Management
Patient was initially admitted to medicine floor and empirically started
on vancomycin and cefepime, after obtaining blood cultures. On transfer
to the ICU, his mental status worsened and had to be emergently
intubated for airway protection. Norepinephrine and vasopressin were
initiated for blood pressure support. Antibiotic coverage was broadened
with meropenem and nystatin. Later, the patient developed ventricular
tachycardia with hemodynamic instability requiring electric
cardioversion. Amiodarone infusion was started. Given the recent history
of catheter ablation for atrial fibrillation, a CT chest with contrast
was ordered (Figure 1), which showed multiple air bubbles located
between the esophagus and posterior aspect of the left atrium,
concerning for atrio-esophageal fistula. Due to patient’s neurological
status, no surgical intervention was recommended by cardiothoracic
surgery.