Tuber&
and Lung Disease (1992) 13, 174-176
An unusual presentation of oesophageal tuberculosis S. P. Gupta*, A. Arorat, D. K. Bhargavat *Department India
of Medicine and TDepartment
of Gastroenterology,
All India Institute of Medical Sciences, New Delhi,
R Y. Oesophageal tuberculosis secondary to tuberculous mediastinal lymphadenopathy is a very unusual presentation of adult tuberculosis. We report a young patient who presented with anorexia and weight loss. The chest radiograph and CT scan revealed mediastinal lymphadenopathy causing extrinsic oesophageal compression on the barium swallow. This was confirmed by upper gastrointestinal endoscopy. Four weeks later, because of spontaneous partial relief in dysphagia, upper gastrointestinal endoscopy was repeated and revealed an ulcerated lesion with nodular margins at the mid-oesophagus. Biopsy from the ulcer margin revealed non-caseating granulomas. The patient had complete relief of dysphagia and other symptoms within 3 weeks of start of antituberculosis therapy.
S U MMA
.!?. La tuberculose oesophagienne secondaire 21une lymphadenopathie mediastinale tuberculeuse est une presentation trb rare de la tuberculose chez l’adulte. Le cas d’un malade jeune souffrant d’anorexie et d’amaigrissement est present& La radiographie thoracique et l’echographie ont rCvClCune lymphadenopathie mediastinale provoquant une compression oesophagienne extrindque lors de la deglutition barytee, confirmee par une endoscopie gastro-intestinale haute. Quatre semaines plus tard, a la suite du soulagement partiel et spontane de la dysphagie, une nouvelle endoscopie gastro-intestinal a CtCfaite et a rev616 une lesion ulceree avec des bords nodulaires situ& au milieu de l’oesophage. Une biopsie du bord de l’ulcere a montre des granulomes non-cadeux. Le malade a bCnCfici6d’un soulagement total de la dysphagie et autres sympt8mes trois semaines apt-es le debut du traitement anti-tuberculeux.
R I? S l-IM
La tuberculosis esofrigica secundaria a una linfoadenopatia mediastinal tuberculosa es una localization rara de la tuberculosis en el adulto. Se presente el case de un enfermo joven que sufria de anorexia y perdida de peso. La radiograha toracica y la ecografia revelaron una linfoadenopatia mediastinal que provocaba una compresion esofagica extrinseca durante la deglucion baritada, confirmada por endoscopia gastro-intestinal alta. Cuatro semanas mas tarde, despub de una remision espontainea y partial de la disfagia, se realizd una nueva endoscopia gastro-intestinal que revel6 una lesion ulcerada, con bordos nodulares, situada en la parte media de1 esofago. Una biopsia de1 borde de la ulcerea mostr6 granulomas non caseosos. El enfermo present6 un alivio total de la disfagia y de 10s otros sintomas tres semanas despues de1 comenzo de1 tratumiento antituberculoso.
R E S U M EN.
knowledge this is the first case documenting the spread of tuberculosis from mediastinal lymph nodes to the oesophagus.
Oesophageal tuberculosis is a rare manifestation of adult tuberculosis. Until 1987, only 20 cases had been reported in Western literature.’ Infection may be caused by swallowing infected sputum, by direct spread from lung, mediastinal lymph nodes or spine or by retrograde lymphatic spread.’ In this report we describe a young patient with dysphagia due to extrinsic compression of the oesophagus by mediastinal lymphadenopathy. Subsequently, lymph nodes eroded into the oesophagus causing oesophageal ulceration. To the best of our
CASE REPORT A 20-year-old male attended the medical outpatient department of the All India Institute of Medical Sciences Hospital with a 2-month history of anorexia, generalized weakness, weight loss, easy fatiguability and dysphagia for solid foods. There was no history of fever, cough, dyspnoea, hoarseness of voice or other
Correspondence to: Dr S. P. Gupta, Department of Medicine, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110029, India. 174
Oesophageal
tuberculosis
I75
systemic symptoms. Examination revealed mild pallor but no peripheral lymphadenopathy. Systemic examination was non-contributory. The chest radiograph revealed a mediastinal lobulated mass which was confirmed to be located anterior to the oesophagus by a CT scan (Fig. 1). Barium swallow revealed extrinsic compression of the oesophagus in its middle third (Fig. 2). His Mantoux test read 15 x 15 mm after 48 h (with 5 i.u. PPD). An upper gastrointestinal endoscopy revealed only an extrinsic compression of the mid-oesophagus. Since the tissue diagnosis was not clear, thoracotomy was being contemplated for diagnosis and treatment but over the next 2 weeks the patient’s dysphagia improved significantly and he started accepting semi-solid foods. A repeat endoscopic examination revealed an ulcerated nodular lesion 2 x 2 cm on the anterior wall of the mid-oesophagus. A biopsy was taken from the margin of the ulcer. Histopathological examination revealed non-caseating granulomas with epitheloid cells. The patient was put on antituberculosis drugs (isoniazid, ethambutol and rifampicin) and he had complete relief of dysphagia within the next 3 weeks. His appetite improved and his general condition markedly improved. The patient is doing well after 1 year of follow-up.
