A 37-year-old man presented to the Emergency Department with a two-week course of asthenia, weight loss, night sweats, dyspnea, left pleuritic chest pain, and cough with putrid sputum. The patient was HIV-positive for about 7 years (risk factor: intravenous drug use) and had started antiretroviral therapy but with poor therapeutic compliance. His medical history also included a hepatitis C and B virus co-infection, lymph node tuberculosis 10 years before (completed 12 months of treatment), and a left lobar pneumonia 4 years earlier, complicated by empyema (he underwent left lower lobectomy and had a persistent bronchopleural fistula).
On physical examination, he was cachectic with caseous-purulent drainage and exteriorization of air with cough effort from an orifice in the antero-lateral left chest wall (Fig. 1a and b). Acid-fast bacilli were identified in this drainage. Initial exams included hemogram (normocytic and normochromic anemia - hemoglobin 10.0 g/dl [13.0-18.0 g/dl]; lymphocytes in the lower limit of normal - 1.03 x 103/mul [1.0-4.8 x 103/mul]; and thrombocytopenia - 123 x 103/mul [150-440 x 103/mul]), electrolytes (normal values), hepatic enzymes (elevated aspartate aminotransferase - 80 U/L [4-33 U/L]), serum albumin (hypoalbuminemia - 1.8 g/dl [3.4-4.8 g/dl]), and coagulation tests (normal values). His HIV viral load had increased from <20 copies/mL to 107409 copies/mL and his CD4+ count had decreased from 591 cell/mul to 241 cell/muL. The chest radiograph showed bilateral infiltrates (Fig. 2) also evident on the chest computed tomography (CT) scan showing several bilateral cavitary lesions (Fig. 3) and a pleurocutaneous fistula extending from left pleural cavity to left anterolateral chest wall (Fig. 4). He was admitted to the Infectious Diseases Unit with the diagnosis of fistulized pulmonary tuberculosis, confirmed by visualization of acid-fast bacilli, positive polymerase chain reaction and cultures for Mycobacterium tuberculosis in the sputum. Was identified resistance to isoniazid and streptomycin on the culture sensitivity tests. The patient started on antituberculous therapy with rifampin, pyrazinamide and ethambutol and improved symptomatically with a favorable outcome. The discharge from the cutaneous site stopped after 7 days.
Axial CT chest showing subcutaneous emphysema in a fistulous path (arrow) corresponding to the pleurocutaneous fistula extending from left pleural cavity to left anterolateral chest wall.