TYPE: Late Breaking Case Report TOPIC: Pediatrics INTRODUCTION: The close anatomical relationship between the esophagus and the lung makes the latter vulnerable for esophageal diseases which are relatively common in children. CASE PRESENTATION: We report the observation of a 4-year-old girl with poly malformations suggestive of VACTERL syndrome. She underwent surgery on her first day of life for esophageal atresia with a tracheoesophageal fistula. At the age of 5 months, she developed a chronic cough and a recurrent pneumonia. The barium swallow study showed a massive supra carinal GERD, an anastomotic esophageal diverticulum and an early opacification of the bronchial tree evoking a GERD which floods the lungs or a tracheoesophageal fistula (figure). The pulmonary involvement on the thoracic CT scan was impressive with a tree-in-bud sign, parenchymatous condensations, atelectasis in retractile band, bronchiectasis and ground glass areas. she received proton pump inhibitor and anti inflammatory long term azithromycin treatment. The control barium swallow test objectified vanishing of the lung flooding. The outcome was marked by a recurrent wheezing requiring tretatment by inhaled corticosteroid. DISCUSSION: Aspiration pneumonitis is the main complication of esophageal diseases. The challenge is to determine its mechanism; is it GERD, tracheoesophageal fistula, esophageal stenosis or diverticulum as reported in this case. the objective of an early diagnosis is to not delay the appropriate treatment and to stabilize the respiratory function before irreversible damage occur, namely, bronchiectasis, bronchiolitis or lung fibrosis. CONCLUSIONS: Thus, clinical and radiological monitoring of the respiratory system in the context of esophageal disease is a crucial element to watch out for complications at an early stage. DISCLOSURE: Nothing to declare. KEYWORD: lung