Mediastinitis, pseudo-aneurysm formation, aortic bleed, and death from endoscopic botulinum toxin injection.

Endoscopic botulinum toxin injection is considered a safe and viable option for the management of achalasia [1,2]. Although esophageal perforation and mediastinitis are well-documented complications of this treatment, pseudo-aneurysm formation of the thoracic aorta following intersphincteric injection is exceedingly rare [3]. We report the first published fatality from a thoracic aorta pseudo-aneurysm bleed following inter-sphincteric botulinum toxin injection. Endoscopists should be vigilant of this potentially fatal complication. An 89-year-oldwomanwith a background of previous myocardial infarction and a permanent pacemaker for complete heart block complained of severe left scapular pain and pleuritic right chest pain 8 days after an endoscopic botulinum toxin injection. The toxin had been injected into the four quadrants of the lower esophageal sphincter using a 5mm needle (25 units into each quadrant). She had undergone 3-monthly endoscopic botulinum toxin injections for the previous 8 years. A chest radiograph showed no acute abnormalities. A computed tomography (CT) pulmonary angiogram revealed inflammatory changes around the esophagus suggesting mediastinitis without gas bubbles to prove perforation. There was also a small 7-mm aortic pseudo-aneurysm (found only in retrospect) (●" Video 1). She was started on intravenous meropenem. Discussions with a cardiothoracic tertiary center confirmed the decision of conservative management and agreed with the choice of antibiotic. Fig.1 Esophagogastroduodenoscopy images taken near the level of the gastroesophageal junction. a Narrowing of the lumen with the corresponding external compression from the hematoma. b Further extrinsic obstruction of the esophagus.