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Year : 2019 | Volume : 7 | Issue : 1 | Page : 21 - 24  


Case Reports
Esophageal tuberculosis presenting as dysphagia: A rare case

Ram D. Madne1, Anil Helgire2, Venkatramana K Sonkar3*

 1 Physician, 2 Clinical Assistant, Shree Krishna Hospital, Nanded, Maharashtra, India

3 Associate Professor, Department of Community Medicine, Malla Reddy Institute of Medical Sciences, Hyderabad, Telangana, India

*Corresponding Author

Email: sonkar123@gmail.com                                                               

Summary: 

Tuberculosis of esophagus is rare, studies estimate that it constitutes about 0.3% of gastrointestinal TB cases and is usually secondary to tuberculosis focus elsewhere in the body, most commonly pulmonary tuberculosis. We report a case of tuberculosis of esophagus in a 50 year old male secondary to mediastinal lymph nodes for which we treated him conservatively with antitubercular drugs. The patient shows significant clinical improvement with decrease in dysphagia and odynophagia and weight gain as well as complete resolution of symptoms.

Key words: Tuberculosis, dysphagia, case

Introduction: 

Dysphagia is difficulty or discomfort in moving food from the mouth to the stomach. Tuberculosis though a systemic disease rarely causes dysphagia.  Tuberculosis of esophagus is rare, studies estimate that it constitutes about 0.3% of gastrointestinal TB cases 1 and is usually secondary to tuberculosis focus elsewhere in the body, most commonly pulmonary tuberculosis. 2 The spread to esophagus usually occurs from mediastinal tuberculous glands and is less often due to swallowing of infected sputum, hematogenous dissemination or lymphatic route of infection. 3 The preferred site of disease is the middle one third of esophagus. 4 Even though there is increased incidence of extra-pulmonary tuberculosis in HIV positive patients, there is hardly any report on esophageal tuberculosis as an isolated lesion. 5

CASE REPORT: 

A 50 year old male patient presented with low grade fever with evening rise of temperature, dry cough and generalized weakness since 6 months for which he had taken treatment but develops dysphagia and odynophagia of 15 days duration. He had progressive dysphagia for solid foods at first, which progressed to liquids later on. The odynophagia was limited to the retrosternal region without any radiation. He had no history of vomiting, hematemesis, melena, regurgitation or aspiration of food, hemoptysis or breathlessness. Patient had habit of taking almost 8-10 cup of tea per day and is chronic tobacco chewer. He had left alcohol intake five years back.

Physical examination revealed a moderately nourished male, mildly pale with weight loss of 5 kg in last two months. Vital signs were normal. There was no lymphadenopathy, oral or skin lesions. Examination of chest and abdomen did not reveal any positive findings.

At investigation level we found Hemoglobin 9.3 g/dl, total leukocyte count 7,900/cmm with a normal differential count, ESR 52 mm in the first hour (Wintrobes Method). Peripheral blood smear showed normocytic and normochromic anemia. Liver and renal functions and blood sugar were normal. Tuberculin test was positive (10 mm. induration). Chest skiagram showed no abnormality. Patient was HIV negative.

Endoscopic ultrasonography (EUS) showed a small smooth swelling 35 cm from the incisor teeth with a linear deep ulcer with granulation tissue at its base. Few lower para-esophgeal (10-15mm) and sub-carinal (18mm) enlarged lymph nodes present, one of which is communicating with thickened esophageal wall.

CT chest showed thickening of mid thoracic esophagus causing moderate luminal narrowing with no proximal dilatation along with multiple mediastinal lymph nodes especially periesophageal region, focal consolidation present in right upper lobe and bilateral hilar peribronchial region. The histo-pathological report reveals an ulcerated mucosa without epithelium or gland covered by granulation tissue and sub mucosa shows non necrotizing granuloma with no evidence of malignancy. Acid fast bacilli were not detected on Z.N. stain.

Although Z N Staining was negative for Acid Fast Bacilli but histo-pathological findings strongly suggestive of tuberculous lesion so patient was started on anti-tuberculosis treatment comprising Isoniazid (5mg/kg), Rifampicin (10mg/kg), Ethambutol (25mg/kg) and Pyrazinamide (25mg/kg) for two months and Isoniazid (5mg/kg), Rifampicin (10mg/kg) for 7 months. The patient gradually improved, with decrease in dysphagia and odynophagia and weight gain as well as complete resolution of symptoms. 

DISCUSSION: 

The global burden of tuberculosis remains enormous, mainly because of poor control and coexisting nature of Mycobacterium tuberculosis and HIV.

