Case Report: Recovery after 108 days of venovenous extracorporeal membrane oxygenation for rifampicin-resistant pulmonary tuberculosis with bronchopleural fistula

Persistent air leakage from a bronchopleural fistula complicates respiratory support in severe pulmonary tuberculosis because positive-pressure ventilation may impede fistula healing. A 26-year-old woman with type 1 diabetes and incompletely treated rifampicin-resistant tuberculosis developed extensive bilateral cavitary disease, a large left pneumothorax, and refractory respiratory failure. Her PaO 2 /FiO 2 ratio remained approximately 62 mmHg despite pleural drainage and invasive ventilation. Venovenous extracorporeal membrane oxygenation (VV-ECMO) was continued for 108 days, allowing lower airway pressures during antituberculosis treatment, pleural drainage, and pleurodesis. Treatment was complicated by acute kidney injury, thrombocytopenia, right ventricular dysfunction, nosocomial infection, and two circuit exchanges. Three consecutive sputum acid-fast bacilli smears, beginning on Day 63, were negative; visible air leakage had ceased by Day 107. Computed tomography confirmed pneumothorax resolution before ECMO removal on Day 108. Mechanical ventilation continued until Day 208, and the tracheostomy tube was removed on Day 300. Antituberculosis treatment lasted 18 months, and follow-up sputum smears and cultures were negative. The patient regained independent walking and normal daily activities. Imaging more than four years after ECMO removal showed residual cavities and bronchiectatic abnormalities without recurrent pneumothorax. This course illustrates the different timescales of microbiological response, air-leak resolution, and functional recovery during prolonged treatment.