Non-surgical resolution of a delayed esophagopleural fistula caused by tuberculous mediastinal lymphadenitis: Diagnostic challenges and therapeutic success

Abstract

Background

Esophagopleural fistula (EPF) is an abnormal pathological communication between the esophagus and the pleural space. While EPF is typically associated with malignancy or iatrogenic injury, tuberculosis (TB) is a rare cause, with only a limited number reported cases. Here, we present a case of TB related EPF that developed following diagnostic surgery and was successfully treated with anti-TB therapy alone, without the need for surgical intervention.

Case presentation

A 58-year-old male presented with a three-month history of a six-kilogram weight loss, chronic cough and sputum production. Chest computed tomography (CT) revealed necrotic lymphadenopathy with air bubbles within the 2R lymph node, located in the paratracheal region just below the origin of subclavian artery, raising suspicion for primary lung cancer. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) was performed, but histopathological analysis revealed only non-neoplastic bronchial tissue and lymphoid aggregates. Given the detection of a hypermetabolic lesion in the 2R lymph node on positron emission tomography-computed tomography (PET-CT), raising suspicion of malignancy, a surgical biopsy was performed. However, histopathological examination revealed only chronic active inflammation. One-month postoperatively, the patient developed EPF, which was initially managed with nasogastric tube feeding and antibiotics for aspiration pneumonia. Microbiological tests, including sputum and bronchoscopic washing, were unremarkable. The patient was discharged after approximately 40 days at his request, despite persistent EPF without clinical improvement. Four months later, he was re-admitted due to worsening aspiration symptoms and progressive lung lesions. Repeat microbiological testing ultimately confirmed pulmonary TB, with positive acid-fast bacilli (AFB) staining and Xpert MTB/RIF assay results. Standard four-drug anti-TB therapy led to significant clinical improvement, with complete resolution of the EPF on follow-up CT after six months. The patient fully recovered without surgical intervention.

Conclusions

This case highlights the diagnostic challenges of TB presenting as isolated lymphadenopathy and underscores the importance of repeated testing for accurate diagnosis. Furthermore, it demonstrates that TB-related EPF can be successfully managed with medical therapy alone, even in cases of advanced disease.