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Wong V, Ahmed A, Manoharan A, Wang W. Esophagomediastinal Fistula Closed Endoscopically in a Young Patient With Tuberculosis and Human Immunodeficiency Virus. Cureus 2023; 15:e34813. [PMID: 36915848 PMCID: PMC10008089 DOI: 10.7759/cureus.34813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/09/2023] [Indexed: 02/11/2023] Open
Abstract
Tuberculosis is a primary lung disease that can spread to the lymph nodes, vertebrae, and gastrointestinal tract. The esophagus can be affected by mediastinal lymphadenitis, mostly in immunocompromised patients, leading to the formation of esophagomediastinal fistulas. They can cause dysphagia, pleuritic chest pain, and choking coughs from recurrent aspiration. The treatment is surgery but endoscopic interventions using over-the-scope endoclips, stents, medical adhesives, and sutures are successful alternatives. We present a case of an esophagomediastinal fistula in a patient with tuberculosis and human immunodeficiency virus that was successfully treated with through-the-scope endoclips.
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Affiliation(s)
- Vincent Wong
- Internal Medicine-Pediatrics, Rutgers University New Jersey Medical School, Newark, USA
| | - Ahmed Ahmed
- Gastroenterology and Hepatology, Rutgers University New Jersey Medical School, Newark, USA
| | - Anjella Manoharan
- Internal Medicine-Pediatrics, Rutgers University New Jersey Medical School, Newark, USA
| | - Weizheng Wang
- Gastroenterology and Hepatology, Rutgers University New Jersey Medical School, Newark, USA
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Ye T, Zong Y, Zhao G, Zhou A, Yue B, Zhao H, Li P. Role of Endoscopy in Esophageal Tuberculosis: A Narrative Review. J Clin Med 2022; 11:jcm11237009. [PMID: 36498584 PMCID: PMC9740747 DOI: 10.3390/jcm11237009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 11/16/2022] [Accepted: 11/17/2022] [Indexed: 11/29/2022] Open
Abstract
Esophageal tuberculosis (ET) is a rare infectious disease of the gastrointestinal tract. Awareness of ET is deficient due to its low incidence. Unexplained dysphagia and upper gastrointestinal bleeding are the most common symptoms of ET. The prognosis is generally good if patients are diagnosed properly and receive anti-tubercular treatment promptly. However, ET is difficult to differentiate from other diseases. Endoscopic techniques such as esophagogastroduodenoscopy (EGD), endoscopic ultrasonography (EUS), contrast-enhanced harmonic endoscopic ultrasonography (CH-EUS), elastography, and endoscopic ultrasound--guided fine-needle aspiration (EUS-FNA) improve the diagnosis of ET. Thus, the characteristics of ET and other difficult-to-detect diseases according to EGD and EUS were summarized. Intriguingly, there is no literature relevant to the application of CH-EUS and elastography in ET. The authors' research center was first in introducing CH-EUS and elastography into the field of ET. The specific manifestation of ET based on CH-EUS was discovered for the first time. Correlative experience and representative cases were shared. The role of endoscopy in acquiring esophageal specimens and treatment for ET was also established. In this review, we aim to introduce a promising technology for the diagnosis and treatment of ET.
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Affiliation(s)
| | | | | | | | | | | | - Peng Li
- Correspondence: (H.Z.); (P.L.)
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Wu YL, Tsai MC, Wang WL. An Unusual Esophageal Ulcerative Lesion Mimicking Esophageal Cancer. Gastroenterology 2022; 162:e4-e6. [PMID: 33964265 DOI: 10.1053/j.gastro.2021.05.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 05/03/2021] [Indexed: 12/02/2022]
Affiliation(s)
- Yi-Ling Wu
- Department of Internal Medicine, E-Da Hospital/I-Shou University, Kaohsiung, Taiwan; School of Medicine, College of Medicine, I-Shou University, Kaohsiung, Taiwan
| | - Ming-Chang Tsai
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan; School of Medicine, Chung Shan Medical University, Taichung, Taiwan; Department of Internal Medicine, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - Wen-Lun Wang
- Department of Internal Medicine, E-Da Hospital/I-Shou University, Kaohsiung, Taiwan; School of Medicine, College of Medicine, I-Shou University, Kaohsiung, Taiwan.
