Management of children with tuberculous broncho‐esophageal fistulae

Introduction Broncho-esophageal fistula (BOF) is a rare complication of Mycobacterium tuberculosis (MTB). TB-associated BOF presents either as acute respiratory failure, aspiration pneumonia or as a complication of surgical decompression of thoracic lymph nodes. Methods All children with TB- associated BOF were included. TB was diagnosed if MTB was cultured from respiratory secretions, Ziehl-Neelsen (ZN) smear was positive, GeneXpert MTB/RIF was positive or a chest radiograph revealed radiographic features typical of TB. BOF was diagnosed by a contrast swallow study and/or flexible bronchoscopy. Chest computed tomography (CT) scan was performed, if required. Results Total of 20 children were diagnosed with TB-associated BOF between 1999 and 2019, with a 75% survival. A total of 85% BOF involved the left main bronchus. A total of 80% of patients were MTB culture or ZN smear-positive. Chest X-ray abnormalities included: extensive parenchymal disease (80%) and lymph gland enlargement (45%). CT features included visualization of the BOF (60%), esophageal air (73%) and pneumomediastinum (40%). BOF closure was achieved by surgical closure (46%), spontaneous closure (26%), fibrin glue (13%), and esophageal stent (13%). Multivariant regression analysis showed that C- reactive protein (CRP), albumin and CRP/albumin ratio were associated with mortality. Conclusion Most TB-associated BOF are left-sided. It presents either acutely, with respiratory failure, or with chronic respiratory symptoms of aspiration. Children requiring invasive ventilation have high mortality. Most TB-associated BOF requires surgical intervention, although the use of fibrin glue offers an attractive alternative option.