(Chest. 2001;120:1031-1033.)
© 2001
American College of Chest Physicians
Cough in a Patient With an Infusion Port*
Ching Wong, MD;
Nandita Joshi, MD;
Senthil Nachimuthu, MD;
Gajalakshmi Vaka, MD and
John Bakoss, MD, FCCP
*
From the Department of Internal Medicine, Lutheran Medical Center, Brooklyn, NY.
Correspondence to: Nandita Joshi, MD, 7201 4th Ave, Apt B-10, Brooklyn, NY 11209; e-mail: nanditajoshi{at}yahoo.com
 |
Abstract
|
|---|
In this case report, we describe a patient with a history of
fallopian tube adenocarcinoma who had an infusion port in place for the
past 4 years. During the course of her stay in the hospital for
pneumonia, she developed a cough that became worse with the infusion of
fluids through the port. A portogram done to investigate this problem
revealed the presence of a portobronchial fistula. This is the first
reported case of a portobronchial fistula. Various possibilities to
explain the formation of portobronchial fistula are discussed.
Key Words: chemotherapy • cough • infusion port • portobronchial fistula • portogram
|
Introduction
|
|---|
Long
-term central venous access has become an essential part of treatment
for patients receiving chemotherapy. Although the use of long-term
vascular access devices, particularly infusion ports, has enhanced the
lives of oncology patients, it has added a new set of
challenges.1
2
In this case, we report an unusual
complication related to the long-term use of an infusion port.
|
Case Report
|
|---|
A 56-year-old Hispanic woman was admitted to the hospital for
complaints of stuffy nose and sore throat followed by fever, chills,
and cough productive of yellow sputum for 1 week prior to admission.
The diagnosis of right lower lobe pneumonia was made by chest
radiograph (Fig 1
).
The patient had a history of fallopian tube adenocarcinoma (stage III),
which had been diagnosed 4 years previous to the hospital admission.
The adenocarcinoma was treated with a total abdominal hysterectomy with
bilateral salpingo-oophorectomy and omentectomy followed by
chemotherapy with paclitaxel and carboplatin. The patient had two
recurrences in the abdomen. Each time, she was treated with
chemotherapy consisting of nine courses of paclitaxel and carboplatin.
Complete remission was achieved in both instances. The patient had
received her last course of chemotherapy 8 months prior to admission.
The patient had had a double-lumen infusion port inserted in the left
subclavian vein 4 years previously for chemotherapy. The port was
flushed every 2 months with normal saline solution and heparin as part
of maintenance care, with the last flushing procedure occurring 2
months before the current admission. Over a period of time, one lumen
of the port became blocked and could not be used. The other functioning
lumen then was used for IV chemotherapy. The catheter tip had been
positioned in the lower third of the superior vena cava since
insertion.
The patient’s vital signs on admission to the hospital were as
follows: temperature, 101.6°F; pulse rate, 100 beats/min; respiratory
rate, 20 breaths/min; and BP, 110/70 mm Hg. A physical examination was
significant for the presence of rales in the right base of the lung.
Laboratory data on admission to the hospital were as follows: WBC
count, 6,400/mm3; hematocrit, 39.8; and platelet
count, 163,000/mm3. There were normal levels of
electrolytes, normal renal function, and normal results for
urinalysis. Cultures of blood, sputum, and urine were negative.
The patient was started on IV fluids (ie, normal saline
solution) at 42 mL/h and IV levofloxacin through the port. The
fever and cough improved with treatment. Later, the patient described a
different, more severe cough associated with dyspnea, while the
antibiotic was infusing through the port. As cough is one of the
adverse effects of treatment with levofloxacin,3
the antibiotic was changed to cefazolin. The patient still complained
of cough during antibiotic infusion. To investigate this problem,
normal saline solution was infused via the port at a rapid rate. The
patient developed the same symptoms of cough with dyspnea as mentioned
earlier. A portogram was done and revealed a leakage of contrast
material into the respiratory tract through the right bronchus (Figs 2 -4
). This confirmed the presence of a portobronchial fistula. Bronchoscopy
showed acute and chronic inflammatory changes in the bronchial wall but
failed to reveal a visible opening in the respiratory tract.