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Clinical approach to pediatric neck masses: Retrospective analysis of 98 cases. North Clin Istanb 2017; 4:225-232. [PMID: 29270570 PMCID: PMC5724916 DOI: 10.14744/nci.2017.15013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Accepted: 07/23/2017] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVE: Pediatric neck masses (PNMs) are a frequently encountered problem in otorhinolaryngology practice. The clinical approach to cervical masses in childhood varies from that of adults. Due to differences among clinicians in the assessment of a PNM, studies investigating this subject are significant contributions to the literature. For this reason, a review was conducted of pediatric PNM cases with an open biopsy (incisional/excisional) and a histopathological diagnosis. METHODS: The hospital records of 98 (34 girls, 64 boys) pediatric patients aged between 8.5 months and 16 years were reviewed. The history, physical examination findings, blood tests, medical treatments, imaging reports, and the pathology and/or microbiology results of the patients were recorded and evaluated. The cervical masses were categorized according to the etiology, imaging features, size, and location. RESULTS: Surgical biopsy was planned due to the suspicion of malignancy, typical clinical presentation or location, or size greater than 20 mm despite antibiotherapy for 2 to 6 weeks. Excisional biopsy (91.8%) was the first choice for histopathological sampling. Infectious masses were observed most commonly, followed by congenital and neoplastic masses, at a rate of 49%, 27.6%, and 23.4%, respectively. Hodgkin lymphoma was the most frequent type of malignancy (39.1%). Thyroglossal and branchial cysts constituted 74.1% of congenital masses. Sixty-seven percent of all masses were solid, and the lateral levels of the neck were the most affected locations (44.9%). CONCLUSION: In most cases, the diagnosis can be made with a detailed history and physical examination. In the presence of nonspecific findings, blood tests, imaging, and histopathological sampling are required. Ultrasound should be the first preference for imaging, and excisional biopsy is suggested rather than fine needle aspiration biopsy for histopathological sampling in pediatric neck masses.
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Abstract
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.
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Sharma M, Ecka RS, Somasundaram A, Shoukat A, Kirnake V. Endoscopic ultrasound in mediastinal tuberculosis. Lung India 2016; 33:129-34. [PMID: 27051097 PMCID: PMC4797428 DOI: 10.4103/0970-2113.177451] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Background: Tubercular lymphadenitis is the commonest extra pulmonary manifestation in cervical and mediastinal locations. Normal characteristics of lymph nodes (LN) have been described on ultrasonography as well as by Endoscopic Ultrasound. Many ultrasonic features have been described for evaluation of mediastinal lymph nodes. The inter and intraobserver agreement of the endosonographic features have not been uniformly established. Methods and Results: A total of 266 patients underwent endoscopic ultrasound guided fine needle aspiration and 134 cases were diagnosed as mediastinal tuberculosis. The endoscopic ultrasound location and features of these lymph nodes are described. Conclusion: Our series demonstrates the utility of endoscopic ultrasound guided fine needle aspiration as the investigation of choice for diagnosis of mediastinal tuberculosis and also describes various endoscopic ultrasound features of such nodes.