DISCUSSION
Fig.2-Barium mid-oesophagus
Primary upper gastrointestinal tuberculosis is rare,3 even in countries with a high incidence of tuberculosis. The reported incidence of tuberculous oesophagitis is 0.15% in collected necrospy materials4 The relative rarity of oesophageal tuberculosis is partly explained by the mucosal protective mechanisms such as the squamous cell lining of the oesophagus, its tubular structure and other factors that prevent prolonged contact of infectious material with the mucosa. The relative rarity of oesophageal tuberculosis is all the more surprising when one considers the proximity of this organ to the lungs
Fig.l-CT Scan of the chest showing a lobulated mediastinal front of the oesophagus.
mass in
swallow film showing anterior compression of the caused by the overlying mediastinal mass.
and mediastinum and the fact that the oesophageal mucosa is commonly bathed by swallowed infected sputum.’ It is believed that secondary oesophageal involvement most likely occurs as a result of continuous extension from caseous hilar or mediastinal nodes, tubercular spondylitis or adjacent tuberculous lung infections. Until recently it was thought that tuberculous mediastinal lymphadenitis was an infrequent manifestation of primary tuberculosis in adults though quite common in children, but recent reports have indicated that the incidence of tuberculous mediastinal lymphadenopathy may have been underestimated5,6 and previous exposure to infection, racial characteristics and a possible genetic tendency towards lymphatic involvement in non-whites may be predisposing factors to medistinal tuberculosis5~’ This case illustrates one of the ways of oesophageal involvement; namely, spread from mediastinal lymph nodes. Initially the patient had dysphagia due to extrinsic oesophageal compression by mediastinal lymph nodes which was confirmed on endoscopy. A partial relief of symptoms necessitated a repeat endoscopy after 4 weeks which revealed a nodular ulcerated lesion which showed non-caseating granulomas on histopathological examination. We postulate that the caseous lymph nodes causing oesophageal compression extruded their contents by invading the
oesophagus, resulting in the partial spontaneous relief of dysphagia noticed by the patient. The diagnosis of tuberculosis was supported by the positive Mantoux test, presence of non-caseating granulomas on histopathological examination and a prompt response to antituberculosis therapy. References 1. Dam Lew B, Prengley D, Wolinsky E, Spangnuolo P J. Gesophageal tuberculosis: Mimicry of gastrointestinal malignancy. Rev Infect Dis 1987: 9: 140-146.
2. Kramer P. Infections of the esophagus. In Bockus H L ed. Gastroenterology 3rd edn. Philadelphia: WB Saunders, 1974: pp 329-338. 3. Seiverwright N, Feehally .I, Wicks ACB. Primary tuberculosis of the oesophagus. Am J Gastroenteroll984; 79: 842-843. 4. Madjllessi SHM, Tavassolie H. Primary tuberculous nranulomatous oesophagogastroduodenitis: a report of a case. J Trap-Med Hyg. 1985; 88: 253-256. 5. Bloonberg T J, Dow C T. Contemporary mediastinal tuberculosis. Thorax 1980; 35: 392-396. 6. Liv C I, Fields W R, Shaw C I. Tuberculous mediastinal lymphadenopathy in adults. Radiology 1978; 126: 369-371. 7. Amorosa J K, Smith P R, Cohen J R, Ramsey C, Lyons H A. Tuberculous mediastinal lymphadenitis in the adult. Radiology 1978; 126: 365-368.
