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TUBERCULOSIS OF THE OESOPHAGUS : A REPORT OF FOUR CASES
DN Amarapurkar, R Baijal, S Agal, PP Kulshetra
Dept. of Gastroenterology, Bombay Hospital and Jagjivanram Hospital, Mumbai.
INTRODUCTION
Tuberculosis of the oesophagus is a rare disease. It will be, however, more frequently encountered in the future, as the number of immunocompromised patients is growing. This condition is usually secondary to infections in other thoracic sites, such as lungs, larynx or mediastinum.[2][3][4] The diagnosis is difficult if the suspicion of tuberculosis is not raised and it may be mistaken for oesophageal carcinoma. Dysphagia and cough after ingestion of fluids and food are common symptoms without any specific signs in these patients. Diagnosis is based on a combination of oesophagography, oesophagoscopy, bronchoscopy and computed tomographic scan. Most cases can be successfully treated with antituberculous therapy, although patients with oesophageal tuberculosis in the presence of AIDS do not respond as well to antituberculous therapy.
We present four cases of oesophageal tuberculosis in non immunocompromised patients.
CASE REPORT
Case 1
A 36 year old male presented with a two month history of gradually worsening dysphagia, anorexia, weight loss and low grade fever. Physical examination and blood investigations were normal. HIV serology was negative. Upper gastrointestinal endoscopy showed a mass lesion just above the gastrooesophageal junction which was initially thought to be oesophageal carcinoma but endoscopic biopsy revealed caseating granuloma. Barium swallow examination showed a filling defect in the lower third of esophagus. Chest radiograph and computed tomography of the chest were normal. He was treated with antituberculous drugs for one year with complete recovery. The patient started improving within 4 weeks of starting treatment. Repeat endoscopy was normal.
Case 2
A 25 year old man presented with complaints of cough on swallowing food for five years. There was no history of dysphagia, odynophagia or fever. Physical examination and blood investigations were unremarkable. HIV serology was negative. Upper gastrointestinal endoscopy showed a fistulous opening in mid oesophagus. A fistulogram was done through the opening in the mid oesophagus which revealed an oesophago bronchial communication. Barium swallow examination confirmed a fistulous tract between the oesophagus and right main bronchus. Chest X-ray and CT scan of the chest were normal. The patient underwent surgery for closure of the fistulous tract. At surgery a lymph node was seen near the fistulous communication. Histological examination of the lymphnode revealed a caseating granuloma. He was given antituberculous chemotherapy for one year with complete recovery.
Case 3
A 63 year old male with gradually worsening odynophagia, dysphagia, anorexia and weight loss for two months. There was no history of cough, fever, haematemesis or melaena. Physical examination and blood investigations were normal. HIV serology was negative. Chest X-ray and barium swallow examination were normal. Upper gastrointestinal endoscopy revealed a discrete, shallow ulcer in mid oesophagus around 10 mm in diameter. The rest of the oesophagus was normal. Endoscopic biopsy from the ulcer revealed caseating granuloma. CT scan of the chest showed enlarged mediastinal lymph nodes. He was treated with antituberculous drugs for one year. His symptoms started improving within 4 weeks. Repeat endoscopy revealed no ulcer.
Case 4
A 55 year old female presented with a one month history of dysphagia and odynophagia. She had no fever, weight loss or cough. Physical examination, blood investigations, chest X-ray and barium swallow examination were normal. HIV serology was negative. Upper gastrointestinal endoscopy showed a discrete, shallow ulcer, 10 mm in diameter, 26 mm from incisors. Rest of the oesophagus was normal. CT scan of the chest revealed mediastinal lymphadenopathy. She was treated with antituberculous chemotherapy with rapid recovery of symptoms within 6 weeks of starting treatment. Repeat endoscopy was normal.
DISCUSSION
Oesophageal tuberculosis occurs in three forms: ulcerative, hypertrophic and granular.[1] The most common form is that of tubercular ulcer, which is irregular in outline. There is a greyish base and irregularly infiltrated edges. When oesophageal tuberculosis presents in the form of a tumourlike growth with stricture, it is most easily mistaken for carcinoma. The common site of oesophageal involvement is in the mid oesophagus near the bifurcation of the trachea due to close proximity to the mediastinal lymph nodes. Tuberculous mediastinitis affects the oesophagus by the effect of pressure, adhesions or by actual rupture of caseous peribronchial lymph nodes with subsequent fistula formation.[5]
Oesophageal tuberculosis is usually cured without sequelae using antituberculous chemotherapy. This applies even in the presence of tracheooesophageal fistula. The first successful case of tuberculous tracheooesophageal fistula managed medically was reported in 1976.[5] Further successful cases have been reported.[2] In patients who respond to antituberculous therapy, improvement is usually rapid, with symptoms resolving in one to two months. Most cases of primary tuberculosis of the oesophagus can be treated successfully with antituberculous chemotherapy. Many cases of secondary oesophageal tuberculosis can also be cured by effective chemotherapy, except in patients with AIDS, who do not respond as well to antituberculous drugs. This may be a reflection of the compromised immune status since disseminated tuberculosis recently has been recognized as an early manifestation of AIDS.[2]The four cases being reported depict the different forms in which oesophageal tuberculosis can manifest endoscopically i.e. as an ulcer, a mass lesion and a fistula. All the four cases tested negative for HIV. One of the cases was primary oesophageal tuberculosis with no evidence of tuberculosis at any other site. The other three cases had mediastinal lymphadenopathy. On CT scan of chest the patient with oesophagobronchial fistula required surgery along with antituberculous chemotherapy, while the other three improved with medical management alone. All the cases showed rapid improvement in symptoms within 4-6 weeks of starting chemotherapy and repeat endoscopy showed complete healing of the lesions.
REFERENCES
1. Famming AR, Guindi R, Farid A. Tuberculosis of the esophagus. Thorax 1969; 24 : 254-56.
2. Rosario MT, Roso CL, Camero GM. Esophageal tuberculosis. Dig Dis Sci 1989; 34 : 81-4.
3. Gordon AH, Marshall JB. Esophageal tuberculosis : Difinitive diagnosis by endoscopy. Am J Gastroenterol 1990; 85 : 174-7
4. Eng J, Sabanathan S. Tuberculosis of esophagus. Dig Dis Sci 1991; 36 : 536-40.
5. Wigley FM, Murray HW, Mann RB, Saba GP, Kashima H, Mann JJ. Unusual manifestation of tuberculosis : TE fistula. Am J Med 1976; 60 : 310-14.
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