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Affiliation(s)
- Malay Sharma
- Department of Gastroenterology, Jaswant Rai Speciality Hospital, Saket, Meerut, Uttar Pradesh, India
| | - Ruth Shifa Ecka
- Department of Gastroenterology, Jaswant Rai Speciality Hospital, Saket, Meerut, Uttar Pradesh, India
| | - Aravindh Somasundaram
- Department of Gastroenterology, Kovai Medical Center and Hospital, Coimbatore, Tamil Nadu, India
| | - Abid Shoukat
- Department of Gastroenterology, Jaswant Rai Speciality Hospital, Saket, Meerut, Uttar Pradesh, India
| | - Vijendra Kirnake
- Department of Gastroenterology, Jaswant Rai Speciality Hospital, Saket, Meerut, Uttar Pradesh, India
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Nishiyama N, Mori H, Kobara H, Rafiq K, Fujihara S, Katou K, Aritomo Y, Ono M, Kamada H, Oryu M, Kanaji N, Masaki T. Esophageal anthracosis with tuberculous lymphadenitis confirmed on transesophageal endoscopic ultrasound-guided fine-needle aspiration. Intern Med 2014; 53:577-80. [PMID: 24633027 DOI: 10.2169/internalmedicine.53.1562] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Esophageal anthracosis with tuberculous lymphadenitis is a very rare disease. Almost all reported cases are diagnosed using multiple endoscopic biopsies or thoracic esophagectomy. The present case report describes a case of esophageal anthracosis with tuberculous lymphadenitis that was diagnosed using transesophageal endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) alone. After taking antituberculosis drugs, the patient's chest pain was relieved and she recovered. The patient achieved an excellent outcome following the use of less invasive methods than mediastinoscopy. If no esophageal anthracotic lesions are found on the mucous membrane layer of the esophagus, transesophageal endoscopic ultrasound-guided fine-needle aspiration is a suitable approach for diagnosing esophageal anthracosis.
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Affiliation(s)
- Noriko Nishiyama
- Department of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, Japan
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Xiong L, Mao X, Li C, Liu Z, Zhang Z. Posterior mediastinal tuberculous lymphadenitis with dysphagia as the main symptom: a case report and literature review. J Thorac Dis 2013; 5:E189-94. [PMID: 24255790 DOI: 10.3978/j.issn.2072-1439.2013.09.03] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2013] [Accepted: 09/04/2013] [Indexed: 11/14/2022]
Abstract
INTRODUCTION Mediastinal tuberculous lymphadenitis (MTL) is mostly seen in primary tuberculosis in children, uncommon observed in adults. It usually presents the toxic symptoms of tuberculosis but rarely with symptoms characteristic of esophageal compression, such as dysphagia. Such patients can easily be misdiagnosed as esophageal neoplasm and get delayed or faulty treatment. CASE REPORT A 32-year-old man presented with dull chest pain of one month and dysphagia of five days. CRP was elevated, and a skin test was strongly positive. At upper endoscopy, a protruding lesion covered by normal mucosa was seen at 26 cm from the upper incisor. Barium swallow showed visible external compressive stricture on the middle-lower esophagus with normal mucosal pattern. Chest computed tomography (CT) scan showed a subcarinal mass adjacent to the esophageal wall in posterior mediastinum. An endoscopic ultrasonography (EUS) revealed a hypoechoic lesion suspected of esophageal stromal tumor in the fourth layer. A tissue was obtained by ultrasound-guided fine-needle aspiration (EUS-FNA), but cytopathology, bacilliculture and PCR test had no special findings. The patient required experimental antitubercular treatment and the protruding lesion shrank gradually during therapy period. CONCLUSIONS MTL could not be ignored in the differential diagnosis of posterior mediastinal mass with dysphagia. Analyzing and evaluating test results comprehensively is the key to make correct diagnosis and timely treatment. The experimental antituberculous treatment should be used if MTL is highly suspected.
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Affiliation(s)
- Liangkun Xiong
- Department of General Surgery, Zhongnan Hospital of Wuhan University, Wuhan 430071, China
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Ni B, Lu X, Gong Q, Zhang W, Li X, Xu H, Zhang S, Shao Y. Surgical outcome of esophageal tuberculosis secondary to mediastinal lymphadenitis in adults: experience from single center in China. J Thorac Dis 2013; 5:498-505. [PMID: 23991308 DOI: 10.3978/j.issn.2072-1439.2013.08.33] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2013] [Accepted: 08/16/2013] [Indexed: 11/14/2022]
Abstract
OBJECTIVE Esophageal tuberculosis (ET) is a rare disorder often easily misdiagnosed. The aim of this study is to evaluate the clinical features and to highlight the surgical role in treatment and complication management for undiagnosed ET. METHODS Between June 2006 and June 2011, six esophageal tuberculosis cases were retrospectively reviewed for their clinical presentations, radiological findings, endoscopic views, surgical treatment and outcome. RESULTS The prevalent rate of ET was 0.30%. All patients, aged from 28 to 71 years, presented with dysphagia in six, weight loss in four, and each of retrosternal pain, epigastric pain, fever with cough in one. The duration ranged from two weeks to two months. Involvement of esophagus observed at middle segment in five patients, and at lower segment in one. Endoscopy demonstrated diverticulum with polyps in one patient, ulcer formation in one, and extraneous compression with intact mucosa in four. Five patients underwent video-assisted thoracoscopic surgery (VATS) and one was performed thoracotomy perforation repair for esophagopleural fistula. Diagnoses of all cases were confirmed by histopathological examination and acid-fast bacilli culture. Drug sensitivity test revealed multidrugs resistant mycobacterium tuberculous in one case. All patients discharged and recovered by antituberculous treatment with follow-up time ranged from 12 to 45 months. CONCLUSIONS ET should be considered as a causative factor for dysphagia. Surgery should be applied in undiagnosed ET. VATS is useful in improving rate of confirmative diagnosis, and relieving symptom of dysphagia. Thoracotomy repair is reserved for complications of ET.
