esophagopleural fistula ( epf ) is an uncommon condition despite the anatomical proximity of the trachea and esophagus . causes of epf include pneumonectomy for suppurative or tubercular disease and carcinoma of the lung and malignancy of the esophagus . non - malignant epf is due to trauma or infection . the most common infectious cause of epf is tuberculosis , the others being syphilis , mycotic disease , and crohn 's disease . perforation of the esophagus and subsequent fistula formation can occur as a result of foreign bodies , barrett 's ulcer , and more rarely boerhaave 's syndrome . spontaneous development of a fistula between the esophagus and pleura is rarely described in the literature . a 34-year - old male was admitted with a 1-month history of cough , breathlessness , regurgitation during feeding , and chest discomfort . he was a known case of bipolar mood disorder and was on antipsychotics for the last 7 years . general survey was unremarkable . on chest examination , an enlarged right hemithorax with decreased movement of the right chest and stony dull note over the right hemithorax from the fourth , eighth , and ninth intercostal spaces downward along the midclavicular , midaxillary , and scapular chest x - ray revealed right pleural effusion . on thoracocentesis , there was a dry tap . on ultrasonography of the thorax , there was minimal right pleural collection with internal echoes ( not amenable for aspiration ) . on high - resolution computed tomography ( hrct ) of the thorax , an encysted collection ( 7.9 cm  8.5 cm  10 cm ) was noted in the right pleural space showing air and food particles in it with a linear fistulous communication from the distal esophagus , and on oral contrast administration , the contrast medium was seen to enter into the collection [ figures 1 and 2 ] . finally , the upper gastrointestinal ( gi ) endoscopy confirmed a large fisulous tract measuring 9 mm at the distal esophagus without any mucosal abnormality . with the definite diagnosis of epf , the patient was transferred to the department of cardiothoracic and vascular surgery ( ctvs ) where thoracotomy and closure of the fistula were performed . during the procedure , a number of possible causes for the development of epf following pneumonectomy for suppurative disease of the lung have been suggested . anatomically , the esophagus lies much closer to the right hemithorax than to the left , the left being separated from the pleural cavity by the aorta . the possibility of direct epf and extent of mediastinitis are determined by the anatomic relationship of the esophagus and the pleura , the amount of mediastinal fat , and intervening connective tissue . fistula related to empyema was the most commonly reported case in the preantibiotic era . nonetheless , there continues to be isolated reports of posttuberculous pyopneumothorax fistulas . erosion of an empyema into the esophagus and rupture of caseating lymph nodes into the esophagus are the possible mechanisms . in our case , the cause of epf was unclear . evidence of malignancy was undetectable from radiology and no specific infectious agent was isolated at the time of diagnosis and treatment . esophageal injury should be considered when a patient presents with retrosternal chest pain , fever , dysphagia , and dyspnea , especially when the patient gives antecedent history of instrumentation or surgery . the diagnosis of epf can be suspected clinically ; however , for confirmation , imaging is required . the imaging modalities include chest radiograph , ultrasound , barium swallow , contrast - enhanced computed tomography ( ct ) , and magnetic resonance imaging ( mri ) with each modality having its advantages , and chest ct is a very useful modality . leaks of the esophagus are associated with high mortality and the need to be treated as soon as possible . therapeutic options include surgical repair or resection or conservative management with antibiotic therapy and cessation of oral intake . endoscopic treatment with fibrin glue , clip , suturing , and metallic stents has been described . to conclude , spontaneous development of epf is an unusual condition entity with nonspecific clinical presentation . ct of chest is a very useful modality for early diagnosis and management of epf . it should be performed in patients with pleural effusion presenting with nonspecific clinical symptoms before any intervention or drainage .