A 52-year-old woman presented to the emergency department in February 2012 with a productive cough of 2 months duration and recurrent pneumonia. The patient had a history of recurrent bacterial pneumonias and stage IIIC squamous cell esophageal cancer that was managed with chemotherapy and radiotherapy. Chest imaging (panel A) revealed a right lower lobe infiltrate consistent with a possible early pneumonia. Because of the large amount of expectoration, computed tomography was performed, results of which revealed a large tracheoesophageal fistula approximately 1 cm proximal to the carina (panel B). The patient was sent to a tertiary care facility for treatment and was lost to follow-up. 

In adults, 50% of acquired tracheoesophageal fistulas manifest in the context of a mediastinal malignancy.¹ Mediastinal malignancies, which have an incidence of 4.5% in US adults, are caused by esophageal cancer in 77% of cases.² Tracheoesophageal fistula is considered an urgent oncologic complication.³ Physicians should therefore consider tracheoesophageal fistula in the differential diagnosis for pneumonia in patients with a history of mediastinal cancer, particularly esophageal cancer.