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Affiliation(s)
- Buqing Ni
- Department of Cardiothoracic Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China
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Affiliation(s)
- A R L Medford
- North Bristol Lung Centre, Southmead Hospital, Bristol, UK
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Hata Y, Sakamoto S, Otsuka H, Sato K, Sato F, Makino T, Sugino K, Isobe K, Tochigi N, Sibuya K, Shiraga N, Takagi K. EBUS-TBNA-related complications in a patient with tuberculous lymphadenopathy. Intern Med 2013; 52:2553-9. [PMID: 24240796 DOI: 10.2169/internalmedicine.52.9273] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is becoming more common for diagnosing intrathoracic lymphadenopathy, including tuberculous lymphadenopathy. We herein report two cases of complications possibly related to EBUS-TBNA for tuberculous lymphadenopathy. The first patient was a 26-year-old woman who developed intrabronchial polypoid granulomas exclusively at puncture sites two months after undergoing EBUS-TBNA. Although endobronchial extension may occur, the risk of aggravation caused by puncture should be considered. The second patient was a 39-year-old woman with transient smear-positive bloody sputum that developed immediately after EBUS-TBNA and persisted for three days. Temporary isolation following EBUS-TBNA should be considered for possible tuberculous lymphadenopathy.
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Affiliation(s)
- Yoshinobu Hata
- Department of Chest Surgery, Toho University Omori Medical Center, Japan
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Jenssen C, Alvarez-Sánchez MV, Napoléon B, Faiss S. Diagnostic endoscopic ultrasonography: Assessment of safety and prevention of complications. World J Gastroenterol 2012; 18:4659-76. [PMID: 23002335 PMCID: PMC3442204 DOI: 10.3748/wjg.v18.i34.4659] [Citation(s) in RCA: 76] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2012] [Revised: 07/06/2012] [Accepted: 07/18/2012] [Indexed: 02/06/2023] Open
Abstract
Endoscopic ultrasonography (EUS) has gained wide acceptance as an important, minimally invasive diagnostic tool in gastroenterology, pulmonology, visceral surgery and oncology. This review focuses on data regarding risks and complications of non-interventional diagnostic EUS and EUS-guided fine-needle biopsy (EUS-FNB). Measures to improve the safety of EUS und EUS-FNB will be discussed. Due to the specific mechanical properties of echoendoscopes in EUS, there is a low but noteworthy risk of perforation. To minimize this risk, endoscopists should be familiar with the specific features of their equipment and their patients’ specific anatomical situations (e.g., tumor stenosis, diverticula). Most diagnostic EUS complications occur during EUS-FNB. Pain, acute pancreatitis, infection and bleeding are the primary adverse effects, occurring in 1% to 2% of patients. Only a few cases of needle tract seeding and peritoneal dissemination have been reported. The mortality associated with EUS and EUS-FNB is 0.02%. The risks associated with EUS-FNB are affected by endoscopist experience and target lesion. EUS-FNB of cystic lesions is associated with an increased risk of infection and hemorrhage. Peri-interventional antibiotics are recommended to prevent cyst infection. Adequate education and training, as well consideration of contraindications, are essential to minimize the risks of EUS and EUS-FNB. Restricting EUS-FNB only to patients in whom the cytopathological results may be expected to change the course of management is the best way of reducing the number of complications.
