Pneumocephalus resulting from chest infection complicated by pleural-subarachnoid fistula

Abstract

Pleural-subarachnoid fistula is a rare type of Cerebrospinal fluid fistula with less than 60 cases reported in the literature. Here we present a case of 55-year-old female patient, known case of acute myeloid leukemia on chemotherapy, who developed pleural-subarachnoid fistula due to invasive atypical apical lung fungal infection. All of the reported cases in the literature were secondary to trauma or post-surgery. To our knowledge, this is the first reported case of pleural-subarachnoid fistula developed as sequela of fungal infection.

Fig. 1

non-enhanced CT of the brain: (A, B) a Large amount of intraventricular air with air-fluid levels (arrows). (B, C) Also, Multiple scattered locules are present at subarachnoid space in the bilateral frontal and left temporal lobes (arrowheads) and basal cisterns (dashed arrows).

Fig. 2

AP chest radiograph: right apical cavitary lesion with irregular wall.

Fig. 3

non-enhanced CT guided biopsy of right upper lobe posterior cavitary mass (arrow). The image demonstrates the biopsy needle tract away from the spinal canal.

Fig. 4

Multi sequence MRI of the thoracic spine: (A, B) Well-defined heterogeneous signal intensity cavitary lesion at the right paravertebral region at the upper-level T3 down to lower T4 level (arrows). (C)The lesion showed erosion and involvement of the adjacent posterior right T3-4 with extension posteriorly into the right posterior paraspinal region (arrow). There is limited right neural foramina extension at the T3-4 level (arrowheads). However, no intraspinal extension.

Fig. 5

Non-enhanced HRCT of the chest: (A) Right apical cavitary lesion with involvement of the right paraspinal muscles (arrow). Multiple air foci are present within the collection and in the paraspinal muscles involvement. (B) Adjacent osseous rarefaction is noted at the posterior aspect of the right 3rd and 4th ribs as well as right transverse processes of the same levels. (C) Displaced fractures of the right 3rd and 4th ribs are present (arrow), with involvement of the T3 right transverse process, lamina, and pedicle (arrowheads).

Fig. 6

Thoracic spine CT myelogram: at the level of T3-T4, there is contrast extravasation noted tracking from the spinal canal through a fistulous tract (arrow) along the right neural foramina into the right pleural cavity (arrowhead) likely secondary to a dural tear.