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

Background A 62-year-old obese, diabetic female underwent endoscopic esophageal injection of botulinum toxin type A ( Botox((R)); 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((R)) (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((R)) 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.