noncancerous causes of bronchoesophageal fistula ( bef ) are rare and in a majority of the cases are due to trauma or infection , the most common being granulomatous disease .
the combination of mediastinal lymphadenopathy and cough following intake of food should alert the treating clinicians about possibility of tuberculous bronchoesophageal fistula .
however , a few case reports have suggested that tuberculous bef can be effectively treated with medical management alone .
a 25 year old woman , with no premorbid illnesses presented with a history of cough during eating for 3 months duration and mucoid , non blood tinged sputum production for 1 month .
there was also no history of foreign body aspiration , ingestion of toxic or corrosive substances or any surgical procedures in past .
her younger sister was detected to have pulmonary tuberculosis 1 yr back and completed antituberculous treatment .
she had been married for 9 months , had regular menstrual cycles and no history of high risk behaviour . on examination she exhibited mild pallor .
there was no icterus , cyanosis , clubbing or lymph node enlargement . pulse rate  86/min , regular ; blood pressure 
110/70  mmhg ; respiratory rate  16/min ; and she was afebrile . cardiovascular , respiratory , gastrointestinal , nervous system examination were within normal limits .
investigations showed wbc 11,200/cmm , with 64% neutrophils and 31% lymphocytes , hgb  10  g / dl , platelet count 230,000/cmm and esr was 55  mm / h .
renal and liver function tests were within normal limits.retroviral screening and autoimmune markers were negative.sputum afb was negative.tuberculin skin test showed an induration measuring 15    15  mm .
esophagoscopy was performed which revealed a 30  mm ulcer with irregular borders with communication into respiratory tract , 25  cm from the oral cavity .
computed tomography scan of thorax with three dimensional reconstruction was done which showed mediastinal lymphadenopathy , with erosion of posterior wall of left main bronchus , with a fistulous tract into anterolateral wall of esophagus ( fig .
bronchoscopy revealed inflamed mucosa which revealed granulomatous inflammation on biopsy.afb staining of bronchial secretions was negative , but tested positive for m.tuberculosis by pcr .
( b & c ) 3d reconstruction of computed tomography thorax showing fistula between left bronchus and esophagus.fig .
( b & c ) 3d reconstruction of computed tomography thorax showing fistula between left bronchus and esophagus .
treatment comprised of an intensive phase for the first two months in which four antituberculous drugs ( isoniazid , rifampicin , pyrazinamide , ethambutol ) were given .
this was followed by a continuation phase for next four months consisting of two drugs ( isoniazid and rifampicin ) .
bronchoscopy was done after completing 4 months of treatment and showed normal bronchial lumen with disappearance of fistulous tract.computed tomography of thorax showed resolution of lung lesions without any fistula .
bef poses a challenge to the clinician for accurate diagnosis which if confirmed can offer the patient a potential cure from repeated pulmonary infections .
some patients are able to avoid the paroxysms of cough by swallowing in the supine position ( ono 's sign ) .
braimbridge and keith classified congenital bef into four types depending on the site of the fistulous tract .
49% of acquired bef are malignant in etiology and the rest are secondary to benign causes such as trauma , tuberculosis , actinomycosis and esophageal diverticulosis .
trauma  foreign body ingestion  instrumentation  crushing trauma  operative trauma  chemical burns causes of acquired esophagobronchial fistula .
the development of bef in tuberculosis and other granulomatous diseases are related to mediastinal lymph node involvement .
inflammation in and around these enlarged lymph nodes lead to involvement of neighboring structures or organs particularly the esophagus and the trachea near its bifurcation resulting in periesophagitis and peritracheitis .
if , however necrosis and caseation occur in the lymph nodes with local abscess formation , secondary rupture into the esophagus , trachea or main stem bronchi results in fistula .
there was evidence of numerous necrotic mediastinal lymphnodes in the computed tomography performed in our patient .
henceforth , fistula would have been caused by the erosion of lymphnode rather than a primary bronchial tuberculosis .
the therapy of esophagobronchial communication is usually surgical , performed by division of the fistulous tract and resection of any portion of the lung irreversibly damaged by the suppurative process .
if the fistulous tract originates from lymph nodes with no parenchymal complication , simple ligation and resection of the fistula can be performed . however , in our case surgical treatment was not required . in a similar study in 3 patients infected with human immunodeficiency virus presenting with tuberculous bronchoesophageal fistula ,
thus , tuberculous bef if diagnosed early , both the causative process and the complicating fistula may be effectively treated with antituberculous chemotherapy without the need of surgical intervention .
we , authors here by declare that we have no conflict of interest regarding the publication of this article .
this article has not been published elsewhere or has not been sent to another journal .
 we report a case of bronchoesophageal fistula associated with tuberculosis . 
 a 25  year old woman presented to us with 3 month history of cough worsening with deglutition . 
 radiological examination revealed mediastinal lymphadenopathy and bronchoscopy with esophagoscopy confirmed the presence of fistulous communication with features of endobronchial tuberculosis . 
 histological examination of bronchial biopsy specimen showed non necrotic granuloma with the pcr positive for mycobacterium tuberculosis in her bronchial secretions . 
 she was begun on antituberculous treatment and became asymptomatic after 2 months . 
 bronchoscopy done during follow up after 4 months showed normal bronchial lumen with disappearance of fistulous tract . 
 imaging showed resolution of lung lesions . 
Introduction
Case report
Discussion
Conflict of interest