Multiple Tuberculous Bronchopleural Fistulas Complicated by Hydropneumothorax: A Case Report of Successful Conservative Management.

We report the case of a 61-year-old man with poorly controlled diabetes mellitus and a history of chronic smoking who presented with two months of fever, productive cough, weight loss, and night sweats. Initial chest radiography revealed a right cavitary lesion with hydropneumothorax, and pleural fluid analysis was positive for Mycobacterium tuberculosis by GeneXpert with markedly elevated adenosine deaminase. Despite catheter drainage and anti-tuberculosis therapy (ATT), a persistent pneumothorax prompted chest tube insertion. Computed tomography confirmed multiple bronchopleural fistulas, a rare complication of pulmonary tuberculosis usually requiring surgical management. Given his stable clinical condition, a conservative strategy was adopted. He improved on ATT with the gradual resolution of pneumothorax. He was discharged with a pneumostat and remained well at follow-up, with weight gain and no recurrence after completing six months of therapy. This case illustrates that selected patients with multiple tuberculous bronchopleural fistulas and hydropneumothorax can be successfully managed conservatively with close monitoring and effective ATT, avoiding the need for surgical intervention.