AJR 2000; 175:819-820
© American Roentgen Ray Society
CT of Bronchopericardial Fistula
An Unusual Complication of Multidrug-Resistant Tuberculosis in HIV Infection
Jeffrey A. Bennett1 and
Linda B. Haramati
1
Both authors: Department of Radiology, Albert Einstein College of Medicine and
Montefiore Medical Center, 111 E. 210th St., Bronx, NY 10467.
Received December 9, 1999;
accepted after revision February 10, 2000.
Address correspondence to L. B. Haramati.
Introduction
Pneumopericardium, air or gas within the pericardial space, is rare. Most
commonly it is caused by trauma or iatrogenic factors such as thoracic surgery
or positive pressure mechanical ventilation. About 25% of cases are caused by
diseases in contiguous organs, with direct communication between the
pericardial sac and an air-containing structure such as a bronchus, the
esophagus, or the stomach [1].
Less common causes include infection in the pericardial fluid by gas-producing
organisms and other causes of increased intrathoracic pressure
[1]. Chest CT can be useful to
define the underlying disease and to determine the number and location of
fistulas, if present. We report a patient with AIDS who had
multi-drug-resistant pulmonary tuberculosis with a bronchopericardial fistula
presenting as pneumopericardium. The bronchopericardial fistula was directly
visualized on CT.
Case Report
A 30-year-old woman with HIV infection presented with fever, cough,
pleuritic chest pain, and shortness of breath and was admitted to the
hospital. Her HIV risk factors included needle sticks while working as a
janitor in a hospital and unprotected hetero-sexual sex. Her CD4 cell count
was 17/µL. During her hospitalization, she was diagnosed with
multidrug-resistant tuberculosis, and appropriate four-drug antituberculous
therapy was initiated. Three weeks later, the patient developed stabbing
left-sided chest and abdominal pain.
Chest radiography revealed pneumopericardium. The pericardium was thickened
and septate (Fig. 1A). Chest CT
on the same day revealed pneumopericardium with a markedly thickened and
nodular pericardium and multiple septations in the pericardial space
(Fig. 1B). Numerous ill-defined
small centrilobular nodules were present in the lungs bilaterally with a
predominance in the upper lobes and on the left side. A focal area of
consolidation was present in the anterior segment of the left upper lobe. A
bronchopericardial fistula in the left upper lobe was directly visualized on
one 5-mm-thick section (Fig.
1C).
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Fig. 1B. —30-year-old woman with HIV infection. Chest CT scan reveals
pneumopericardium with septations within pericardial space. Pericardium is
nodular and thickened. Note numerous ill-defined centrilobular nodules in lung
parenchyma.
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The patient's antituberculous therapy was continued. Although the
pneumopericardium was shown on chest radiographs for many months, the
bronchopericardial fistula eventually healed, and the pneumopericardium
resolved after 8 months of antituberculous therapy.
Discussion
Bronchopericardial fistula can be inferred from pneumopericardium
associated with conditions known to cause fistula formation. However, to our
knowledge, direct CT visualization of a bronchopericardial fistula has not
been reported.
Necrotizing pulmonary processes can occasionally fistulize to the pleura
or, rarely, to the pericardium. Pulmonary infections that may result in
fistula formation include necrotizing bacterial pneumonia, tuberculosis
[2], histoplasmosis, and
invasive pulmonary aspergillosis
[3]. Bronchogenic carcinoma can
also result in bronchopericardial fistula. Both blunt and penetrating trauma
can cause a bronchopericardial fistula. Trauma includes iatrogenic
manipulation such as left-sided thoracentesis and thoracic surgery. Infected
automatic implantable cardioverter defibrillators are a recently described
iatrogenic cause of bronchopericardial fistula
[4].
Our patient had late-stage AIDS and was being treated for extensive
multidrug-resistant pulmonary tuberculosis. Patients with HIV infection are
predisposed to developing tuberculosis at all levels of CD4 cell count.
However, at low CD4 cell counts, the patients are predisposed to presenting
with widespread tuberculosis. Bronchopleural and bronchoesophageal
[2] fistulas have been reported
as complicating pulmonary tuberculosis in patients with HIV infection.
However, to our knowledge, a directly visualized bronchopericardial fistula
has not been previously described as complicating pulmonary tuberculosis in
AIDS.
CT has been shown to be useful in revealing peripheral bronchopleural
fistulas with various causes in patients having persistent pneumothorax or
empyema [5]. Direct
visualization of a bronchopleural fistula can be helpful in treating patients
in whom tube thoracostomy has failed; and those in whom surgical closure,
transbronchial occlusion, or interventional radiologic placement of Gianturco
coils to close the fistula is contemplated
[5,
6].
Pneumopericardium, unlike pneumothorax, often does not require specific
treatment. The appropriate therapy is usually directed toward the underlying
disease. However, tension pneumopericardium leading to cardiac tamponade
occasionally complicates pneumopericardium
[3,
7,
8]. This complication is
thought to be caused by a ball valve mechanism preventing air from leaving the
pericardial space [3].
Traditional therapy for tension pneumopericardium has been tube decompression.
Treatment directed toward closing the bronchopericardial fistula may be more
easily undertaken if the fistula is directly imaged.
This case illustrates the usefulness of CT in directly visualizing a
bronchopericardial fistula. Although the presence of a fistula can be inferred
in patients with pneumopericardium and known pulmonary disease, trauma, or
iatrogenic manipulation, careful review of the CT scan obtained using thin
sections through the area of suspected fistula can be successful in directly
showing the bronchopericardial fistula.
Acknowledgments
We thank Eleanor Murphy for her assistance in manuscript preparation.
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Introduction
Case Report
