Dysphagia due to tuberculosis

Oesophageal Tuberculosis: A Systematic Review Focusing on Clinical Management

Oesophageal tuberculosis, an uncommon form of extrapulmonary tuberculosis, has been reported mainly as small case series and the literature is heterogeneous. A systematic review to characterize the clinical presentation, evaluation and management of oesophageal tuberculosis was performed. Electronic databases were searched with keywords: esophagus OR esophageal AND tuberculosis. We included original papers and case series (> 4 patients) with oesophageal tuberculosis. Twenty-two studies reporting 311 patients were included. Mean age in most of the studies was 31-51 years and male gender constituted 50.5% patients. Dysphagia (72.3%), odynophagia (22.4%) and chest pain (31.3%) were predominant symptoms. Mid-oesophagus was the commonest site of involvement (88%). Endoscopic findings included ulcers (59.9%), submucosal bulge (31.7%), extrinsic compression (24.8%) and pseudotumour (5.8%). On endoscopic ultrasound, presence of hypoechoic (69.5%), heteroechoic (47.6%) and matted (86.3%) mediastinal lymph nodes and oesophageal wall involvement (67.3%) were common findings. Computed tomography showed mediastinal lymphadenopathy (76.5%) and oesophageal thickening (52.1%). Diagnosis was confirmed by granuloma (72.3%) and acid fast bacilli positivity (32.5%) in mots patients. Response to antitubercular therapy was excellent; 97.7% patients recovered and 2.3% patients died. Surgery (14.5%) and oesophageal stenting (11.4%) were required infrequently. Oesophageal tuberculosis should be considered in endemic regions as a cause of dysphagia because early treatment is associated with excellent outcomes.

Clinical and endoscopic features of esophageal tuberculosis: a 20-year retrospective study

BACKGROUND

Tuberculosis of the esophagus is a rare clinical entity. There is a paucity of data on esophageal tuberculosis. This study aims to analyze the clinical and endoscopic features of esophageal tuberculosis over the last 20 years.

METHODS

We retrospectively analyzed the data of 14 patients with esophageal tuberculosis between January 1999 to January 2019 at Nanfang Hospital. Tuberculosis was considered diagnostic if histopathological results showing epithelioid granuloma with or without caseous necrosis. Records of clinical features, imaging findings, endoscopic features and outcome of antitubercular treatment were evaluated.

RESULTS

A total of 14 patients with definite esophageal tuberculosis were included. 7 patients (50%) presented with dysphagia, followed by 6 patients (42.86%) had retrosternal pain and another had cough (7.14%). On endoscopy, involvement of esophagus was observed at mid-segment mostly and findings included bulging lesions in 10 patients (71.43%), ulcer in 3 patients (21.43%), and tracheoesophageal fistula in 1 patient (7.14%). Endoscopic ultrasound showed a heterogeneous hypoechoic lesion with indistinct margins or interruption of the five layers structure of esophageal wall. Endoscopic ultrasound demonstrated mediastinal lymphadenopathy adjacent to esophageal pathology in 7/11(63.64%). Antitubercular treatment resulted in a good response with complete remission in all patients.

CONCLUSIONS

Esophageal tuberculosis is rare and frequently misdiagnosed due to the lack of diagnostic signs. There needs to be a high index of clinical suspicion among patients with dysphagia or retrosternal pain. Endoscopic biopsy and endoscopic ultrasound-guided FNA can help in achieving the correct diagnosis in esophageal tuberculosis.

Oesophageal tuberculosis with concomitant candidiasis: a rare cause of dysphagia

We present a case of a 23-year-old woman with dysphagia. She was reportedly newly diagnosed with HIV and had been initiated on antiretroviral treatment and tuberculosis (TB) prophylaxis. Oesophagogastroduodenoscopy revealed an irregular, ulcerative oesophageal lesion. Subsequent histopathology revealed M ycobacterium tuberculosis as well as C andida albicans A CT scan demonstrated widespread disease with miliary TB. She was subsequently initiated on antituberculous and antifungal medications. TB is one of the most common and deadly infectious diseases in the world, with the highest rates seen in the developing countries. It commonly occurs as an opportunistic infection of HIV. Despite its potential for systemic infection, infection of the oesophagus is incredibly rare, more so as a co-infection with candida. This case highlights the need to have a high index of suspicion in high risk groups, as early treatment is crucial in addressing this global health crisis.

Bronchoesophageal Fistula due to Esophageal Tuberculosis

This is a case report regarding a patient who presented with 6 months of dysphagia and subsequent 40-pound weight loss. The patient underwent imaging, suggestive of pulmonary TB. Further workup of his dysphagia with esophagogastroduodenoscopy and bronchoscopy revealed two bronchoesophageal fistulas. Tuberculosis is an important differential diagnosis of prolonged dysphagia in immunocompetent patients.

Esophageal Mycobacterium avium-intracellulare infection in a bone marrow transplant patient: Case report and literature review

Mycobacterium avium-intracellulare complex (MAC) is the most common cause of nontuberculous mycobacterial (NTM) disease in humans. We report a case of esophageal MAC disease in a patient who had allogeneic bone marrow transplant for acute lymphoblastic leukemia. Although pulmonary MAC in immunocompromised host is not uncommon, there are only a few cases of NTM-associated esophageal mass reported. Our report and literature review highlight the importance of considering MAC in the differential diagnosis of dysphagia or odynophagia.

