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hydrostatic pressure and edema of the face. Patients with this condition usually have a poor prognosis and median life expectancy is approximately 6 months.[4]

2. 3. 4.

 Hamid Shaaban, Tejas Modi, Hiren Patel , Abhishek Kumar1, Michael Maroules1 1


Departments of Hematology and Oncology, Saint Michael’s Medical Center, Newark, 1Saint Joseph’s Regional Medical Center, Paterson, New Jersey, USA. E‑mail: [email protected]

Tavora  F, Rassaei  N, Shilo  K, Foss  RD, Galvin  JR, Travis  WD, et al. Occult primary parotid gland acinic cell adenocarcinoma presenting with extensive lung metastasis. Arch Pathol Lab Med 2007;131:970‑3. McCurdy  MT, Shanholtz  CB. Oncologic emergencies. Crit Care Med 2012;40:2212‑22. Wilson  LD, Detterbeck  FC, Yahalom  J. Clinical practice. Superior vena cava syndrome with malignant causes. N  Engl J Med 2007;356:1862‑9. Yim CD, Sane SS, Bjarnason H. Superior vena cava stenting. Radiol Clin North Am 2000;38:409‑24.

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Brandwein‑Gensler  MS, Gnepp  DR. Low‑grade cribriform cystadenocarcinoma. In: Barnes L, Evenson JW, Reichart P, Sidransky D, editors.World Health Organization Classification of Tumours: Pathology and Genetics of Head and Neck Tumours. Lyon: IARC Press; 2005. p. 233.

DOI: 10.4103/0970-2113.148464

Double fistula: Bronchopleural and pleurocutaneous Sir, A 55‑year‑old male patient came to chest outpatient department with complaints of discharging sinus through the left anterolateral chest wall for the past 1 week. The discharge was serosanguinous and intermittent. The patient was a known case of sputum‑positive pulmonary tuberculosis and is on antitubercular treatment for the past 5 months. There was no previous history of surgery, however, intercostal tube drainage was done for left tubercular hydropneumothorax 5 months back and the tube was kept for 8 days following which it was removed. Initially a possibility of tubercular osteomyelitis of rib with discharging sinus was thought. Patient was referred for computed tomography (CT) scan of chest. CT scan chest showed imaging features of sequelae of pulmonary tuberculosis in both lungs with loculated left pneumothorax. There was presence of left bronchopleural fistula with upper lobe bronchus communicating with the left pleural cavity [Figure 1] with another fistula extending from left pleural cavity to left anterolateral chest wall [Figure 2a and b]. Hence a diagnosis of left sided double fistula, that is, bronchopleural and pleurocutaneous fistula was made. The patient was unfit for surgery, hence bronchoscopic closure of bronchopleural fistula was done using glue injection. The external opening of pleurocutaneous fistula was closed using skin sutures and patient was continued antituberculosis treatment. Patient improved symptomatically and the discharge from the cutaneous site stopped after 2 weeks. 88

Figure 1: Axial CT chest showing direct communication of left upper lobe bronchus with the loculated pneumothorax (black arrow) suggestive of bronchopleural fistula



Figure 2: (a and b) Coronal and axial reformatted CT chest sections showing fistulous communication of loculated left pneumothorax with the external surface of left anterolateral chestwall (black arrows) Lung India • Vol 32 • Issue 1 • Jan- Feb 2015

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Intercostal tube drainage was planned for left loculated pneumothorax, however, the patient did not turn up for intercostal drainage tube insertion and repeat CT examination. The most common cause for bronchopleural fistula is postoperative following pulmonary resection. Other causes include lung necrosis due to infection, chemotherapy or radiotherapy for lung cancer, persistent spontaneous pneumothorax, and tuberculosis.[1] The treatment includes bronchoscopic injection of glues, coils, sealants, and surgery.[1] Pleurocutaneous fistula is a pathologic communication between the pleural space and the subcutaneous tissues. The causes include infectious process complication, neoplasm, foreign body aspiration, or iatrogenic procedures like tube thoracostomy. [2‑4] The usual diagnosis is by imaging studies like CT, magnetic resonance imaging, and transcutaneous ultrasound. Double fistula, that is, bronchopleural and pleurocutaneous fistula due to sequelae of pulmonary tuberculosis is very rare and one should be aware of this entity, so that proper diagnosis can be made using CT and can be appropriately managed depending on the case and cause for fistula.

Senthil Kumar Aiyappan, Upasana Ranga, Saveetha Veeraiyan Department of Radiodiagnosis and Imaging, Saveetha Medical College and Hospital, Kancheepuram, Tamil Nadu, India E‑mail: [email protected]

REFERENCES 1. 2. 3. 4.

Lois  M, Noppen  M. Bronchopleural fistulas: An overview of the problem with special focus on endoscopic management. Chest 2005;128:3955‑65. Lin MT, Shih JY, Lee YC, Yang PC. Pleurocutaneous fistula after tube  thoracostomy: Sonographic findings. J  Clin Ultrasound 2008;36:523‑5. Kesieme EB, Dongo A, Ezemba N, Irekpita E, Jebbin N, Kesieme C. Tube thoracostomy: Complications and its management. Pulm Med 2012;2012:256878. Navani N, Punwani S, Humphries PD, Booth HL. Pleuro‑cutaneous fistula complicating chest drain insertion for tuberculous effusion. QJM 2010;103:799‑800.

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Lung India • Vol 32 • Issue 1 • Jan - Feb 2015 89

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Double fistula: Bronchopleural and pleurocutaneous.

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