Esophageal tuberculosis is a rare disease, estimated to account for 0.15% of deaths from tuberculosis6. Esophageal tuberculosis is of two types, i.e., primary and secondary. Primary esophageal tuberculosis without active extra-esophageal tuberculosis is even more uncommon, and most patients with this condition have underlying mucosal defects, such as Barretts esophagitis or esophageal cancer. 7

Most reported cases of esophageal TB are secondary as observed in our case resulting from direct extension from adjacent infected structures, including mediastinal or hilar lymph nodes, a pulmonary focus, vertebral bodies, or the larynx. Less commonly, it is caused by haematogenous spread in miliary TB. 8-11  

This patient presented with dysphagia which is most frequent presenting symptom of esophageal TB, occurring in over 90% of cases. 8-11 Other common symptoms include odynophagia and retrosternal pain. Constitutional symptoms like fever, weight loss, and anorexia significantly present in this case are also common and sometimes confused with esophageal malignancy. 6

Tuberculous lesions can occur in any segment of the esophagus but are most common in the mid-esophagus as seen in present case, just proximal to the tracheal bifurcation, because of its proximity to the mediastinal and hilar lymph nodes around the bifurcation of the trachea. 8-11 Macroscopically, the most common lesion encountered is a solitary esophageal ulcer but stricture and fistula may be seen in later cases. 8-11 Mediastinal tuberculous lymph node compression indenting as a sub mucosal mass can be observed in some patients causing luminal narrowing.  A hypertrophic growth mimicking esophageal cancer may be seen at times. 8 rarely, malignancy and TB of the esophagus may coexist, and a definitive diagnosis of both is possible only after careful histological examination. 9 The rarest type of lesion is the granular form with small mucosal miliary granuloma, a form usually secondary to haematogenous spread of infection. 12

Esophageal tuberculosis should be suspected in patients with pulmonary or systemic tuberculosis who develop dysphagia and odynophagia. Approximately 50% of cases demonstrate pulmonary involvement on radiography. Mediastinal status, including periesophageal lymph node, esophageal wall thickness, and pulmonary involvement can be further demonstrated by chest CT scans.13  CT chest is done in our case which shows meditational lymph nodes and right upper lobe parenchyma involvement which is absent on radiography. Upper gastro-intestinal endoscopy taking biopsy specimens is the diagnostic procedure of choice in esophageal TB.8-12 A CT scan of the thorax and/or EUS is mandatory for differentiating primary from secondary infection.

Confirmation of the diagnosis of esophageal TB requires histological demonstration of caseating granuloma as seen in our case and AFB from the endoscopic biopsies or isolation of Mycobacterium Tuberculosis from tissue specimens. 14 However, AFB could not be demonstrated in our case as it is absent several times in esophageal tuberculosis. In addition, tissue should be sent for PCR-MTB and mycobacterial culture. ELISA testing is 80% sensitive for gastrointestinal tuberculosis. 15 

Delay in diagnosis and appropriate therapy might induce severe complications which include bleeding, perforation, fistula formation16 aspiration pneumonia, fatal hematemesis, traction diverticula, and esophageal strictures 17 which were not present in our patient. Differential diagnosis of esophageal tuberculosis includes esophageal carcinoma, Crohns disease, moniliasis, actinomycosis, syphilis, and esophageal injury secondary to ingestion of caustic material. 17 Paroxysmal postprandial cough or frequent aspiration pneumonia is suggestive of trachea-esophageal fistula. The most feared complication of esophageal TB is an aorto-esophageal fistula which can result in massive hematemesis and death. 8

Esophageal TB is managed with anti-tuberculous drugs; surgery being reserved for complications including a non-healing trachea-esophageal or broncho-esophageal fistula, stricture, or bleeding from an aorto-esophageal fistula. 8-11 Present case is treated with 2 months isoniazid, rifampicin, ethambutol, and pyrazinamide and 7 month isoniazid and rifampicin.  A 6 to 9 month course of anti-tuberculous chemotherapy is sufficient for immune-competent patients treated with a regimen consisting of four first-line drugs, namely isoniazid, rifampicin, ethambutol, and pyrazinamide for the initial 2 months, then continuing with isoniazid and rifampicin for another 4 to 7 months. 9, 10, 18 It is necessary to give therapy for longer if one or more of these drugs cannot be used because of intolerance or drug resistance. 18 In cases of MDR-TB, defined as TB caused by organisms showing in vitro resistance to at least both isoniazid and rifampicin, the total treatment duration should be extended to at least 18 months, and the regimen should comprise 5 to 6 drugs to which the organisms are susceptible for the initial 6 months, followed by 3 to 4 drugs subsequently. 19

Maintenance of a good nutritional state is imperative especially considering the altered liver metabolism and vitamin deficiencies associated with it.

CONCLUSION:

Although rare, esophageal tuberculosis must be kept in mind in patients with dysphagia, especially in countries with high prevalence of tuberculosis, even in immune-competent patients. Active pulmonary tuberculosis should be ruled out, since early recognition of this infection is very important for public health. Treatment of esophageal tuberculosis with antituberculous drugs is curative, although complications may sometimes occur.

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  19. Guidelines on the management of patients with multi-drug resistant tuberculosis in Hong Kong. March 2005.  Tuberculosis in Hong Kong. Available from: http://www.info.gov.hk/tb_chest/doc/MDRTBguide_050325.pdf. Accessed 28 Jun 2006

                Fig. 1:- OGD Scopy Shows esophageal wall swelling with small ulcer

                Fig:-2:- EUS shows para-esophageal and sub-carinal lymph nodes along with esophageal wall thickening





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