Esophagomediastinal and esophagobronchial fistulas associated with invasive aspergillosis.

having esophageal cancer. She was given neoadjuvant chemoradiotherapy and esophagectomy was carried out. Reconstruction was accomplished with a gastric pull-up through the posterior mediastinal route. After 6 years of the treatment, the patient had high grade fever, which was refractory to treatment with antibiotics. A chest computed tomography (CT) scan demonstrated mixed fluid and soft tissue density in the posterior mediastinum, partially within the wall of the esophagus (●" Fig. 1). A Gastrografin esophagogram confirmed the existence of esophagomediastinal and esophagobronchial fistulas (●" Fig. 2).We considered these fistulas as the cause of the fever, and carried out percutaneous drainage. Gastrointestinal endoscopy revealed an esophagomediastinal fistula with necrotic tissues (●" Fig. 3). Although both sputum and blood cultures did not reveal the causative organism, high levels of serum galactomannan (whose production is proportional to the Aspergillus fungal load in tissue) were demonstrated (> 5.0 ng/mL; cut-off value < 0.5 ng/mL). On the basis of this finding, along with the persistent fever and CT appearances, a diagnosis of probable invasive aspergillosis was made in accordance with the European Organisation for the Research and Treatment of Cancer/Mycoses Study Group (EORTC/ MSG) consensus criteria [1]. Treatment with antifungal agents led to a fall in the temperature, reduction in the hematological parameters, including galactomannan, and resolution of the radiological findings. At 1 month, endoscopy revealed healing of the fistula (●" Fig. 4). Aspergillus is a common airborne organism that can be highly pathogenic under immunocompromised conditions such as prolonged neutropenia after chemotherapy or organ transplantation [2]. Mediastinitis caused by Aspergillus infection usually occurs by airborne contamination of the cardiothoracic surgical field in the months following the surgery [3]. Invasive aspergillosis is a fairly rare condition, but can be devastating if there is a delay in diagnosis [4]. This diagnosis needs to be considered in a patient with antibiotic-refractory infection in the presence of local immunocompromising factors such as irradiation-induced lung injury.