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Endobronchial Hodgkin's Disease and Bronchoesophageal Fistula
696 plantiertem Elektrischem Schrittmacher. Klin Wschr 43:1232,1965 2 Harris A: Pacemaker "heart sound." Brit Heart J 29:608, 1967 3 Murdock, MI, Meyers BA, Bacos JM: Auscultatory clicks produced by pacemaker catheters. Ann Intern Med 68: 1320, 1968 4 Kramer DH, Moss AJ, Shah PM: Mechanisms of extracardiac pacemaker sound (abstr). Circulation (suppl VI) 38:119, 1968 5 Mowrer MM, Prempree A, Staewen W, et al: Pacemaker sound in bipolar pacing systems (abstr ). Amer J Cardiol 23:129,1969 6 Pupillo GA, Linhart JW: Chest-wall stimulation and phonocardiography in the identification of the pacemaker heart sound. Ann Intern Med 73:439,1970 7 Korn M, Shoenfeld CD, Ghahramani A, et al: The pacemaker sound. Amer J Med 49:451, 1970 8 Misra KP, Korn M, Ghahramani AR, et al: Auscultatory findings in patients with cardiac pacemakers. Ann Intern Med 74:245,1971 9 Bowditch HP: Uber die Eigenthum Lichkeiten der Reizbarkeit welche die Musk elfasern des Herzens zeigen. Ber Sachs Ges Wiss (Math-Phys classe ) 23:652, 1871
10 Morris Jr, n, Whalen RE, McIntosh HD, et al: Permanent ventricular pacemakers. Comparison of transthoracic and transvenous implantation. Circulation 36:587,1967 11 Massumi RA: An unusual complication of the transvenous pacemaker. Amer Heart J 81 :259, 1971 12 Litten M: Uber die Normalen bei jeder Respiration am thorax Sichtbaren Zwerchfellsbewegungen. Deutsche Med Wchnscht 18:273, 1892 13 Palmer TE, Finestone AJ, Leary J: Endocardial pacemaker-induced diaphragmatic contractions. JAMA 200: 127, 1967 14 Birch LM, Berger M, Thomas PA: Synchronous diaphragmatic contraction. Amer J Cardiol 21 :88, 1968 15 Nathan DA, Center S, Pina RE, et al: Perforation during indwelling catheter pacing. Circulation 33: 128, 1966 16 Fort ML, Sharp JT: Perforation of the right ventricle by pacing catheter electrode. Amer J CardioI16:6l0, 1965 17 Barker PS, McLeod A, Alexander J: The excitatory process observed in the exposed human heart. Amer Heart J 5:720,1930 18 Mowrer MM, Aranaga CE, Tabatznik B: Unusual patterns of conduction produced by pacemaker stimuli. Amer Heart J 74:24, 1967 19 Barold SS, Narula OS, Javier RP, et al: Significance of right bundle branch block patterns during pervenous ventricular pacing. Brit Heart J 31 :285, 1969 20 Spitzberg JW, Milstoc M, Wertheim AR: An unusual site of ventricular pacing occurring during the use of the transvenous catheter pacemaker. Amer Heart J 77 :529, 1969 21 Castellanos [r, A, Maytin 0, Lemberg L, et al: Unusual QRS complexes produced by pacemaker stimuli, with special reference to myocardial tunneling and coronary sinus stimulation. Amer Heart J 77 :732, 1969
RENZI' AND LESAGE
Endobronchial Hodgkin's Disease and Bronchoesophageal Fistula Gilda Renzi, M.D., F.G.G.P.,o and, Robert Lesage, M.D. oO
A patient with Hodgkin's disease compUcated in the terminal stage by endobronchial involvement and bronchoesophageal fistula is reported. The patient died of recurrent bronchopneumonia secondary to the fistula. Even though mechloretbamine (Mustargen) intravenously and radiotherapy locally were given, no improvement was noted.