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Navani N, Molyneaux PL, Breen RA, Connell DW, Jepson A, Nankivell M, Brown JM, Morris-Jones S, Ng B, Wickremasinghe M, Lalvani A, Rintoul RC, Santis G, Kon OM, Janes SM. Utility of endobronchial ultrasound-guided transbronchial needle aspiration in patients with tuberculous intrathoracic lymphadenopathy: a multicentre study. Thorax 2011; 66:889-93. [PMID: 21813622 PMCID: PMC3361304 DOI: 10.1136/thoraxjnl-2011-200063] [Citation(s) in RCA: 128] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has emerged as an important tool for the diagnosis and staging of lung cancer but its role in the diagnosis of tuberculous intrathoracic lymphadenopathy has not been established. The aim of this study was to describe the diagnostic utility of EBUS-TBNA in patients with intrathoracic lymphadenopathy due to tuberculosis (TB). METHODS 156 consecutive patients with isolated intrathoracic TB lymphadenitis were studied across four centres over a 2-year period. Only patients with a confirmed diagnosis or unequivocal clinical and radiological response to antituberculous treatment during follow-up for a minimum of 6 months were included. All patients underwent routine clinical assessment and a CT scan prior to EBUS-TBNA. Demographic data, HIV status, pathological findings and microbiological results were recorded. RESULTS EBUS-TBNA was diagnostic of TB in 146 patients (94%; 95% CI 88% to 97%). Pathological findings were consistent with TB in 134 patients (86%). Microbiological investigations yielded a positive culture of TB in 74 patients (47%) with a median time to positive culture of 16 days (range 3-84) and identified eight drug-resistant cases (5%). Ten patients (6%) did not have a specific diagnosis following EBUS; four underwent mediastinoscopy which confirmed the diagnosis of TB while six responded to empirical antituberculous therapy. There was one complication requiring an inpatient admission. CONCLUSIONS EBUS-TBNA is a safe and effective first-line investigation in patients with tuberculous intrathoracic lymphadenopathy.
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Affiliation(s)
- Neal Navani
- Centre for Respiratory Research, University College London, 5 University Street, London WC1E 6JJ, UK
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Role of EUS for the evaluation of mediastinal adenopathy. Gastrointest Endosc 2011; 74:239-45. [PMID: 21802583 DOI: 10.1016/j.gie.2011.03.1255] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2011] [Accepted: 03/30/2011] [Indexed: 12/11/2022]
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Tay CW, Deans DAC, Khor JLC, Seet JE, So BYJ. Suspected oesophageal cancer in a 33 year old lady. Int J Surg Case Rep 2010; 2:13-5. [PMID: 22096676 PMCID: PMC3199616 DOI: 10.1016/j.ijscr.2010.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2010] [Accepted: 10/05/2010] [Indexed: 10/18/2022] Open
Abstract
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.
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Affiliation(s)
- Chee Wei Tay
- Department of Surgery, National University Hospital, 5 Lower Kent Ridge Road, Singapore 119074, Singapore
| | | | - Jen Lock Christopher Khor
- Department of Gastroenterology & Hepatology, National University Hospital, 5 Lower Kent Ridge Road, Singapore 119074, Singapore
| | - Ju Ee Seet
- Department of Pathology, National University Hospital, 5 Lower Kent Ridge Road, Singapore 119074, Singapore
| | - Bok Yan Jimmy So
- Department of Surgery, National University Hospital, 5 Lower Kent Ridge Road, Singapore 119074, Singapore
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Sharma M, Somasundaram A, Mahadevan B. Image of the month. Endoscopic ultrasound in a case of a widened mediastinum. Clin Gastroenterol Hepatol 2010; 8:e94. [PMID: 20215065 DOI: 10.1016/j.cgh.2010.02.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2010] [Revised: 02/14/2010] [Accepted: 02/21/2010] [Indexed: 02/07/2023]
Affiliation(s)
- Malay Sharma
- Department of Gastroenterology, Jaswant Rai Speciality Hospital, Meerut, India
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