We report a 35-year-old HIV-1-positive man who not past nor futureed with severe dyspnea and a nonproductive cough Three fiberoptic bronchoscopic examination revealed an infiltrating and vegetating tracheal mass that was diagnosed as necrotizing candidiasis of the trachea.

We report a 35-year-old HIV-1-positive man who not past nor futureed with severe dyspnea and a nonproductive cough Three fiberoptic bronchoscopic examination revealed an infiltrating and vegetating tracheal mass that was diagnosed as necrotizing candidiasis of the trachea. The lesion followed in the formation of a tracheoesophageal fistula that eventually l to the death of the patient. Postmortem examination showed cytomegalovirus vasculitis in the esophageal wall. (Chest 1994; 106:284-85)

CMV = cytomegalovirus; TE = tracheoesophageal

Tracheoesophageal (TE) fistulas caused by the agency of Candida albicans are rare, on the same level in HIV-1-positive patients. Despite a high oftenness of oral and esophageal candidiasis in HIV-1-positive patients, respiratory tract infections caused by dint of Candida species are quite rare. We not absent an HIV-1-infected man who died as a inference of complications of a TE fistula.

CASE REPORT

A 35-year-old HIV-1-positive man was hospitalized in January 1991 for evaluation of worsening dyspnea. The diagnosis of HIV-1 infection had been made 5 years prior to hospital admission.

In October 1989 the patient existinged with an interstitial pneumonia. Although Pneumocystis carinii could not be isolated, he answered to therapy with trimethoprim/sulfamethoxazole. He had no other AIDS-defining illnesses prior to this hospital admission and was receiving no medication. onward physical examination, the blood influence was 130/80 mm Hg, the pulsation was 80/min, the respiratory rate was 20/min, and he was afebrile. Head and neck examination revealed festering discharge from the right ear, if it were not that no evidence of oral thrush. Findings from examination of the chest and abdomen were unremarkable. No skin lesions or lymphoadenopathy was noted.

conclusions of hematologic laboratory evaluation were normal, with the exception of a CD4+ lymphocyte regard of [3/mm.sup.3]. Serum biochemistry reflection revealed the following: a grape-sugar level of 67 mg/dl; K+ of 25 mEq/L; Na+ of 135 mEq/L; Cl- of 90 mEq/L; [Ca.sup.2+] of 66 mg/dl; total bilirubin of 27 mg/dl; and direct bilirubin of 21 mg/dl A chest radiograph revealed a right basilar infiltrate. civilization of sputum and the right ear discharge were positive for Streptococcus pneumoniae.

Antibiotic therapy was initiated with amoxicillin, 1 g each 8 h orally. Fiberoptic bronchoscopy revealed the nearness of a vegetating and infiltrating mass involving the upper third of the trachea. in succession the eighth hospital day, his temperature spiked to 39[degrees]C and his dyspnea continued to worsen.

Hydrocortisone therapy, 20 mg intramuscularly each 24 h, was started and the amoxicillin was changed to ceftriaxone, 1 g intramuscularly each 24 h. Three consecutive tuberculin skin exhibitions using 10, 50, and 100 IU of PPD were nonreactive at 48 h X-ray tomography of the larynx and trachea demonstrated a gros filling blemish starting 3 cm below the beginning of the trachea and extending inferiorly for 10 cm The lumen of the trachea was irregular and almost completely occluded

forward the 25th hospital day, viral civilization of peripheral blood polymorphonuclear lonely dwellings was positive for cytomegalovirus (CMV) and he was started onward a regimen of intravenous ganciclovir, 250 mg each 12 h. As well, because the patient was still febrile (39 to 395[degrees]C) imipenem therapy, 500 mg each 6 h, was started and the ceftriaxone therapy was discontinued.

Tracheoscopy revealed a necrotic mass extending into the wall of the trachea and eroding the cartilage commencing 3 cm below the beginning of the trachea and extending inferiorly for 7 cm Collapse of the walls of the trachea was also noted. A tracheal prosthesis could not be placed befitting to the length of the lesion. Histologic examination of biopsy specimens showed necrotizing candidiasis of the trachea. Examination for Mycobacterium tuberculosis and Mycobacterium avium-intracellulare was negative. The patient was started forward a regimen of fluconazole, 400 mg intravenously each day. The chest radiograph was unchanged at this time.

A third fiberoptic bronchoscopic exam revealed no change. Microscopic examination of the bronchoalveolar aspirate was positive for Staphylococcus aureus for which the patient was treated with vancomycin, 1 g intravenously each 24 h.

The patient continued to be dyspneic and febrile and onward the 59th hospital day, the antifungal therapy was changed to amphotericin B 5 mg/d intravenously, gradually increased to 30 mg/d A barium esophagogram performed onward the 61st hospital day revealed passage of the barium into the trachea and bronchi (Fig 1)

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His clinical status continued to deteriorate with worsening dyspnea, and he died forward the 67th hospital day of tory arrest. Post-mortem examination showed a TE fistula of 50 cm in diameter (Fig 2) and CMV vasculitis in the esophageal wall.

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DISCUSSION

The patient reported herein is unique in that the TE fistula can be correlated the pair to a deep esophagitis owed to CMV and to an invasive tracheal candidiasis.

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