Broncho-esophageal fistula leading to lung abscess: A life-threatening emergency detected on FDG PET/CT in a case of carcinoma of middle third esophagus
A 37-year-old male presented with grade III dysphagia. He also had recent onset high grade fever with chills. Nasogastric tube (NGT) was placed. Upper gastro-intestinal endoscopy (UGIE) showed friable mass in the middle third of esophagus, biopsy from which showed adenocarcinoma cells. Staging FDG PET/CT study was done. Maximum intensity projection image showed an hypermetabolic area in mid-thorax [-thick arrow] with diffuse low grade uptake around it [-thin arrow]. Axial fused PET/CT image [Figure and - arrow] showed a large intensely FDG avid soft-tissue mass in the middle third of esophagus, closely abutting the right main and segmental bronchi, measuring 32 mm × 32 mm, with maximum standardized uptake value of 27.2. Abutting this mass, a centrally necrotic ill-defined mass, with air pockets within and peripheral low intensity FDG uptake in the thick walls; was seen in the right lung parenchyma, in the lower lobe [Figure and -arrow heads]. Minimum intensity projection (minIP) reformatted sagittal [] and axial CT [] images showed a definite communication (arrow-head) between the mass (thick arrow) and the right lower lobar bronchus (thin arrow). Patient, when again asked for any complaints, said to have coughing immediately after swallowing. On collating history and imaging findings and also considering the fact that the patient underwent interventions like NGT placement and UGIE, a diagnosis of lung abscess secondary to BE fistula was made. Patient was started immediately on antibiotics and underwent esophageal stenting. Radiotherapy, though indicated, was ruled out due to presence of BE fistula.