An Open-and-Shut Case: Using Open Window Thoracostomy and Thoracomyoplasty to Tackle Pulmonary Tuberculosis Complications

Abstract Introduction: Bronchopleural fistula (BPF) is a relatively uncommon but serious complication in pulmonary Mycobacterium tuberculosis infection. Although the incidence of tuberculous BPF is not well-documented in large-scale studies, it is recognized as a significant complication. (1) Management requires a tailored approach based on the patient's condition and treatment response, with anti-tuberculosis therapy being crucial for controlling active infections. (2) Failing conservative treatment of tuberculous BPF, surgical therapy includes open window thoracostomy (OWT) to provide continuous drainage of the pleural space and create negative pressure aiding in closure of the fistula. (3, 4, 5) We report a rare case of tuberculous BPF successfully treated with OWT and subsequent thoracomyoplasty. Case Presentation: A 33-year-old man with a history of incarceration was diagnosed with pulmonary tuberculosis (TB) one-year ago after presenting to the hospital with a spontaneous pneumothorax. During his hospitalization, he faced further challenges due to the development of a persistent pneumothorax and empyema secondary to a bronchopleural fistula, necessitating video-assisted thoracoscopic surgery (VATS) with doxycycline pleurodesis, and eventually OWT. He was then discharged to multi-specialty outpatient care including pulmonology, infectious disease, and wound care. After 6 months of RIPE therapy followed by rifampin and isoniazid therapy, monthly sputum samples remained negative for TB. His road to recovery was further complicated by multiple wound infections with Proteus mirabilis prompting his presentation to our hospital. After appropriate treatment, evaluation of the OWT demonstrated healthy granulation tissue. Comparative imaging revealed improvement of lung parenchyma and shrinkage of the thoracostomy site. Resolution of the BPF was confirmed by bilevel positive pressure ventilation while flooding the thoracostomy with sterile water. It was then decided to pursue closure of the thoracostomy with thoracomyoplasty via pedicled latissimus dorsi flap. Postoperatively, the patient demonstrated stable respiratory function and successful wound healing. Discussion: In cases of tuberculous bronchopleural fistula (BPF) and associated empyema that fails standard management, open window thoracostomy (OWT) is an effective surgical approach for infection control in the pleural space. After healing of the pleural cavity, thoracomyoplasty is a viable option for obliteration of the OWT, utilizing muscle flaps to restore chest wall integrity. This case highlights a rare complication of pulmonary tuberculosis treated with a complex combination of surgical drainage and reconstruction.