esophagopleural fistula ( epf ) is an uncommon condition despite the anatomical proximity of the trachea and esophagus .
causes of epf include pneumonectomy for suppurative or tubercular disease and carcinoma of the lung and malignancy of the esophagus .
non - malignant epf is due to trauma or infection . the most common infectious cause of epf is tuberculosis , the others being syphilis , mycotic disease , and crohn 's disease .
perforation of the esophagus and subsequent fistula formation can occur as a result of foreign bodies , barrett 's ulcer , and more rarely boerhaave 's syndrome .
spontaneous development of a fistula between the esophagus and pleura is rarely described in the literature .
a 34-year - old male was admitted with a 1-month history of cough , breathlessness , regurgitation during feeding , and chest discomfort .
he was a known case of bipolar mood disorder and was on antipsychotics for the last 7 years .
general survey was unremarkable . on chest examination , an enlarged right hemithorax with decreased movement of the right chest and stony dull note over the right hemithorax from the fourth , eighth , and ninth intercostal spaces downward along the midclavicular , midaxillary , and scapular
chest x - ray revealed right pleural effusion . on thoracocentesis , there was a dry tap .
on ultrasonography of the thorax , there was minimal right pleural collection with internal echoes ( not amenable for aspiration ) . on high - resolution
computed tomography ( hrct ) of the thorax , an encysted collection ( 7.9 cm  8.5 cm  10 cm ) was noted in the right pleural space showing air and food particles in it with a linear fistulous communication from the distal esophagus , and on oral contrast administration , the contrast medium was seen to enter into the collection [ figures 1 and 2 ] .
finally , the upper gastrointestinal ( gi ) endoscopy confirmed a large fisulous tract measuring 9 mm at the distal esophagus without any mucosal abnormality . with the definite diagnosis of epf
, the patient was transferred to the department of cardiothoracic and vascular surgery ( ctvs ) where thoracotomy and closure of the fistula were performed . during the procedure ,
a number of possible causes for the development of epf following pneumonectomy for suppurative disease of the lung have been suggested .
anatomically , the esophagus lies much closer to the right hemithorax than to the left , the left being separated from the pleural cavity by the aorta .
the possibility of direct epf and extent of mediastinitis are determined by the anatomic relationship of the esophagus and the pleura , the amount of mediastinal fat , and intervening connective tissue .
fistula related to empyema was the most commonly reported case in the preantibiotic era . nonetheless , there continues to be isolated reports of posttuberculous pyopneumothorax fistulas .
erosion of an empyema into the esophagus and rupture of caseating lymph nodes into the esophagus are the possible mechanisms . in our case , the cause of epf was unclear .
evidence of malignancy was undetectable from radiology and no specific infectious agent was isolated at the time of diagnosis and treatment .
esophageal injury should be considered when a patient presents with retrosternal chest pain , fever , dysphagia , and dyspnea , especially when the patient gives antecedent history of instrumentation or surgery .
the diagnosis of epf can be suspected clinically ; however , for confirmation , imaging is required .
the imaging modalities include chest radiograph , ultrasound , barium swallow , contrast - enhanced computed tomography ( ct ) , and magnetic resonance imaging ( mri ) with each modality having its advantages , and chest ct is a very useful modality .
leaks of the esophagus are associated with high mortality and the need to be treated as soon as possible .
therapeutic options include surgical repair or resection or conservative management with antibiotic therapy and cessation of oral intake .
endoscopic treatment with fibrin glue , clip , suturing , and metallic stents has been described .
to conclude , spontaneous development of epf is an unusual condition entity with nonspecific clinical presentation .
ct of chest is a very useful modality for early diagnosis and management of epf .
it should be performed in patients with pleural effusion presenting with nonspecific clinical symptoms before any intervention or drainage .
 esophago - pleural fistula ( epf ) is an uncommon condition , despite of an anatomical proximity of these structures . 
 causes of epf include pneumonectomy for suppurative or tubercular disease of lung and carcinoma lung , malignancy of esophagus . 
 benign epf is rare and may be due to trauma or infection . 
 the most common infectious cause is tuberculosis . 
 spontaneous development of fistula between esophagus and pleura is rarely described in literature . 
 we , hereby present a spontaneous case of such a rare entity in a middle - aged male . 
INTRODUCTION
CASE REPORT
DISCUSSION
CONCLUSION