and Lung Disease (1992) 13, 174-176
An unusual presentation of oesophageal tuberculosis S. P. Gupta*, A. Arorat, D. K. Bhargavat *Department India
of Medicine and TDepartment
of Gastroenterology,
All India Institute of Medical Sciences, New Delhi,
R Y. Oesophageal tuberculosis secondary to tuberculous mediastinal lymphadenopathy is a very unusual presentation of adult tuberculosis. We report a young patient who presented with anorexia and weight loss. The chest radiograph and CT scan revealed mediastinal lymphadenopathy causing extrinsic oesophageal compression on the barium swallow. This was confirmed by upper gastrointestinal endoscopy. Four weeks later, because of spontaneous partial relief in dysphagia, upper gastrointestinal endoscopy was repeated and revealed an ulcerated lesion with nodular margins at the mid-oesophagus. Biopsy from the ulcer margin revealed non-caseating granulomas. The patient had complete relief of dysphagia and other symptoms within 3 weeks of start of antituberculosis therapy.
S U MMA
.!?. La tuberculose oesophagienne secondaire 21une lymphadenopathie mediastinale tuberculeuse est une presentation trb rare de la tuberculose chez l’adulte. Le cas d’un malade jeune souffrant d’anorexie et d’amaigrissement est present& La radiographie thoracique et l’echographie ont rCvClCune lymphadenopathie mediastinale provoquant une compression oesophagienne extrindque lors de la deglutition barytee, confirmee par une endoscopie gastro-intestinale haute. Quatre semaines plus tard, a la suite du soulagement partiel et spontane de la dysphagie, une nouvelle endoscopie gastro-intestinal a CtCfaite et a rev616 une lesion ulceree avec des bords nodulaires situ& au milieu de l’oesophage. Une biopsie du bord de l’ulcere a montre des granulomes non-cadeux. Le malade a bCnCfici6d’un soulagement total de la dysphagie et autres sympt8mes trois semaines apt-es le debut du traitement anti-tuberculeux.
R I? S l-IM
La tuberculosis esofrigica secundaria a una linfoadenopatia mediastinal tuberculosa es una localization rara de la tuberculosis en el adulto. Se presente el case de un enfermo joven que sufria de anorexia y perdida de peso. La radiograha toracica y la ecografia revelaron una linfoadenopatia mediastinal que provocaba una compresion esofagica extrinseca durante la deglucion baritada, confirmada por endoscopia gastro-intestinal alta. Cuatro semanas mas tarde, despub de una remision espontainea y partial de la disfagia, se realizd una nueva endoscopia gastro-intestinal que revel6 una lesion ulcerada, con bordos nodulares, situada en la parte media de1 esofago. Una biopsia de1 borde de la ulcerea mostr6 granulomas non caseosos. El enfermo present6 un alivio total de la disfagia y de 10s otros sintomas tres semanas despues de1 comenzo de1 tratumiento antituberculoso.
R E S U M EN.
knowledge this is the first case documenting the spread of tuberculosis from mediastinal lymph nodes to the oesophagus.
Oesophageal tuberculosis is a rare manifestation of adult tuberculosis. Until 1987, only 20 cases had been reported in Western literature.’ Infection may be caused by swallowing infected sputum, by direct spread from lung, mediastinal lymph nodes or spine or by retrograde lymphatic spread.’ In this report we describe a young patient with dysphagia due to extrinsic compression of the oesophagus by mediastinal lymphadenopathy. Subsequently, lymph nodes eroded into the oesophagus causing oesophageal ulceration. To the best of our
CASE REPORT A 20-year-old male attended the medical outpatient department of the All India Institute of Medical Sciences Hospital with a 2-month history of anorexia, generalized weakness, weight loss, easy fatiguability and dysphagia for solid foods. There was no history of fever, cough, dyspnoea, hoarseness of voice or other
Correspondence to: Dr S. P. Gupta, Department of Medicine, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110029, India. 174
Oesophageal
tuberculosis
I75
systemic symptoms. Examination revealed mild pallor but no peripheral lymphadenopathy. Systemic examination was non-contributory. The chest radiograph revealed a mediastinal lobulated mass which was confirmed to be located anterior to the oesophagus by a CT scan (Fig. 1). Barium swallow revealed extrinsic compression of the oesophagus in its middle third (Fig. 2). His Mantoux test read 15 x 15 mm after 48 h (with 5 i.u. PPD). An upper gastrointestinal endoscopy revealed only an extrinsic compression of the mid-oesophagus. Since the tissue diagnosis was not clear, thoracotomy was being contemplated for diagnosis and treatment but over the next 2 weeks the patient’s dysphagia improved significantly and he started accepting semi-solid foods. A repeat endoscopic examination revealed an ulcerated nodular lesion 2 x 2 cm on the anterior wall of the mid-oesophagus. A biopsy was taken from the margin of the ulcer. Histopathological examination revealed non-caseating granulomas with epitheloid cells. The patient was put on antituberculosis drugs (isoniazid, ethambutol and rifampicin) and he had complete relief of dysphagia within the next 3 weeks. His appetite improved and his general condition markedly improved. The patient is doing well after 1 year of follow-up.
