Esophageal Tuberculosis with Lymphoesophageal Fistula

Abstract

Mycobacterial tuberculous involvement of the gastrointestinal tract is a frequent site of extra pulmonary tuberculosis but esophageal involvement is rare. Here, we describe a patient with unique presentation of esophageal tuberculosis. Patient was a 25-year-old Indian woman who had immigrated to U.S. at age of 16. Two weeks prior to her hospitalization, she developed odynophagia and substernal chest discomfort. She was started on a proton pump inhibitor without resolution of her symptoms. An upper GI series revealed large esophageal ulcer with possible perforation. Patient was healthy and without any medical or surgical history. She had no allergies and was taking lansoprazole 30 mg once a day. At the time of immigration, her purified protein derivative test (PPD) was negative. She had not been to India since her immigration. Her vital signs were normal and she appeared comfortable. There was no palpable lymphadenopathy. The lungs were clear on auscultation. Neurologic examination revealed no abnormalities. All laboratory-test results were normal. Barium swallow revealed linear esophageal ulceration on the right side of mid-esophagus but no perforation. CT scan of chest, abdomen, and pelvis revealed 2.3 × 3.4 × 5.0 cm enhancing subcarinal mass that was inseparable from the esophagus. Esophagogastroduodensocopy revealed a 4-cm deep, friable ulcer with a sinus/fistula tract in the mid-esophagus. Cytology and biopsies with special stains for AFB, fungus, viruses were negative. Bronchoscopy revealed hyperemia of the airways and bulging in the medial aspect of the right mainstem bronchus. Bronchoalveolar lavage culture and cytology was negative. On video mediastinoscopy, multiple small lymph nodes surrounding a large, rubbery mass were identified. Multiple biopsies of the mass and the lymph nodes revealed noncaseating granulomas and cultures were positive for Mycobacterium tuberculosis. PPD was positive at more than 15 millimeters. A diagnosis of isolated esophageal tuberculosis was made and patient was started on four-drug regimen of ethambutol, isoniazid, pyrazinamide, and rifampin. Cultures were subsequently positive for Mycobacterium tuberculosis. With treatment, fistula has healed on subsequent endoscopies. In conclusion, tuberculosis should be suspected in patients with odynophagia and large esophageal ulcerations in a patient with appropriate demographic history. Invasive methods may be needed to make the diagnosis.