Bahaadin Al-Jarani, MD
Fellow
Memorial Sloan Kettering Cancer Center
New York, NY
Disclosure information not submitted.
Wai Soon Chan, MD
Critical Care Fellow
Memorial Sloan Kettering Cancer Center, United States
Disclosure information not submitted.
Alina Dulu, MD
Critical Care Medicine Attending
Memorial Sloan Kettering Cancer Center, United States
Disclosure information not submitted.
Thomas Nahass, MD
Fellow
Memorial Sloan Kettering Cancer Center
New York, NY
Disclosure information not submitted.
Stephen Pastores, MD, MACP, FCCP
Program Director, Critical Care Medicine
Memorial Sloan Kettering Cancer Center
New York, NY, United States
Disclosure information not submitted.
Title: Radiation-Induced Pericardial Cutaneous Fistula
Case Report Body: INTRODUCTION
Radiotherapy can be complicated by dermatitis, radiation-induced ulcers, and chest wall necrosis. Pneumopericardium, air within the pericardial cavity, is a rare entity associated with trauma, thoracic surgery, thoracentesis, infectious pericarditis, cocaine inhalation, and fistula formation between the pericardium and other structures. To our knowledge, we report the first case of a pericardial cutaneous fistula arising as a late effect of radiation therapy for metastatic gastrointestinal stromal tumor (GIST).
DESCRIPTION
A 52-year-old female with a history of metastatic GIST was treated with bowel and liver resections followed by radiation therapy to the liver and the xiphoid metastases 4 years prior to admission. The radiation therapy was complicated by skin changes, dermatitis, and sclerosis on the xiphoid area that slowly worsened over time. She presented to our hospital for management of acute on chronic abdominal pain and was started on empiric antibiotics for presumed sepsis. Soon after her initial presentation, she developed dyspnea and hypoxia. Transthoracic echocardiogram revealed moderate pericardial effusion with no evidence of tamponade. CT of the chest showed a moderate pericardial effusion and new pneumopericardium with fistula to the subxiphoid wound and fluid collection. She underwent pericardial drain placement, which yielded over 300cc of cloudy serosanguinous fluid. Her symptoms, vitals, and oxygen requirements subsequently improved. She remained on broad-spectrum antibiotics for the duration of her hospital stay.
DISCUSSION
Approximately 2-12% of the patients who undergo radiation therapy for breast or lung cancer experience damage to the skin or thorax. In mild cases, radiation dermatitis or ulceration can occur; in more severe cases fistulae may form to deeper structures. There are few case reports of pleurocutaneous fistulas but no report of pericardial cutaneous fistula.
In our case, the patient presented with an initial 3mm subxiphoid deep ulceration that developed slowly and progressed to a 3.5cm fistulous tract that eroded into the pericardium, presenting with pneumopericardium and development of pericarditis. This unique case highlights the importance of potential pericardial cutaneous complications of radiation therapy and the need for rapid diagnosis and treatment.