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International Journal of Clinical Case Reports 2013, Vol.3, No.4, 26
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1964),
however, if untreated, 65% of patients will
develop pulmonary or extrapulmonary tuberculosis
within 5 years (Berger and Mejia, 1973). Residual
pleural thickening is c ommon. In treate d case of
tuberculosis average patient becomes afebrile wit hin 2
weeks, complete reabsorption of fluid t akes place in
6
~12 weeks and the incidence of pleural thickening at
6
~12 months is 50%. Size of original effusion and the
presence or absence of small radiologic residual pleural
disease do not correl ate with subsequent appearance of
active tuberculosis (Roper and Waring, 1955).
After extensive search of literature the average duration
of resolution of pleural effusion in tuberculosis come to
be is at least one month; we could not find any case in
which it had been disappeared in less than two weeks.
This feature makes case perplexing.
After getting the new radiological finding, patient was
interrogated for any bout of e xcessive cough with
copious amount of secretion and any other symptom
suggestive of expulsion of fluid through airway or GI
tract. There was no history of any
new respiratory
symptom since the start of ATT.
There was a history of vomiting after one week of start
of treatment, the contents being muco-purulent with
tinges of blood at the beginning. We were surprised how
the loculated collection was vanished after an episode of
vomiting, without any radiological evidence of trachea-
esophageal fistula, or esophageal pleural fistula.
So again review of admission CECT scan film was done,
we could make out the two areas of fluid collection
were in communication with each other and presence of
a necrotic lymph node in between pleural fluid and
esophagus. From this we hypothesized this node has
probably given a track for fluid and it was vomited out
as evident in history (as i n esophageal-pleural fistula),
after it closed spontaneously. Follow-up CECT scan
was unable to explain the tract of fluid.
Esophageal-pleural fistula (EPF) is caused by iatrogenic
trauma (esophageal instrumentation or external trauma),
diseases of the esophagus such as corrosive esophagitis,
esophageal ulcer and neoplasm, and rarely spontaneous-
ly (van Den Bos ch and Laros, 1980; Wechsler and
Laufer, 1982). EPF is a n uncommon complication of
iatrogenic trauma (endoscopic instrumentation) or
post-pneumonectomy.
In our case there is no such history of trauma, surgery of
other cause as described. The expulsion of fluid through
esophagus was sudden and was not preceded by typical
symptoms of esophagitis. The radiological signs of the
EPF depend upon site, duration, and severity of
perforation; and more importantly, the integrity of
pleura. The diagnosis of esophageal rupture/EPF is
made clinically; however, for confirmation, the imaging
is required. The imaging modalities include chest
radiograph, ultrasound, barium swallow, contrast-enhan-
ced CT, and MRI wi th each modality having i ts
advantages, and chest CT is very useful modality. In the
index case there were c linical evidences of EPF but
X-ray, barium meal & CECT chest were unable to
explain EPF.
In all cases described earlier there was hist ory
suggestive of EPF and m any times tract cou ld also be
localized. Here there was no history suggestive of EPF
and during brief period of hospitalization there were
only hiccoughs as sym ptoms of GI system. To make
scene more interesting the tract obliterated after the
expulsion of fluid with minimal residual changes. After
vast search of literature we were u nable to f ind such
unique type of presentation of tuberculosis as a
vanishing lung tumor making this case worth to be
shared with medical community as eye opener.
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