esophageal-pleural fistula: the cause or effect of recurrent pneumonia?

Esophageal-pleural (e-p) fistula is introduced to be an uncommon clinical finding maybe due to non-specific clinical pointers and vague radiologic clues. in this regard, the main drivers are esophageal traumatization, endoscopic dilation, irradiation and corrosive agent ingestion as well as major underlying esophageal diseases like carcinomas and tuberculosis. the presented case is a 51-year-old man with medical record of recurrent pneumonias resulted in right lobectomy who admitted to the medical institution with a significant empyema leading to chest tube insertion. it should be noted that the presence of food particles in the chest bottle in addition to the history of previous surgery raised suspicion of a post-surgical e-p fistula formation. attempts were made to find fistula tract and insert an esophageal stent bypassing the fistula opening. however, investigations argued against e-p fistula as an ensuing event after surgery and arose the question that whether e-p fistula would be the cause or effect of pneumonia in the presented case?