Esophageal tuberculosis

Esophageal tuberculosis: A rare case report

After a steady decline throughout the 20^th century, the incidence of tuberculosis (TB) in industrialized countries has started to rise again. However, in developing countries like India, the menace of TB had never been controlled. Gastrointestinal (GI) TB is rare, and the GI tract is considered only the sixth most frequent site of extrapulmonary TB. Esophageal TB (ET) is still rarer. This is a case report of a rare form of ET in a patient presenting with dysphagia. The patient was subjected to upper GI endoscopy, which revealed an ulcerative growth in the distal esophagus. Histopathology revealed ET. The patient was managed conservatively with anti-TB treatment (ATT). In spite of the rare nature of the disease, it can be managed effectively with ATT to avoid complications (fistula, stricture, and esophageal perforation), which might warrant surgery.

Tuberculosis of the gastrointestinal tract and associated viscera

Tuberculosis involvement of the gastrointestinal tract, peritoneum, and associated viscera is an uncommon but well described entity. While peritoneal tuberculosis and tuberculous enteritis are more common, involvement of the esophagus, stomach, colon, rectum, anus, liver, bile ducts, gallbladder, and pancreas can occur. Diagnosis is challenging as cases often mimic neoplasm or inflammatory bowel disease. In this review we outline the pathogenesis, clinical presentation, diagnostic testing, and treatment strategies pertaining to such cases.

Gastrointestinal Tuberculosis

Gastrointestinal tuberculosis (TB) is a fascinating disease which can be observed both in the clinical context of active pulmonary disease and as a primary infection with no pulmonary involvement. It represents a significant clinical challenge because of the resurgence of TB as well as the diagnostic challenges it poses. A high clinical suspicion remains the most powerful tool in an era of medicine when reliance on diagnostic technology increases. Antimicrobial therapy is the mainstay of therapy, but surgical and endoscopic interventions are frequently required for intestinal TB. Gastrointestinal TB is truly the "great mimic" and continues to require the astute clinical acumen of skillful clinicians to diagnose and treat.

Dysphagia as a manifestation of esophageal tuberculosis: a report of two cases

Introduction

Esophageal involvement by Mycobacterium tuberculosis is rare and the diagnosis is frequently made by means of an esophageal biopsy during the evaluation of dysphagia. There are few cases reported in the literature.

Case presentation

We present two cases of esophageal tuberculosis in 85- and 65-year-old male Caucasian patients with initial complaints of dysphagia and epigastric pain. Upper gastrointestinal endoscopy resulted in the diagnosis of esophageal tuberculosis following the biopsy of lesions of irregular mucosa in one case and a sessile polyp in the other. Pulmonary tuberculosis was detected in one patient. In one patient esophageal stricture developed as a complication. Antituberculous therapy was curative in both patients.

Conclusion

Although rare, esophageal tuberculosis has to be kept in mind in the differential diagnosis of dysphagia. Pulmonary involvement has important implications for contact screening.

Esophageal tuberculosis mimicking submucosal leiomyoma- report of a case

We present a case of primary esophageal tuberculosis presenting as solitary submucosal mass in cervical esophagus with clinical features of dysphagia, thus mimicking a submucosal leiomyoma on imaging in a 39 year old lady. Excision of this mass revealed features suggestive of tuberculosis on histopathology.

A solitary tuberculous ulcer in the oesophagus

A 48-year-old woman born in Pakistan was evaluated for dysphagia. Endoscopy showed a solitary ulcerative oesophageal lesion. Cultures were positive for mycobacterium tuberculosis. Additional imaging showed no other manifestations of tuberculosis. Oesophageal tuberculosis is a rare entity, especially as a primary manifestation defined as involvement of the oesophagus without signs of disseminated disease. Therefore, this case was classified as primary oesophageal tuberculosis.

Imaging of esophageal tuberculosis: a review of 23 cases

PURPOSE

To evaluate the various radiological abnormalities in patients with proven esophageal tuberculosis.

MATERIAL AND METHODS

The case records of 23 patients with proven esophageal tuberculosis were evaluated retrospectively for various radiological abnormalities. Twenty-two patients had secondary involvement of esophagus in the form of direct extension of mediastinal and pulmonary tuberculosis or spinal tuberculosis. Only 1 patient had primary involvement of the esophagus with no evidence of disease elsewhere. The diagnosis was confirmed by endoscopic and CT-guided biopsy/aspiration cytology in 7 and 6 cases, respectively. Diagnosis was made on the basis of surgical biopsy of lymph node and autopsy in 1 patient each. In the remaining 8 patients the diagnosis was based on radiological and endoscopic findings and the response to antituberculous treatment.

