S2173 An Unusual Case of Dysphagia: Tuberculous Bronchoesophageal Fistula

Abstract

Introduction: A tuberculous bronchoesophageal fistula (BEF) is a rare cause of dysphagia, with only a handful of cases in the literature, and a lack of consensus on its diagnosis and appropriate management. Case Description/Methods: A 30-year-old male presented with weight loss, worsening dysphagia, and cough on swallowing for 4 months. He also reported having pleuritic chest pain, malaise, and low-grade fever in the week before presentation. He was on immunosuppressive therapy for a renal transplant due to chronic renal failure and had a history of bariatric surgery for morbid obesity. Laboratory testing revealed normocytic anemia, normal white blood cell count, and significantly elevated erythrocyte sedimentation rates as well as C-reactive protein. A purified protein derivative skin test performed 3 months prior to presentation was reportedly negative. The remainder of his laboratory testing, including troponin, cardiac enzymes, and HIV status was negative. A chest x-ray showed left hilar prominence. High-resolution computerized tomography (CT) imaging of the chest showed subcarinal and left hilar lymphadenopathy and a soft-tissue density measuring 3 cm x 2 cm in the subcarinal region, inseparable from the right lateral wall of the mid-esophagus (Figure 1). Upper endoscopy showed an esophageal opening at 30 cm from the incisors (Figure 2). Bronchoscopy showed an opening into the left main bronchus with no airway stenosis. Contrast injection under fluoroscopic guidance confirmed a bronchoesophageal fistula (BEF) (Figure 3). A fully covered self-expanding metal stent was placed to aid in closure (Figure 4). A bronchoalveolar lavage and a Quantiferon test both confirmed active tuberculosis. The patient commenced anti-tuberculosis medications and required repeat endoscopy and replacement of the stent after 8 weeks. A repeat CT chest with oral contrast after 16 weeks showed resolution of the BEF which was confirmed after subsequent stent removal. Discussion: A BEF is uncommon, and not initially considered in patients presenting with dysphagia. In retrospect, our patient reported coughing while drinking, raising suspicions for a BEF. A tuberculous BEF is rare but becomes a distinct possibility in the setting of immunosuppression. Clinicians should remain vigilant for atypical infections in immunosuppressed patients presenting with dysphagia.Figure 1.: CT/ fluoroscopy and endoscopic imaging demonstrating bronchoesophageal fistula.