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.