Bronchopericardial Fistula: A Rare Complication of Necrotizing Pneumonia

Abstract

Pneumopericardium due to bronchopericardial fistula formation is a rare complication secondary to necrotizing pneumonia. Several such cases are reported due to different suppurative bacterial infections. Persistent fistulous communication has been reported to lead to tension pneumopericardium and hemodynamic instability, requiring urgent intervention such as pericardial drainage. A 41-year-old male patient, known to have chronic kidney disease and diabetes mellitus, presented with acute respiratory symptoms. Upon admission, the patient was febrile and required oxygen support via nasal prongs. A chest X-ray showed fibrocavitatory changes on the right side, with patchy air shadowing around the cardiac silhouette and a continuous diaphragm sign. A contrast-enhanced computed tomography (CECT) thorax revealed extensive areas of consolidation with necrotic areas within, forming a thin-walled cavity involving the right middle lobe. Also, suspicious communication of this cavity with the pericardial cavity along the right atrium was seen, with minimal pericardial collection and air foci within. The pleural fluid culture showed growth of Klebsiella pneumoniae. According to the antibiotic sensitivity report, the patient was started on IV meropenem and gentamicin for 21 days while monitoring kidney functions. The patient clinically improved on antibiotics, and follow-up radiological investigations showed resolution of pneumopericardium. In this patient, pneumopericardium was mild, and there was no evidence of tension pneumopericardium. Thus, conservative management with antibiotics was provided, with successful resolution. Unlike this case, if evidence of tension pneumopericardium had been present, emergency interventions for decompression would have been required, and these cases would have had a poor prognosis. This case demonstrates the importance of high suspicion and early diagnosis of pneumopericardium in patients with necrotizing pneumonia. Prompt treatment in these patients can prevent further life-threatening sequelae.

Keywords: broncho-pericardial fistula; cavity; klebsiella pneumoniae (kp); necrotising pneumonia; tension pneumopericardium.

Figure 1. Chest X-ray of the patient on admission showing right middle zone cavitation and continuous diaphragm sign, pericardial air shadowing indicated by yellow arrows.

Figure 2. CECT thorax axial view section showing pericardial air foci suggestive of pneumopericardium, indicated by left arrows. Note the thickened pericardium.

CECT: Contrast-enhanced computed tomography.

Figure 3. CECT thorax axial view section showing suspected fistulous communication of the right middle lobe cavity with the pericardial cavity along the right atrium, indicated by the left arrow.

CECT: Contrast-enhanced computed tomography.