Iatrogenic Bronchopleural Fistula

Abstract

A bronchopleural fistula (BPF) is a communication between the pleural space and the bronchial tree or the lung parenchyma. Despite being a rare entity, a BPF may carry a high mortality rate. Symptoms of BPF are often nonspecific and subtle, so a high index of clinical suspicion is essential for its correct diagnosis, with imaging playing an extremely important role both in the diagnosis and in the selection of the most appropriate therapeutic approach for each patient. This paper reports a case of a 60-year-old male admitted to the hospital for an etiological investigation of a unilateral pleural effusion. The patient underwent several procedures, among them a video-assisted thoracic surgery, complicated by a peripheral BPF. Therapeutic approach for BPFs must be adapted to each particular case. In this patient, a conservative approach proved to be effective. Meanwhile, the patient was diagnosed with pleural tuberculosis, being discharged on antibacillary medication and while improving BPF's manifestations.

Keywords: bronchopleural fistula; chest ct; iatrogeny; radiology.

Figure 1. Supine chest radiograph

Supine chest radiograph that shows a left basal pneumothorax (yellow arrows), pneumomediastinum (green arrow) and extensive thoracic subcutaneous emphysema (blue arrows). Chest tube (pink asterisk).

Figure 2. Non-contrast chest CT, lung window

Non-contrast chest CT, lung window. A) Axial plane and B) Oblique axial plane (magnified view), demonstrates the point of communication between a peripheral enlarged bronchiolar structure and the pleural space, compatible with a bronchopleural fistula (red arrow). Note extensive soft tissue emphysema (blue arrows), large pneumomediastinum (green arrow), left pneumothorax (yellow circle), and left pleural effusion (orange circle). Chest tube (pink asterisk).

Figure 3. Non-contrast chest CT, lung window

Non-contrast chest CT, lung window. A) Coronal plane and B) Oblique coronal plane (magnified view), shows the point of communication between a peripheral enlarged bronchiolar structure and the pleural space, compatible with a bronchopleural fistula (red arrow). Note extensive soft tissue emphysema (blue arrows), large pneumomediastinum (green arrow) and left pneumothorax (yellow circle). Chest tube (pink asterisk).

Figure 4. Non-contrast chest CT, lung window

Non-contrast chest CT, lung window. A) Oblique sagittal plane and B) Oblique sagittal plane (magnified view), demonstrates the point of communication between a peripheral enlarged bronchiolar structure and the pleural space, compatible with a bronchopleural fistula (red arrow). Note extensive soft tissue emphysema (blue arrows) and left pneumothorax (yellow circle). Chest tube (pink asterisk).

Figure 5. Non-contrast chest CT, same axial plane

Non-contrast chest CT, axial images. A) Lung window and B) Soft tissue window, shows focal thickening of the visceral pleura (red arrow) and the air-fluid level of the hydropneumothorax (yellow arrow). Note soft tissue emphysema (blue arrows), left pneumothorax (yellow circle) and left pleural effusion (orange circle).

Figure 6. Non-contrast chest CT, lung window

Non-contrast chest CT, lung window. A) Oblique coronal plane and B) Oblique sagittal plane demonstrates persistence of the bronchopleural fistula, with similar air-leak point (red arrow).

Figure 7. Non-contrast chest CT, lung window, and axial plane

Non-contrast chest CT, lung window, and axial plane show slight reduction in the extent of pneumomediastinum (green arrows) and subcutaneous emphysema (blue arrows). Note bilateral subcutaneous tubes (purple asterisks).

Figure 8. Non-contrast chest CT, same axial plane

Non-contrast chest CT, axial images. A) Lung window and B) Soft tissue window, demonstrates reduction of the left pneumothorax (yellow circle) and the air-fluid level of the hydropneumothorax (yellow arrow). Note left pleural effusion (orange circle), with multiple air bubbles inside.

Figure 9. Non-contrast chest CT, lung window

Non-contrast chest CT, lung window. A) Oblique coronal plane and B) Oblique sagittal plane showing that there is no longer evidence of the peripheral enlarged bronchiolar structure on the left lung neither the point of its communication with the pleural space. In its location, there is now an elongated and filiform structure, with soft tissue density and a fibrous and slightly retractable aspect, sequelae findings derived from the closure of the bronchopleural fistula (red arrows).

Figure 10. Non-contrast chest CT, same axial plane

Non-contrast chest CT, same axial plane. A) Lung window and B) Soft tissue window, showing reexpansion of the left lung base, smaller left pleural effusion (orange circle), and a minimal pneumothorax (yellow arrow).

Figure 11. Diagram of the hospitalization timeline

VATS: video-assisted thoracic surgery; BPF: bronchopleural fistula; PCR: polymerase chain reaction.