Mediastinal granuloma with fistulization to the bronchus intermedius

(A) Chest computed tomography (CT) at the time of presentation in a patient with dysphagia and mild chest pain shows a heterogenous mass with associated calcifications consistent with mediastinal granuloma (arrow). Note the lower density in the center, suggestive of necrosis. (B) One week later the patient had sharp chest pain followed by cough productive of clear to white mucus. The mediastinal mass is much smaller (arrow) and contains small amounts of air (arrowhead). Also noted are focal areas of consolidation in the right lung. The findings are consistent with spontaneous fistula to the adjacent bronchus. (C) CT scan three weeks later shows decompression of the lesion (arrow) with a more mature fistula tract to the bronchus intermedius (arrowhead).