Bronchoscopic biological sealing of a bronchopleural fistula in post-tuberculous lung disease: a case report

BackgroundBronchopleural fistula (BPF) is an abnormal communication between the bronchial tree and pleural space that may result in persistent air leakage, impaired lung re-expansion, and pleural infection. Management can be particularly challenging in patients with chronic structural lung and pleural abnormalities.Case presentationA 59-year-old man with a history of recurrent pulmonary tuberculosis presented with persistent left-sided pleural disease, air leakage during pleural drainage, and incomplete lung re-expansion. Serial chest computed tomography (CT) raised suspicion of a bronchopleural fistula. Sputum testing for Mycobacterium tuberculosis was negative, whereas microbiological examination of pleural fluid supported the presence of a superimposed infected pleural space. Under general anesthesia, flexible bronchoscopy was performed through a rigid bronchoscope. Methylene blue was injected through the left pleural drainage tube, and light-blue fluid was observed emerging from multiple subsegments of the left upper lobe apical segment, directly demonstrating the bronchopleural communication. A bronchoscopic biological sealing procedure was subsequently performed using a thrombin–autologous blood–thrombin sandwich technique. Two additional bronchoscopic interventions using thrombin and human fibrinogen were subsequently performed for reinforcement. On the third intervention, repeat methylene blue testing showed only a small amount of blue fluid leakage, which was no longer apparent after additional local thrombin application. However, persistent pleural infection required subsequent thoracic surgical management, including pleural debridement in November and further surgical management of the residual pleural space in December 2024. The patient remained clinically stable during follow-up through August 2026.ConclusionBronchoscopic biological sealing with autologous blood and thrombin may be a minimally invasive treatment option for selected patients with BPF and persistent air leakage. Methylene blue testing can facilitate direct localization of the bronchopleural communication and guide targeted bronchoscopic sealing. This case also illustrates that control of bronchopleural communication and management of an infected pleural space are distinct but complementary therapeutic goals, emphasizing the importance of adequate drainage and multidisciplinary management.