An 18-month-old girl with known pulmonary tuberculosis, on treatment for 5 months, presented with a history of coughing after feeding and recurrent infections of the left lower lobe. Chest radiograph showed a large right-side mediastinal lymph node, patent airways and pneumonic changes in the right middle lobe. There was gaseous distension of the stomach. Flexible bronchoscopy confirmed a suspected broncho-oesophageal fistula (BOF) in the left main bronchus with caseating material eroding into the lumen. Gastroscopy visualised a calcified lesion in the oesophagus.

Barium swallow (Fig. 1) confirmed the left-side BOF with contrast medium demonstrated in the tracheo-bronchial tree during the ‘swallow’ phase (arrow), without evidence of palatopharyngeal aspiration. Contrast-enhanced CT scan of the chest (Fig. 2) showed enlarged, calcified subcarinal lymphadenopathy compressing the left main bronchus and bronchus intermedius with erosion into the oesophagus (short arrow). A fistula was demonstrated between the oesophagus and the left main bronchus (long arrow). There was bilateral hilar lymphadenopathy. A calcified lymph node was seen extending from the oesophagus to the left main bronchus in the position of the BOF.

Fig. 1
figure 1

Upper gastrointestinal contrast study

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Fig. 2
figure 2

Axial contrast-enhanced CT scan of the chest

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These images confirm that BOF secondary to tuberculosis in children is most likely caused by glandular erosion of a lymph node into both the oesophagus and bronchus, although other explanations for BOF have been reported in adults [1, 2].