RESULTS

Chest radiography (CXR) was abnormal in 65% patients. While the findings were non-conclusive for esophageal tuberculosis, characteristic lesions of tuberculosis in lungs or spine were suggestive of tuberculous etiology. In 15 patients, CT of the chest confirmed the corresponding CXR findings and also showed additional findings of mediastinal lymphadenopathy when CXR was normal. Fourteen patients showed mediastinal lymphadenopathy on CT of the chest. In all these patients, more than one group of lymph nodes was involved. The characteristic hypodense center of lymph nodes suggestive of tuberculosis was seen in 12 patients. Radiological abnormalities seen in barium swallow examination were extrinsic compression, traction diverticula, strictures, sinus/fistulous tracts, kinking and pseudotumor mass of esophagus in decreasing order of frequency. The middle third of the esophagus was found to be the most frequent site of involvement.

Tuberculosis esofágica en paciente inmunocompetente

We present the case of a 68-year-old man who presented dysphagia and weight loss over the previous three months. Esophageal transit showed extreme stenosis suspicious for neoplasia but which was revealed to be a granulomatous inflammatory lesion. Culture of the lesion revealed Mycobacterium tuberculosis. Chest x-ray showed pulmonary tuberculosis. Esophageal tuberculosis should be considered in patients with dysphagia and pulmonary tuberculosis.

Tuberculous involvement of the oesophagus with oesophagobroncheal fistula

Tuberculous involvement of the oesophagus is a rare disease. Even if it is suspected, diagnosis is often difficult though dysphagia and chest pain are the most common symptoms without any other specific signs of tuberculosis. The diagnosis is based on oesophagography, oesophagoscopy, bronchoscopy, and computed tomographic scan. Suspected tuberculosis can be confirmed with histology, smear, and culture. The two most common differential diagnoses are Crohn's disease and carcinoma. The case is reported of a female patient with tuberculous involvement of the oesophagus, who developed an oesophagobroncheal fistula during steroid treatment started for suspicion of Crohn's disease. The patient was immunocompromised due to treatment with azathioprine that she was receiving for multiple sclerosis. The fistula was successfully treated by antituberculous chemotherapy alone.

Diagnosis and treatment of esophagitis in AIDS

At least 30% of patients with AIDS experience esophageal symptoms at some point during the course of HIV infection. The aim of this review is to provide a practical approach to the evaluation and therapy of esophagitis in AIDS.

Esophageal tuberculosis: a rare presentation with massive hematemesis

A 43-year-old female presented with massive hematemesis. Esophagoscopy showed an ulcer 22 to 25 cm from the incisor with active bleeding. A thoracotomy and primary closure of the ulcer was performed. Massive hematemesis recurred 8 days later, resulting in hypovolemic shock. The thoracic esophagus was resected and histological examination showed granuloma with central caseous necrosis. Combined chemotherapy was given for 10 months. At 6 months after the subtotal esophagectomy, the esophagus was reconstructed using the right-side colon.

Tuberculous Lymphadenopathy Causing Dysphagia: Report of Two Cases

We report two cases of tuberculous lymphadenopathy causing dysphagia. The first patient was HIV positive and the second patient had immigrated recently from India. Culture in both patients grew Mycobacterium tuberculosis that was fully sensitive to first line drugs. Dysphagia may result from intrinsic or extrinsic involvement of the esophagus. Extrinsic involvement is more common and results from cervical and mediastinal lymph node enlargement (as in these 2 cases) that causes external compression on the wall of the esophagus. The dysphagia subsided completely after 4 weeks of antituberculous therapy in both cases.

Esophagoaortic fistula caused by esophageal tuberculosis: report of a case

We report herein the case of a 73-year-old woman who was urgently admitted to hospital with severe hematemesis. An emergency endoscopy revealed a protruding lesion 36 cm from the incisors; however, respiratory insufficiency precluded surgery and despite aggressive medical treatment, the patient's respiratory status continued to deteriorate, leading to death on the 36th hospital day. An autopsy revealed the source of the hemorrhage to be a fistula connecting the esophagus and the descending aorta. Histopathologic studies showed that this fistula was caused by esophageal tuberculosis.

Mediastinal histoplasmosis presenting with esophageal involvement and dysphagia: case study

Esophageal involvement with histoplasmosis is uncommon, but has been recognized in two clinical settings. Most commonly, the esophagus becomes involved as a result of contiguous mediastinal lymphadenopathy. Such patients usually present with dysphagia secondary to midesophageal compression or stricture. The esophagus can also be involved in cases of disseminated histoplasmosis. Esophageal ulcers or nodular lesions are the usual clinical manifestations in this setting. We report a case of mediastinal histoplasmosis with esophageal narrowing and mucosal ulceration that presented with dysphagia. The diagnosis was established at thoracotomy by the histologic finding of necrotizing granulomas and a positive fungal stain. The case was successfully treated with amphotericin B. The literature on esophageal and gastrointestinal histoplasmosis is reviewed.

