Mediastinal complications from tuberculosis are numerous and can originate from primary infection of various structures and from spread from contiguous infection via direct extension or through fistula formations. Primary infections of mediastinal structures include the thymus, mediastinal nodes, and tracheobronchial tree, but also mediastinitis, mediastinal cold abscesses, infected vertebral bodies, HIV with mediastinal nodes, and esophagitis. If any of these structures are infected, they can cause direct involvement of neighboring structures through direct spread or via fistula formation. This process can result in erosion of any of the vascular structures in the mediastinum, or the thoracic duct, leading to vascular catastrophies and chylous fluid collections (pleural or mediastinal). The site and location of the fistula will dictate symptoms. The most common symptoms of tracheobronchial and/or esophageal fistulas are chronic paroxysmal cough, dysphagia, fever, and pneumonia. However, up to 75% of patients may initially have few or no signs or symptoms and a chronic and indolent course. Very infrequently, there are dramatic manifestations of the disease such as symptoms from superior vena caval, esophageal, or bronchial obstruction, and from vascular erosions. It is important to know that in contrast to malignant fistulas, tuberculous fistulas more commonly involve the right and left mainstem bronchi rather than the trachea.