Surgery for intrathoracic tracheoesophageal and bronchoesophageal fistula

Benign tracheoesophageal fistula (TEF) results from an abnormal communication between the posterior wall of the trachea or bronchi and the adjacent anterior wall of the esophagus. It can be acquired or congenital. The onset of the TEF has a negative impact on the patient's health status and quality of life because of swallowing difficulties, recurrent aspiration pneumonia, and severe weight loss. Several acquired conditions may cause TEF. The most frequent is prolonged orotracheal intubation (75% of the cases). Usually, there is an erosion of the tracheal and esophageal wall by the continuous pressure between the endotracheal tube and the esophageal wall; particularly in the presence of a nasogastric or feeding tube within the esophageal lumen. Furthermore, tracheal stenosis is often associated, and adds complexity to the disease. Preparation for the surgical procedure may take weeks or even months. It includes definitive weaning from mechanical ventilation, treatment of respiratory infection, physiotherapy, and correction of malnutrition through enteral feeding. Surgical repair of a TEF is an elective procedure. It consists of division of the fistula, suture of the esophagus and trachea and protection of the suture lines with a buttressed muscle flap. TEF repair is a complex and challenging procedure, thus, high morbidity and mortality are expected. Nonetheless, surgical management yields excellent long-term results, and it should be considered the first-line treatment for this condition. Definitive fistula closure occurs in about 90-95% of the cases.

Tuberculosis presenting as Dysphagia: clinical, endoscopic, radiological and endosonographic features

Objective:

Dysphagia as a presenting manifestation of tuberculosis is rare and there is paucity of data on the clinical, endoscopic and endosonographic features of these patients. We present our data related to the features over last four years.

Methods:

We analyzed retrospectively the clinical, endoscopic, radiological, endosonographic and cytological findings in 14 patients (male: 10; mean age: 37.7 ± 10.4 years) with dysphagia due to tuberculosis presenting to us over last 4 years.

Results:

Nine patients (64.3%) had Grade 1 dysphagia, 4 (28.6%) patients had Grade 2 and 1 patient (7.1%) had Grade 3. Mid esophagus was the commonest site of involvement. Endoscopic findings were extrinsic bulge (50%), linear ulcers (28.6%) and pol-ypoidal ulcerated lesion (7.1%). Endoscopic biopsies were inconclusive. Endoscopic ultrasound (EUS) demonstrated mediastinal lymph nodes being responsible for endoscopic bulge and their infiltration into esophageal wall leading on to ulcers. EUS-guided fine needle aspiration from these nodes established diagnosis in all patients.

Conclusion:

Dysphagia in tuberculosis is most commonly caused by compression by the surrounding mediastinal lymph nodes. EUS is a useful investigation for assessment of these patients.

An Interesting Case of Dysphagia in a HIV Patient

Oesophageal tuberculosis is a rare disease. Tuberculosis (TB) can cause dysphagia due to oesophageal ulcers, Tracheo-Oesophageal Fistulas (TOFs) and an extrinsic compression which is caused by the mediastinal lymph nodes. A 33-year-old gentleman was admitted to our hospital for the evaluation of fever, dysphagia and cough. His chest X-ray was suggestive of miliary tuberculosis. A CT scan of his chest revealed miliary tuberculosis, mediastinal lymphadenopathy and pneumomediastinum. His sputum AFB (acid-fast bacilli) test was positive. An upper gastrointestinal endoscopy revealed a large ulcer in the oesophagus with a fistulous opening which was suggestive of a tracheo-oesophageal fistula. A biopsy from the ulcer was positive for AFB. The test for HIV-1 was positive. A nasogastric feeding tube was placed and the Anti Tubercular Therapy ( ATT) was started. The main aim of this case report is to sensitize the clinicians about the fact that Tuberculosis can present with dysphagia, especially in HIV patients.

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.

Shoulder pain and dysphagia with an unexpected cause

A 31-year-old female pharmacist of Nigerian origin, now resident in London, described 4 months of worsening left-sided subscapular pain despite the use of increasingly potent analgesia. She also described progressive dysphagia, first to solids and later to liquid foods. She remained systemically well, with no associated symptoms and normal physiological observations. In light of raised plasma inflammatory markers and chest radiography demonstrating a widened paraspinal stripe, the patient underwent CT and subsequent MRI of the thorax and upper spine. This revealed bony destruction of multiple higher thoracic vertebrae, with an associated epidural abscess mediating spinal cord impingement at T5. A large prevertebral collection spanning C7-T9 directly compressing and displacing the oesophagus was demonstrated. These findings collectively suggested spinal tuberculosis (Pott's disease); PCR confirmed the presence of Mycobacterium tuberculosis. The patient was successfully treated with oral anti-tuberculous chemotherapy and physiotherapy.

Suspected oesophageal cancer in a 33 year old lady

A previously healthy 33 year old lady presented with acute dysphagia with endoscopic and CT features of oesophageal carcinoma. Endoscopic ultrasound (EUS) revealed a large subcarinal lymph node compressing at the mid-oesophagus. Fine-needle aspiration (FNA) showed a single well-formed epithelioid granuloma with no evidence of malignancy. Molecular analysis showed the aspirate to be positive for Mycobacterium tuberculosis. She continues to improve with standard anti-TB medication without surgery.This is a rare case of acute dysphagia secondary to primary tuberculous mediastinal lymphadenopathy. EUS and FNA have completely altered the clinical management of this lady.