Sarcoidosis Causing Mid-esophageal Traction Diverticulum

Abstract

A 78-year-old man presented to the outpatient clinic department with progressive dysphagia to solid food for a few years. He had the feeling that food gets stuck in his chest with swallowing. He denied any fevers, unintentional weight loss, hemoptysis, sore throat nor odynophagia. He also denied any shortness of breath or wheezing. On examination he was hemodynamically stable. Chest exam revealed lower left lung crackles. He has past medical history of bronchial asthma, allergic rhinitis, pulmonary hypertension and sarcoidosis. Sarcoidosis was diagnosed in 2007 when he presented with a face lesion proved to be lupus pernio by skin biopsy. CT scan of the chest was done in 2012 after an asthma attack concerning for bilateral Pulmonary stellate opacities; Pleural based opacities; and mediastinal and hilar lymphadenopathy. IR guided biopsy obtained at that time showed histological findings of sarcoidosis (Fig. 1). Esophagogram showed an esophageal diverticulum in mid-esophagus measuring 1.5 cm in diameter (fig. 2,3). Absence of esophageal motility abnormality and presence of lung and mediastinal lymph node fibrosis evident by radiological and histological means lead to the diagnosis of traction mid-esophageal diverticulum. Despite presence of symptoms patient was a poor surgical candidate. Diverticula occur in the esophagus quite rarely compared to other areas of the body; it is estimated that diverticula account for less than 1% of all barium gastrointestinal radiographs and likely less than 5% of all cases of dysphagia. Diverticula of the esophagus are classified into three groups: pharyngoesophageal, parabronchial, and epiphrenic. Parabronchial are classified as pulsion and traction diverticula. The latter is found at the midesophagus near the tracheal bifurcation and result from granulomatous inflammation of mediastinal lymph nodes. The resultant desmoplastic reaction in the paraesophageal tissue causes full thickness pinching on the esophageal wall and leads to localized diverticulum. If symptomatic, surgical or endoscopic treatment should be attempted in selected patient. Tuberculosis and histoplasmosis are known etiologies of this condition. To the best of our knowledge, We present the second case in literature with traction esophageal diverticulum in a male also presented with progressive dysphagia. A simple test like esophagogram would provide early diagnosis even if clinical consideration is lacking.and prevent possible morbidity and mortality.Figure 1Figure 2Figure 3