Oesophageal-pleural fistula (spontaneous)

Case contributed by Dr Louise Hartley

Presentation

3 week history of persistent shortness of breath on exertion. Background of COPD.

Patient Data

Age: 65
Gender: Female
X-ray

PA Erect CXR

Large gas-containing collection in the left hemithorax with air-fluid level.  There is loss of the left heart and left hemidiaphragm silhouette and slight mediastinal shift to the right.  Overlying atelectasis in the left midzone.  Gas within the stomach or colon is noted in the left upper quadrant.

CT

CT Chest

Large multiloculated left pyopneumothorax with air-fluid level, enhancing walls and split-pleura sign.  The largest pleural collection occupies the left mid/lower hemithorax (12 cm x 10 cm x 15 cm) and communicates with the smaller left costophrenic collection.  Moderate hiatus hernia whereby the stomach abuts the large collection.

Consolidation and collapse of the adjacent left lung.  No mediastinal lymphadenopathy.  Fibrocalcific scarring at both lung apices in keeping with previous TB. 

Fluoroscopy

Water Soluble Contrast Swallow

Gastric fundus located above the level of the diaphragm in keeping with a hiatus hernia. There is a contrast track which extends laterally from the distal oesophagus just above the gastro-oesophageal junction leading into a left pleural collection.  Contrast also passes through oesophagus into body of the stomach and gastric antrum.  Left intercostal drain in situ.  Findings confirm distal oesophageal-pleural fistula.

Case Discussion

Discussion:  Oesophageal-pleural fistulas are uncommon and the majority are associated with malignancy, previous oesophageal instrumentation or surgery, or a rare complication post-pneumonectomy.  In this case, no primary cause was found.  

Pleural fluid aspirated during CT guided drainage was noted to be unusually black in colour and cultures grew Candida krusei and Saccharomyces cerevisiae.  Interestingly, Candida krusei is a budding yeast used in chocolate production and Saccharomyces cerevisiae in winemaking, baking and brewing.  The patient made slow improvement on IV antifungals and a left thoracotomy and pleural space decortication was performed.

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Case information

rID: 52346
Case created: 3rd Apr 2017
Last edited: 7th Aug 2017
Inclusion in quiz mode: Included

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