I
n the chest, malignant lymphoma may involve lymph nodes, pulmonary parenchyma and the tracheobronchial tree. Endobronchial involvement is rare and may be diagnosed only by bronchoscopic examination. We present a case of Hodgkin's disease with endobronchial involvement and bronchoesophageal fistula formation. CASE REPORT
A 25-year-old white woman followed and treated for Hodgkin's disease over the past four years was admitted to Notre Dame Hospital with the following symptoms: over the past two weeks she had noted a progressive productive cough. She also noted attacks of fever and dysphagia and dyspnea which were intermittent and secondary to the ingestion of solids or liquids and followed by vomiting and regurgitation. She also complained of generalized pruritus and a significant weight loss. Her past history was noteworthy in that, four years previously, she had a biopsy of a supraclavicular node which revealed Hodgkin's disease. At that time, a chest x-ray film showed marked mediastinal adenopathies and the patient was treated by radiotherapy, 2,000 rads, on the mediastinal region. Following this, she had recurrences in the inguinal region and also the splenic angle of the colon and both these responded to radiotherapy. On her last admission, physical examination revealed a patient who was dyspneic, cyanotic and who presented an almost continuous cough. Blood pressure was 120 over 70 mm Hg, temperature was 101°F, pulse rate was 92 per minute and regular, respiration rate was 30 per minute. Palpable lymph nodes were noted in the cervical area. The trachea was in the midline and the neck veins were not distended. Chest examination revealed no dullness but crepitant rales were heard bilaterally. Examination of the abdomen did not reveal any abnormality. Results of routine laboratory tests were normal. Chest x-ray picture revealed probable aspiration bronchopneumonia but no mediastinal adenopathy. A barium swallow showed a fistula between the left main stem bronchus and the esophagus (Fig 1). Esophagoscopy revealed the fistula to be 26 cm on the anterolateral wall. A biopsy specimen was taken but was negative. During esophagoscopy, as the patient coughed, bubbles of air could be seen in the fistula. Bronchoscopy revealed granular tissue partially obstructing the posterior wall of the left main stem bronchus o Active
Physician, Department of Medicine, Notre Dame Hospital; Clinical Professor, University of Montreal, Montreal, Quebec. 00 Active Physician, Department of Pathology, Notre Dame Hospital; Professor, Department of Pathology, University of Montreal.
CHEST, VOL. 61, NO.7, JUNE 1972
697
LACERATION OF TRICUSPID VALVE
knowledge this case seems to be the first antemortem report of bronchoesophageal fistula formation secondary to bronchial involvement by Hodgkin's disease. A tracheoesophageal fistula was reported by Weber in an autopsy case. Prognosis is related to the degree of bronchial involvement and is comparable to the other malignant causes of bronchoesophageal fistula formation.s-" In the present case, radiation therapy and intravenously administered mustargen were of no avail.
1 Higginson JF, Grismer JT:
2
3
4 5
6
FIGURE 1. Fistula between left mainstem bronchus and esophagus. about 1 cm from its origin. The fistula was not visualized but a biopsy specimen was taken which revealed Hodgkin's disease. Bronchography revealed an irregular and stenotic left main stem bronchus but no definite fistula was seen. Treatment consisted of absolute diet, antibiotics and 15 mg of mechlorethamine (Mustargen) was given intravenously. Because of no improvement, gastrostomy and radiotherapy, 2,000 rads, on the left main stem bronchus was tried. A repeat barium swallow showed a persisting bronchoesophageal fistula. The patient continued to have repeated bouts of aspiration bronchopneumonia and she finally died of respiratory insufficiency. An autopsy was refused. PATHOLOGY REPORT
• The specimen submitted was taken from the main -Ieft bronchus. The bronchial epithelium was ulcerated and in the same area, there was invasion of the bronchial wall by the neoplastic process which was of a mixed type of Hodgkin's disease. There were lymphocytes and typical reticular cells a few of which were Reed-Sternberg cells. DISCUSSION
Report of antemortem endobronchial involvement with Hodgkin's disease are rare.>" Most cases are diagnosed postmortem.' Endoscopically, there are granular infiltrates of the mucosa in the trachea or bronchi and these may ulcerate. The differential diagnosis is to be made with other inflammatory or neoplastic lesions obstructing the tracheobronchial tree. Definite diagnosis is made by bronchoscopy and biopsy as in this case. To our
CHEST, VOL. 61, NO.7, JUNE 1972
Obstructing intrabronchial Hodgkin's disease. J Thorac Cardiovasc Surg 20:961, 1950 Atkins JP: Endobronchial lymphoma. Ann Otolaryng (Paris) 60:849,1951 Stem S, et al: Endobronchial presentation of malignant lymphoma. Amer Rev Resp Dis 98:872, 1968 Weber H: Lungenlyrnphogranulome. Beitr Path Anat 84: I, 1930 Fry WA: Malignant tracheo-esophageal fistula treated by combined radiotherapy and surgical excision. Dis Chest 54:4,384, 1968 Killen DA: Tracheo-esophageal fistula resulting from nonpenetrating trauma to the chest. J Thorac Cardiovasc Surg 50:105, 1965
Laceration of the Tricuspid Valve by a Pacemaker Wire* ]aco Eishenield, M.D. OOand Yvonne Lamy, M.Dt
A case of tricuspid valve laceration by a No.5 USCI temporary bipolar pacemaker wire which w. inserted because of idioventricular rhythm foDowing c8nUac arrest in a 69-year-old man with longstanding hypertensive cardiovascular disease is described. Though various mechanical compUcatious induced by pacemaker electrodes have been described no similar case, to our knowledge, h. been reported in the Uterature.
