Esophageal-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

PA Erect CXR

x_ray

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 Chest

ct

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. 

Water Soluble Contrast Swallow

Fluoroscopy

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 esophagus just above the gastro-esophageal junction leading into a left pleural collection.  Contrast also passes through esophagus into body of the stomach and gastric antrum.  Left intercostal drain in situ.  Findings confirm distal esophageal-pleural fistula.

Case Discussion

Discussion:  Esophageal-pleural fistulas are uncommon and the majority are associated with malignancy, previous esophageal 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 color 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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