The port was surgically removed. The patient did not have any more
respiratory complaints and was discharged home. On a follow-up visit 1
month later, the patient had no complaints of cough, and her chest
radiograph was negative.
|
Discussion
|
|---|
The most common reported long-term complications associated with
the use of ports are thrombosis and infection.2
4
Other
complications include obstruction, leakages, and rupture of the
catheter with subsequent embolization.5
No cases of
portobronchial fistula, however, have been reported previously in the
literature.
This is the first reported case of a portobronchial fistula. Three
possible causes for the formation of the portobronchial fistula are as
follows:
1. The superior vena cava lies in close proximity to the
right pulmonary hilum,6
the bronchus being part
of the pulmonary hilum. The curved catheter tip was in the lower third of the superior vena cava and abutted the vessel wall
(Fig 2)
. Constant friction between the tip of the catheter and the
endothelial lining could have led to the formation of a
thrombus1
that fixed the catheter tip to the vessel wall.
Blockage in one lumen of this patient’s port could have been related
to thrombus formation. Over a period of time, this friction of the
catheter against a single spot could have slowly and progressively
eroded the vessel wall. Extension of this erosion into the right
bronchus could have led to the formation of the fistula. 2.
Before use, the catheter is always checked for patency by using a
10-mL syringe to flush the catheter and obtain blood return.
Sometimes, the catheter also is used for blood drawing. The suction
effect produced during these procedures could have caused the tip of
the catheter to adhere to the vessel wall and damage it. A similar
effect is seen when the stomach is eroded by nasogastric tube
suction. 3. The infusion of highly irritating
chemotherapeutic agents over a period of time and constant movement of
the shoulder, which in turn would cause movement of the catheter-tip,
could have injured the vessel wall.
Our patient had no evidence of bleeding from the site of the
fistula. This can be explained by the chronic nature of the causes
described above and an associated fibrous reaction around the site.
|
Conclusion
|
|---|
When a patient with a long-term infusion port presents with
persistent cough exacerbated with the use of the port, a communication
between the port and the respiratory tract should be excluded. A
portogram will be helpful in evaluating this possibility. While current
literature suggests that the ideal location of the catheter tip is
close to the right atrium,2
we recommend that this be
reevaluated. This case also raises the possibility of the formation of
a fistula between the catheter tip and the adjacent mediastinal
structures in a patient with an infusion port.
|
Acknowledgements
|
|---|
The authors thank Eileen Lyons, RN, Nursing
Care Coordinator, IV Team, Lutheran Medical Center, State University of
New York Health Science Center, Brooklyn, NY.
Received for publication February 15, 2001.
Accepted for publication March 13, 2001.
|
References
|
|---|
-
Reyman, PE (1993) Chemotherapy: principles of administration. Groenwald, SL Goodman, M Frogge, MHet al eds. Cancer nursing: principles and practice 3rd ed. ,312-327 Jones and Bartlett Boston, MA.
-
Rauthe, G, Altmann, C (1998) Complications in connection with venous port systems: prevention and therapy. Eur J Surg Oncol 24,192-199[CrossRef][ISI][Medline]
-
Adverse reactions of levofloxacin. In: Sifton DW, Murray L, Kelly GL, eds. Physician’s desk reference 2001. 55th ed. Montvale, NJ: Medical Economics Company, 2001; 2342
-
Brothers, TE, Von Moll, LK, Niederhuber, JE, et al (1998) Experience with subcutaneous infusion ports in three hundred patients. Surg Gynecol Obstet 166,295-301
-
Lam, AW, Chen, YM, Yang, KY, et al (1999) Disconnection of a venous Port-a-Cath followed by embolization after saline flush: rare case report. Jpn J Clin Oncol 29,643-645[Abstract/Free Full Text]
-
Williams, PL, Warwick, R, Dyson, M, et al (1989) Gray’s anatomy 37th ed. ,1275 Churchill Livingstone London, UK.
TOP
Abstract
Introduction
