Bronchomediastinal fistula caused by endobronchial aspergilloma

Endobronchial aspergilloma is a rare condition affecting immunocompromised patients. We present three cases resulting in airway fistulae.

A 68-year-old male with orthotopic heart transplantation presented with fatigue, cough, and dyspnea. A computerized tomography (CT) scan of the chest and bronchoscopy revealed an endobronchial right mainstem mass and airway fistula to the mediastinum. The mass was debrided and biopsy showed Aspergillus fumigatus. He was treated with antifungals and recovered. A 52-year-old male with acquired immunodeficiency syndrome presented with cough, dyspnea, and hypoxemia. Chest CT showed a bronchus intermedius mass and fistula to the mediastinum. Bronchoscopy revealed a necrotic endobronchial mass and pseudomembranes and confirmed the presence of a fistula. The mass was resected bronchoscopically and Aspergillus fumigatus was isolated. He was treated with antifungals and the fistula healed. A 63-year-old male with chronic lymphoid leukemia was admitted for dyspnea, cough, weakness, and dysphagia. Chest CT and bronchoscopy showed a mass causing obstruction of the subglottic trachea and a fistula to the mediastinum. Biopsy showed Aspergillus fumigatus and he was treated with antifungals. The sinus healed but the patient died of leukemia.

Risk factors for airway aspergilloma include immune deficiency, mucosal damage, and ischemia. We report airway fistula formation as a complication of this infection, which has not been previously emphasized.

Endobronchial aspergillomas may form fistulae to the mediastinum. Aggressive treatment with antifungals and bronchoscopic interventions are required.