title: Acute fever and seizure in a patient with recent atrial fibrillation ablation.
abstract: Patients undergoing radiofrequency ablation for treatment of atrial fibrillation may present critically ill with complications of atrial esophageal fistula, commonly manifesting as neurologic deficits and septicemia difficult to distinguish from other acute etiologies without a high index of suspicion. The temporal variability in fistula formation and symptom presentation, along with their nonspecific features, makes diagnosis often a late finding with historically high morbidity and mortality. We present a patient admitted to a medical intensive care unit with status epilepticus and recurrent positive blood cultures for organisms commonly associated with the gastrointestinal (GI) tract. Chest computed tomography (CT) without contrast, transthoracic echocardiography, and initial neurologic imaging were unhelpful. A diagnosis was ultimately made by upper endoscopy of the esophagus after hematemesis with suspicion for GI bleed, at which point surgical intervention was attempted but without success. This case reviews the clinical features of atrial esophageal fistula formation and its initial diagnosis and management.
authors.affiliation: Division of Pulmonary and Critical Care Medicine, Mayo Clinic, 200 First St. SW, Rochester, MN 55905, USA.
authors.forename: Alice
authors.initials: A
authors.lastname: Gallo de Moraes
authors.affiliation: Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA.
authors.forename: Pratik A
authors.initials: PA
authors.lastname: Patel
authors.affiliation: Division of Pulmonary and Critical Care Medicine, Mayo Clinic, 200 First St. SW, Rochester, MN 55905, USA.
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Mahal
authors.affiliation: Department of Neurology, Division of Critical Care, Mayo Clinic, Rochester, MN, USA.
authors.forename: Christopher L
authors.initials: CL
authors.lastname: Kramer
authors.affiliation: Department of Anesthesia, Mayo Clinic, Rochester, MN, USA.
authors.forename: Juan C
authors.initials: JC
authors.lastname: Diaz Soto
authors.affiliation: Division of Pulmonary and Critical Care Medicine, Mayo Clinic, 200 First St. SW, Rochester, MN 55905, USA. Electronic address: moua.teng@mayo.edu.
authors.forename: Teng
authors.initials: T
authors.lastname: Moua
mesh_terms: D000368:Aged; D001281:Atrial Fibrillation / Q000601:surgery*; D017115:Catheter Ablation / Q000009:adverse effects*; D002544:Cerebral Infarction / Q000209:etiology; D004452:Echocardiography; D004937:Esophageal Fistula / Q000209:etiology*; D017809:Fatal Outcome; D005334:Fever / Q000209:etiology; D006325:Heart Atria / Q000601:surgery; D006801:Humans; D008297:Male; D011183:Postoperative Complications / Q000209:etiology; D013226:Status Epilepticus / Q000209:etiology*; D014057:Tomography, X-Ray Computed; D016157:Vascular Fistula / Q000209:etiology*
keywords: Atrial fibrillation ablation; Atrial-esophageal fistula; Fever; Seizure; Sepsis