The Hidden Culprit: A Computed Tomography Diagnosis of H-Type Tracheoesophageal Fistula in an Adult Revealed After Two Decades of Pulmonary Infections

We report a case of a 41-year-old male with undocumented cardiopathy, managed with furosemide, spironolactone, digoxin, and acetylsalicylic acid, presenting with progressive dyspnea and recurrent respiratory infections since childhood. The patient exhibited worsening dyspnea over four months, escalating to New York Heart Association (NYHA) classification stage IV. Physical examination revealed lower limb edema, right pleural effusion, jugular vein distension, hepatojugular reflux, bilateral crepitant rales, and abdominal distension. Diagnostic workup showed right axis deviation on ECG, bilateral bronchial and interstitial syndrome on chest X-ray, and negative GeneXpert (Cepheid, Sunnyvale, California, United States) for Koch's bacillus. Transthoracic echocardiography indicated paradoxical septum and right cavity dilation. Computed tomography (CT) scan revealed bilateral cystic bronchiectasis, right pleural effusion, mediastinal and hilar lymphadenopathies, right cardiac chambers dilation, tracheal diverticulitis, tracheoesophageal communications, and a left main bronchus-esophagus fistula. Laboratory tests indicated leukocytosis with neutrophilia. The patient was admitted to the Intensive care unit (ICU) for respiratory infection management, pulmonary artery hypertension control, and bypass of the tracheoesophageal fistula (TEF) with a nasogastric tube pending surgical repair. This case highlights a probable congenital H-type TEF as the underlying cause of the patient's recurrent respiratory infections. TEF, typically diagnosed at birth, can rarely present in adulthood, with the H-type being a rare form. Symptoms often include recurrent pneumonia, hemoptysis, and meal-associated coughing. Diagnosis involves thoracic imaging and endoscopy, with esophagography and CT scans being critical for detecting the fistula. Treatment options include surgical and endoscopic interventions, with the cervical approach often preferred for operative correction. Early diagnosis of congenital TEF is crucial for preventing recurrent infections and associated complications. Healthcare providers should maintain vigilance for TEF in patients with unexplained recurrent respiratory infections, ensuring timely and effective management through appropriate diagnostic and therapeutic strategies.