[Bronchobiliary fistula associated with combined abscess of lung and liver]

Abstract

History and physical examination: A 43-year-old, cachectic, alcohol-addicted patient was admitted to the hospital due to hemoptysis and fever of up to 40 degrees C for the last 4 days. Physical examination revealed pleural rubs in the right lower lung and a diffuse pain in the right upper quadrant of the abdomen. The right upper quadrant of the abdomen also showed scars from several surgical interventions on the small intestine, the liver and the biliary tract and deformed caudal ribs due to an accident 23 years earlier.

Diagnostics, therapy, and clinical course: Chest X-ray, ultrasound and computed tomography (CT) showed abscess cavities in lung and liver communicating through the diaphragm. Under antibiotic therapy the abscess was drained. Cultures showed Klebsiella pneumoniae and Streptococcus viridans. Continuous lavage of the abscess cavities and antibiotic therapy led to an improvement in parameters of inflammation and clinical status. Imaging after 10 days of treatment showed a contrast enrichment in the abscess cavities and a bronchobiliary fistula accounting for temporary biliptysis. The drainage was removed after 29 days, when similar imaging revealed no further sign of an abscess cavity and a previous CT follow-up had proven a distinct decrease of the abscesses.

Conclusion: Bronchobiliary fistulas are very rare. In most cases they are caused by hepatic or subphrenic abscesses, resulting from different conditions. The development of an bronchobiliary fistula originating from a Klebsiella pneumoniae pneumonia, as indicated by this report, has not been described so far. In the patient presented here, treatment was achieved due to continuous drainage despite the large extent of the abscess.