V
ari ous mechanical complications induced by pacemaker electrodes have been reported: perforation of the right ventricle, with secondary tamponade' or loss of pacing" and other less common complications such as adhesive endocarditis produced by adhesions to the tricuspid valve," formation of thrombi with secondary pulmonary embolism and development of congestive heart failure secondary to obstruction of the right atrium." °From the Divisions of Cardiology and Pathology, Coney Island Hospital, Brooklyn. oOFellow in Cardiology, Coney Island Hospital. tStaff Pathologist, Coney Island Hospital and Clinical Instructor of Pathology, State University of New York Downstate Medical Center.
10 Morris Jr, n, Whalen RE, McIntosh HD, et al: Permanent ventricular pacemakers. Comparison of transthoracic and transvenous implantation. Circulation 36:587,1967 11 Massumi RA: An unusual complication of the transvenous pacemaker. Amer Heart J 81 :259, 1971 12 Litten M: Uber die Normalen bei jeder Respiration am thorax Sichtbaren Zwerchfellsbewegungen. Deutsche Med Wchnscht 18:273, 1892 13 Palmer TE, Finestone AJ, Leary J: Endocardial pacemaker-induced diaphragmatic contractions. JAMA 200: 127, 1967 14 Birch LM, Berger M, Thomas PA: Synchronous diaphragmatic contraction. Amer J Cardiol 21 :88, 1968 15 Nathan DA, Center S, Pina RE, et al: Perforation during indwelling catheter pacing. Circulation 33: 128, 1966 16 Fort ML, Sharp JT: Perforation of the right ventricle by pacing catheter electrode. Amer J CardioI16:6l0, 1965 17 Barker PS, McLeod A, Alexander J: The excitatory process observed in the exposed human heart. Amer Heart J 5:720,1930 18 Mowrer MM, Aranaga CE, Tabatznik B: Unusual patterns of conduction produced by pacemaker stimuli. Amer Heart J 74:24, 1967 19 Barold SS, Narula OS, Javier RP, et al: Significance of right bundle branch block patterns during pervenous ventricular pacing. Brit Heart J 31 :285, 1969 20 Spitzberg JW, Milstoc M, Wertheim AR: An unusual site of ventricular pacing occurring during the use of the transvenous catheter pacemaker. Amer Heart J 77 :529, 1969 21 Castellanos [r, A, Maytin 0, Lemberg L, et al: Unusual QRS complexes produced by pacemaker stimuli, with special reference to myocardial tunneling and coronary sinus stimulation. Amer Heart J 77 :732, 1969
RENZI' AND LESAGE
Endobronchial Hodgkin's Disease and Bronchoesophageal Fistula Gilda Renzi, M.D., F.G.G.P.,o and, Robert Lesage, M.D. oO
A patient with Hodgkin's disease compUcated in the terminal stage by endobronchial involvement and bronchoesophageal fistula is reported. The patient died of recurrent bronchopneumonia secondary to the fistula. Even though mechloretbamine (Mustargen) intravenously and radiotherapy locally were given, no improvement was noted.
I
n the chest, malignant lymphoma may involve lymph nodes, pulmonary parenchyma and the tracheobronchial tree. Endobronchial involvement is rare and may be diagnosed only by bronchoscopic examination. We present a case of Hodgkin's disease with endobronchial involvement and bronchoesophageal fistula formation. CASE REPORT
A 25-year-old white woman followed and treated for Hodgkin's disease over the past four years was admitted to Notre Dame Hospital with the following symptoms: over the past two weeks she had noted a progressive productive cough. She also noted attacks of fever and dysphagia and dyspnea which were intermittent and secondary to the ingestion of solids or liquids and followed by vomiting and regurgitation. She also complained of generalized pruritus and a significant weight loss. Her past history was noteworthy in that, four years previously, she had a biopsy of a supraclavicular node which revealed Hodgkin's disease. At that time, a chest x-ray film showed marked mediastinal adenopathies and the patient was treated by radiotherapy, 2,000 rads, on the mediastinal region. Following this, she had recurrences in the inguinal region and also the splenic angle of the colon and both these responded to radiotherapy. On her last admission, physical examination revealed a patient who was dyspneic, cyanotic and who presented an almost continuous cough. Blood pressure was 120 over 70 mm Hg, temperature was 101°F, pulse rate was 92 per minute and regular, respiration rate was 30 per minute. Palpable lymph nodes were noted in the cervical area. The trachea was in the midline and the neck veins were not distended. Chest examination revealed no dullness but crepitant rales were heard bilaterally. Examination of the abdomen did not reveal any abnormality. Results of routine laboratory tests were normal. Chest x-ray picture revealed probable aspiration bronchopneumonia but no mediastinal adenopathy. A barium swallow showed a fistula between the left main stem bronchus and the esophagus (Fig 1). Esophagoscopy revealed the fistula to be 26 cm on the anterolateral wall. A biopsy specimen was taken but was negative. During esophagoscopy, as the patient coughed, bubbles of air could be seen in the fistula. Bronchoscopy revealed granular tissue partially obstructing the posterior wall of the left main stem bronchus o Active
Physician, Department of Medicine, Notre Dame Hospital; Clinical Professor, University of Montreal, Montreal, Quebec. 00 Active Physician, Department of Pathology, Notre Dame Hospital; Professor, Department of Pathology, University of Montreal.
