A53-07 An Unintended Connection: Pneumopericardium Following Benign Esophageal Dilation

Abstract Background Pneumopericardium following esophageal dilation is a rare but serious complication caused by the formation of an esophagopericardial fistula, which can rapidly progress to sepsis and refractory shock. We present a case of pneumopericardium secondary to esophageal perforation after dilation, complicated by polymicrobial urinary tract infection and multiorgan failure. Case A 68-year-old male with intellectual disability, esophageal stricture status post dilation one month prior, LA grade B esophagitis, and PEG dependence presented with acute hypoxic respiratory failure. On arrival, he was febrile (101 °F), tachypneic (RR 40), and hypotensive, requiring a non-rebreather and vasopressor support with norepinephrine and vasopressin after inadequate fluid resuscitation. Laboratory data showed lactic acid 6.3 mmol/L, WBC 10 × 109/L, and urinalysis with 363 WBCs and bacteria. CTA chest demonstrated a moderate pneumopericardium with pericardial effusion, patulous esophagus, small bilateral pleural effusions, and right upper lobe tree-in-bud opacities. Point-of-care ultrasound showed no tamponade physiology.He was intubated for worsening respiratory distress and started on vancomycin, piperacillin-tazobactam, and micafungin. Phenylephrine was added for refractory shock. At 72 hours, he developed atrial fibrillation with rapid ventricular response requiring cardioversion. Liver enzymes increased, consistent with shock liver. CT with oral contrast via PEG confirmed a leak at the gastroesophageal junction, consistent with perforation. Urine cultures grew Pseudomonas, Klebsiella, and Proteus.At 96 hours, he developed bilateral pleural effusions requiring chest tubes. He underwent EGD with fluoroscopic stent placement across the perforation. Post-procedure, he developed unstable atrial fibrillation requiring cardioversion and amiodarone infusion. He experienced a brief PEA arrest with return of spontaneous circulation after epinephrine. His course was complicated by refractory shock, multiorgan failure, and ventilator dependence. After failed extubation and reintubation, he developed vasopressor-induced gangrene. Due to guardianship constraints, consent for tracheostomy and comfort care was delayed. He ultimately suffered a final PEA arrest and expired. Discussion Pneumopericardium, or air within the pericardial sac, was first described in 1844(1) and remains exceedingly rare. It is typically associated with malignancy, trauma, surgical or endoscopic intervention, or caustic injury(2). No prior cases have been reported following esophageal dilation. Management depends on hemodynamic stability; in the absence of tamponade physiology, close ICU monitoring is warranted. Definitive treatment involves repair of the esophagopericardial fistula, often via esophageal stent placement(3,4). Broad-spectrum antibiotics and antifungal therapy are recommended in cases complicated by septic shock(5). This abstract is funded by: None