Primary tuberculosis of the oesophagus

Abstract

There are only a few cases of primary tuberculosis of the oesophagus described in the literature. We report a 55-yearold Asian man who presented with dysphagia and at endoscopy appeared to have a carcinoma of the oesophagus. The patient reported an 8-month history of weight loss and dysphagia. Endoscopy showed a large, ulcerating, polypoid lesion, 25 cm from his incisors, with appearances typical of a carcinoma (figure, top). Histology of the lesion showed inflammatory exudate in the sub-mucosa with discrete epithelioid granulomas (figure, bottom). No acidfast bacilli were seen. Further questioning revealed a history of fever and night sweats but no known contact with tuberculosis. He had lived in the UK for the past 8 years. Examination was unremarkable and his chest radiograph was normal. A barium swallow confirmed mucosal irregularity, but showed no other abnormality. He had a mild normocytic anaemia with a raised erythrocyte sedimentation rate (30 mm/h). He was also noted to be hyponatraemic (120 mmol/L) and hypoalbuminaemic (30 g/dL). The next day he had a high fever and became drowsy. He was noted to have a transient, partial, left third-nerve palsy. Computed tomograph of his brain showed an area of contrast enhancement around the right sylvian fissure but no other abnormality. There was raised protein (2·44 g/dL) in cerebrospinal fluid and a lymphocytosis (120 cells 10/L). A diagnosis of tuberculous meningitis was suspected and antituberculosis treatment was started. Subsequently, gastric washings were found to contain acid-fast bacilli. Mantoux test and cultures were negative. He made an uneventful recovery. Most oesophageal tuberculosis appears to be secondary to spread from surrounding structures. This patient had a normal chest radiograph and barium swallow showed no evidence of extrinsic involvement. The development of tuberculous meningitis was considered a secondary phenomenon, perhaps related to the biopsy, 10 days earlier. When primary tuberculous oesophagitis does occur it may affect a previously abnormal mucosa. There was no suggestion of this in our case. The rarity of primary tuberculous oesophagus may be related to oesophageal protective mechanisms such as rapid transit and peristalsis as well as the natural defence of smooth squamous epithelium and swallowed saliva. Dysphagia is the most common presenting symptom and the endoscopic appearance often mimics carcinoma. This case underlines the important message that tuberculosis should always be considered when cancer is suspected, especially in at-risk populations.These include not only people migrating from endemic areas but also the increasing number of individuals infected with HIV.