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Acquired tracheo-esophageal fistulas (TEFs) are challenging. The most common causes are prolonged intubation, malignancy, and trauma whereas granulomatous infections like tuberculosis are rare. Endoscopic intervention with esophageal or tracheal stenting or clipping is of unproven benefit in the management of such lesions, where surgical repair is almost invariably required. We report a case of a 32-year-old man, with a case of multidrug-resistant pulmonary tuberculosis. He had no history of malignancy or trauma. The patient developed spontaneous TEF probably due to mediastinal lymph node necrosis. Multiple attempts were made using staplers, clips, and atrial septal defect (ASD) device closure but were unsuccessful. The nuanced complication leads to very individualized course of treatment which was optimal for this patient.

Acquired tracheo-esophageal fistula in adult—a classical case of ‘what not to do’