DISCUSSION
Fig.2-Barium mid-oesophagus
Primary upper gastrointestinal tuberculosis is rare,3 even in countries with a high incidence of tuberculosis. The reported incidence of tuberculous oesophagitis is 0.15% in collected necrospy materials4 The relative rarity of oesophageal tuberculosis is partly explained by the mucosal protective mechanisms such as the squamous cell lining of the oesophagus, its tubular structure and other factors that prevent prolonged contact of infectious material with the mucosa. The relative rarity of oesophageal tuberculosis is all the more surprising when one considers the proximity of this organ to the lungs
Fig.l-CT Scan of the chest showing a lobulated mediastinal front of the oesophagus.
mass in
swallow film showing anterior compression of the caused by the overlying mediastinal mass.
and mediastinum and the fact that the oesophageal mucosa is commonly bathed by swallowed infected sputum.’ It is believed that secondary oesophageal involvement most likely occurs as a result of continuous extension from caseous hilar or mediastinal nodes, tubercular spondylitis or adjacent tuberculous lung infections. Until recently it was thought that tuberculous mediastinal lymphadenitis was an infrequent manifestation of primary tuberculosis in adults though quite common in children, but recent reports have indicated that the incidence of tuberculous mediastinal lymphadenopathy may have been underestimated5,6 and previous exposure to infection, racial characteristics and a possible genetic tendency towards lymphatic involvement in non-whites may be predisposing factors to medistinal tuberculosis5~’ This case illustrates one of the ways of oesophageal involvement; namely, spread from mediastinal lymph nodes. Initially the patient had dysphagia due to extrinsic oesophageal compression by mediastinal lymph nodes which was confirmed on endoscopy. A partial relief of symptoms necessitated a repeat endoscopy after 4 weeks which revealed a nodular ulcerated lesion which showed non-caseating granulomas on histopathological examination. We postulate that the caseous lymph nodes causing oesophageal compression extruded their contents by invading the
oesophagus, resulting in the partial spontaneous relief of dysphagia noticed by the patient. The diagnosis of tuberculosis was supported by the positive Mantoux test, presence of non-caseating granulomas on histopathological examination and a prompt response to antituberculosis therapy. References 1. Dam Lew B, Prengley D, Wolinsky E, Spangnuolo P J. Gesophageal tuberculosis: Mimicry of gastrointestinal malignancy. Rev Infect Dis 1987: 9: 140-146.
2. Kramer P. Infections of the esophagus. In Bockus H L ed. Gastroenterology 3rd edn. Philadelphia: WB Saunders, 1974: pp 329-338. 3. Seiverwright N, Feehally .I, Wicks ACB. Primary tuberculosis of the oesophagus. Am J Gastroenteroll984; 79: 842-843. 4. Madjllessi SHM, Tavassolie H. Primary tuberculous nranulomatous oesophagogastroduodenitis: a report of a case. J Trap-Med Hyg. 1985; 88: 253-256. 5. Bloonberg T J, Dow C T. Contemporary mediastinal tuberculosis. Thorax 1980; 35: 392-396. 6. Liv C I, Fields W R, Shaw C I. Tuberculous mediastinal lymphadenopathy in adults. Radiology 1978; 126: 369-371. 7. Amorosa J K, Smith P R, Cohen J R, Ramsey C, Lyons H A. Tuberculous mediastinal lymphadenitis in the adult. Radiology 1978; 126: 365-368.