Esophageal infections: risk factors, presentation, diagnosis, and treatment

Infections of the esophagus are unusual in the general population and strongly imply immunodeficiency, although immunocompetent individuals are not exempt. HIV infection is predominant among risk factors for infectious esophagitis. For all immunocompromised patients, the most frequently identified esophageal pathogens are Candida, CMV, and HSV. Peculiar to HIV-infected patients are idiopathic esophageal ulcers as well as unusual bacteria and parasites. Patterns of presentation differ with each infecting organism, and clinical features should be used as a guide in achieving a correct diagnosis. For example, a patient with AIDS presenting with esophageal symptoms and thrush, along with abdominal pain, nausea, vomiting, and fever, is unlikely to resolve all symptoms with empiric antifungal therapy alone. Parsimony of diagnosis does not hold among immunodeficient patients in whom concurrent infections are common. Accurate and timely diagnoses are essential as effective treatments are available for particular etiologies. Finally, among immunocompromised patients, all esophageal symptoms are not necessarily due to an infection, and possible diagnoses of pill esophagitis, acid-peptic injury, or structural and functional abnormalities should not be overlooked.

Oesophageal tuberculosis mimicking a tumour during treatment for nodal tuberculosis

A patient with cervical lymph node tuberculosis developed a tubercular ulcer in the oesophagus eight weeks after starting treatment. This was probably due to a drug related hypersensitivity reaction in an adjacent mediastinal lymph node and subsided with continued treatment.

Esophageal disease in the acquired immunodeficiency syndrome: etiology, diagnosis, and management

Esophageal disease is a common complication and cause of morbidity in patients with human immunodeficiency virus (HIV) infection. Opportunistic esophageal diseases may occur in patients with long-standing infection or may be the initial manifestation of HIV disease. Although a variety of both opportunistic and nonopportunistic disorders result in esophageal disease in this population, candidal esophagitis is the most common cause of symptomatic disease. Ulcerative esophagitis resulting from cytomegalovirus and idiopathic esophageal ulceration constitute the next most important etiologies. In contrast to other immunocompromised hosts, herpes simplex virus esophagitis appears to be relatively uncommon. Multiple simultaneously discovered esophageal disorders have been documented in up to 50% of patients. Opportunistic neoplasms are an infrequent cause of symptomatic disease. Candidal esophagitis may present with either dysphagia or odynophagia, and oropharyngeal candidiasis is usually present at the time of diagnosis. In contrast, ulcerative esophagitis is usually first manifested by moderate to severe odynophagia. Barium esophagography and upper endoscopy are the most commonly employed diagnostic modalities for the evaluation of the symptomatic patient. Although barium esophagography may identify specific abnormalities, this procedure appears to be relatively insensitive for the detection of mild candidal disease as well as nondiagnostic for ulcerative lesions when compared with endoscopy. In the HIV-infected patient with new-onset esophageal symptoms, an empiric trial of a systemically acting oral antifungal agent should probably be the initial management strategy. If the patient does not respond to standard therapy within 1 to 2 weeks, an endoscopic evaluation appears to be the most cost-effective diagnostic test given the diversity of potential disorders, the possibility of one or more co-pathogens or diseases, the potential for an immediate diagnosis, and the availability of mucosal biopsy to make a definite diagnosis of ulcerative or mass lesions. Given the presently available therapy for these diverse processes, establishing a definitive diagnosis in the symptomatic patient not responsive to empiric antifungal therapy is warranted.

Tuberculosis of the esophagus

Tuberculosis of the esophagus is rare. More cases of secondary tuberculosis of the esophagus have been reported compared to primary esophageal tuberculosis. An illustrative case of primary tuberculosis of the esophagus is presented and 54 published cases of esophageal involvement in tuberculosis are reviewed. There were eight primary and 46 secondary cases of esophageal tuberculosis. There were more male than female patients (M/F = 2.6:1) with an average age of 39.2 years (range 6 months to 75 years). Diagnosis can be difficult, being based on clinical, radiological, endoscopic, and histological features and on the response to chemotherapy. Most cases can be successfully treated with antituberculous chemotherapy even in the presence of fistulous tracts. Patients with esophageal tuberculosis in the presence of AIDS do not respond as well to antituberculous chemotherapy.