Double fistula: Bronchopleural and pleurocutaneous.

Sir,

A 55-year-old male patient came to chest outpatient department with complaints of discharging sinus through the left anterolateral chest wall for the past 1 week. The discharge was serosanguinous and intermittent. The patient was a known case of sputum-positive pulmonary tuberculosis and is on antitubercular treatment for the past 5 months. There was no previous history of surgery, however, intercostal tube drainage was done for left tubercular hydropneumothorax 5 months back and the tube was kept for 8 days following which it was removed. Initially a possibility of tubercular osteomyelitis of rib with discharging sinus was thought. Patient was referred for computed tomography (CT) scan of chest. CT scan chest showed imaging features of sequelae of pulmonary tuberculosis in both lungs with loculated left pneumothorax. There was presence of left bronchopleural fistula with upper lobe bronchus communicating with the left pleural cavity [Figure 1] with another fistula extending from left pleural cavity to left anterolateral chest wall [Figure 2a and b]. Hence a diagnosis of left sided double fistula, that is, bronchopleural and pleurocutaneous fistula was made. The patient was unfit for surgery, hence bronchoscopic closure of bronchopleural fistula was done using glue injection. The external opening of pleurocutaneous fistula was closed using skin sutures and patient was continued antituberculosis treatment. Patient improved symptomatically and the discharge from the cutaneous site stopped after 2 weeks. Intercostal tube drainage was planned for left loculated pneumothorax, however, the patient did not turn up for intercostal drainage tube insertion and repeat CT examination.

Figure 1

Axial CT chest showing direct communication of left upper lobe bronchus with the loculated pneumothorax (black arrow) suggestive of bronchopleural fistula

Figure 2

(a and b) Coronal and axial reformatted CT chest sections showing fistulous communication of loculated left pneumothorax with the external surface of left anterolateral chestwall (black arrows)

The most common cause for bronchopleural fistula is postoperative following pulmonary resection. Other causes include lung necrosis due to infection, chemotherapy or radiotherapy for lung cancer, persistent spontaneous pneumothorax, and tuberculosis.[1] The treatment includes bronchoscopic injection of glues, coils, sealants, and surgery.[1]

Pleurocutaneous fistula is a pathologic communication between the pleural space and the subcutaneous tissues. The causes include infectious process complication, neoplasm, foreign body aspiration, or iatrogenic procedures like tube thoracostomy.[234] The usual diagnosis is by imaging studies like CT, magnetic resonance imaging, and transcutaneous ultrasound.

Double fistula, that is, bronchopleural and pleurocutaneous fistula due to sequelae of pulmonary tuberculosis is very rare and one should be aware of this entity, so that proper diagnosis can be made using CT and can be appropriately managed depending on the case and cause for fistula.