patient received Botox® (Allergan, Irvine, CA) injections for achalasia.
Figure 2: Esophagoduodenoscopy image of the case patient's esophagus performed 13 days after Botox® (Allergan, Irvine, CA) injections for achalasia.

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Author information

Authors and Affiliations

  1. and M Liptay is Faculty in the Department of Thoracic Surgery at Rush University Medical Center, R Mac Iver is currently completing a General Surgery Residency at Northwestern Memorial Hospital, Chicago, IL, USA.,

    Robroy Mac Iver & Michael Liptay

  2. Y Johnson is Faculty in the Department of Gastroenterology at Evanston Northwestern Hospital, Evanston, IL, USA.,

    Yolandra Johnson

Authors
  1. Robroy Mac Iver
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  2. Michael Liptay
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  3. Yolandra Johnson
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Corresponding author

Correspondence to Robroy Mac Iver.

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The authors declare no competing financial interests.

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Iver, R., Liptay, M. & Johnson, Y. A case of mediastinitis following botulinum toxin type A treatment for achalasia. Nat Rev Gastroenterol Hepatol 4, 579–582 (2007). https://doi.org/10.1038/ncpgasthep0951

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