CHEST, VOL. 61, NO.7, JUNE 1972
697
LACERATION OF TRICUSPID VALVE
knowledge this case seems to be the first antemortem report of bronchoesophageal fistula formation secondary to bronchial involvement by Hodgkin's disease. A tracheoesophageal fistula was reported by Weber in an autopsy case. Prognosis is related to the degree of bronchial involvement and is comparable to the other malignant causes of bronchoesophageal fistula formation.s-" In the present case, radiation therapy and intravenously administered mustargen were of no avail.
1 Higginson JF, Grismer JT:
2
3
4 5
6
FIGURE 1. Fistula between left mainstem bronchus and esophagus. about 1 cm from its origin. The fistula was not visualized but a biopsy specimen was taken which revealed Hodgkin's disease. Bronchography revealed an irregular and stenotic left main stem bronchus but no definite fistula was seen. Treatment consisted of absolute diet, antibiotics and 15 mg of mechlorethamine (Mustargen) was given intravenously. Because of no improvement, gastrostomy and radiotherapy, 2,000 rads, on the left main stem bronchus was tried. A repeat barium swallow showed a persisting bronchoesophageal fistula. The patient continued to have repeated bouts of aspiration bronchopneumonia and she finally died of respiratory insufficiency. An autopsy was refused. PATHOLOGY REPORT
• The specimen submitted was taken from the main -Ieft bronchus. The bronchial epithelium was ulcerated and in the same area, there was invasion of the bronchial wall by the neoplastic process which was of a mixed type of Hodgkin's disease. There were lymphocytes and typical reticular cells a few of which were Reed-Sternberg cells. DISCUSSION
Report of antemortem endobronchial involvement with Hodgkin's disease are rare.>" Most cases are diagnosed postmortem.' Endoscopically, there are granular infiltrates of the mucosa in the trachea or bronchi and these may ulcerate. The differential diagnosis is to be made with other inflammatory or neoplastic lesions obstructing the tracheobronchial tree. Definite diagnosis is made by bronchoscopy and biopsy as in this case. To our
CHEST, VOL. 61, NO.7, JUNE 1972
Obstructing intrabronchial Hodgkin's disease. J Thorac Cardiovasc Surg 20:961, 1950 Atkins JP: Endobronchial lymphoma. Ann Otolaryng (Paris) 60:849,1951 Stem S, et al: Endobronchial presentation of malignant lymphoma. Amer Rev Resp Dis 98:872, 1968 Weber H: Lungenlyrnphogranulome. Beitr Path Anat 84: I, 1930 Fry WA: Malignant tracheo-esophageal fistula treated by combined radiotherapy and surgical excision. Dis Chest 54:4,384, 1968 Killen DA: Tracheo-esophageal fistula resulting from nonpenetrating trauma to the chest. J Thorac Cardiovasc Surg 50:105, 1965
Laceration of the Tricuspid Valve by a Pacemaker Wire* ]aco Eishenield, M.D. OOand Yvonne Lamy, M.Dt
A case of tricuspid valve laceration by a No.5 USCI temporary bipolar pacemaker wire which w. inserted because of idioventricular rhythm foDowing c8nUac arrest in a 69-year-old man with longstanding hypertensive cardiovascular disease is described. Though various mechanical compUcatious induced by pacemaker electrodes have been described no similar case, to our knowledge, h. been reported in the Uterature.
V
ari ous mechanical complications induced by pacemaker electrodes have been reported: perforation of the right ventricle, with secondary tamponade' or loss of pacing" and other less common complications such as adhesive endocarditis produced by adhesions to the tricuspid valve," formation of thrombi with secondary pulmonary embolism and development of congestive heart failure secondary to obstruction of the right atrium." °From the Divisions of Cardiology and Pathology, Coney Island Hospital, Brooklyn. oOFellow in Cardiology, Coney Island Hospital. tStaff Pathologist, Coney Island Hospital and Clinical Instructor of Pathology, State University of New York Downstate Medical Center.