Mediastinitis Mimicking Esophageal Perforation after Esophageal Botulinum Toxin Injection

Introduction:Botulinum toxin (BTX) has been used for short-term symptomatic treatment of achalasia. Here, we report a case of mediastinitis mimicking esophageal perforation after BTX injection. Case: A 52-year-old man with a history of hypertension and achalasia treated with pneumatic balloon dilation and later Heller's myotomy in past, had recent recurrence of symptoms. He had two injections of BTX, each leading to symptomatic relief. Third EGD was done with intent of BTX injection. EGD revealed a dilated esophagus with normal-appearing GE junction. Twenty five units of BTX were injected into each of the four quadrants above the GE junction. He presented 4 days later to ED with chest pain, which started post-procedure and had progressively worsened. Physical exam revealed mild epigastric tenderness. He was hemodynamically stable with no signs of fever, leukocytosis, or sepsis. Chest X-ray was normal. CT chest showed heterogenous 5 x 4 x 12 cm lesion along the posterior mediastinal paraspinal region posterior to esophagus with air lucencies contiguous with the esophagus, which raised concern for esophageal perforation with associated walled-off collection. An esophagram was performed, which showed dilated and tortuous esophagus without any extravasation of contrast material (Figure 1). He was managed conservatively and remained stable. He was started on slowly advancing diet, which he tolerated very well and was discharged home. Upon follow-up the patient continues to do well.Figure 1A: Barium swallow shows dilated esophagus but no extravasation of contrast; B: CT of chest shows collection adjacent to esophagus.Discussion: Complications from esophageal BTX injection are reported to be uncommon. Only two cases of serious complications have been reported. MacIver et al reported a case of mediastinitis and Fitzgerald et al reported a esophagogastic fistula. Patients operated after BTX injections are reported to have dense adhesions around the GE junction, which likely are sequelae of repeated inflammatory responses. Our case of non-infectious mediastinitis with large sterile collection represents one of the potential serious complications of BTX injection. Severe inflammatory reactions may mimic perforation on imaging and may result in complex surgical procedures. Transient chest pain has been reported after BTX injection; however, progressively increasing chest pain should raise concern for mediastinitis.