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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 2  |  Issue : 3  |  Page : 106-109

Primary esophageal tuberculosis: A rare presentation of a common disease


1 Department of Medical Gastroenterology and Hepatology, SRM Institute for Medical Science Hospital, Chennai, Tamil Nadu, India
2 Department of Pathology, SRM Institute for Medical Science Hospital, Chennai, Tamil Nadu, India
3 Department of Radiology, SRM Institute for Medical Science Hospital, Chennai, Tamil Nadu, India

Date of Submission09-Jun-2022
Date of Acceptance14-Jun-2022
Date of Web Publication05-Jul-2022

Correspondence Address:
Rohan Vijay Yewale
Department of Medical Gastroenterology and Hepatology, SRM Institute for Medical Science Hospital, No 1, Jawaharlal Nehru Salai, 100 Feet Road, Vadapalani, Chennai - 600 026, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ghep.ghep_19_22

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  Abstract 


Developing countries such as India, harbor almost a quarter of global tuberculosis (TB) burden. Esophageal involvement in TB, itself is a rare entity with primary esophageal TB reported only as isolated case reports. We report a case of an immunocompetent young adult who presented with dysphagia as the solitary symptom. Upper GI endoscopy and barium swallow showed a midthoracic esophageal stricture. He was subsequently diagnosed with “primary” esophageal TB based on histological examination of endoscopic biopsy showing features consistent with TB and demonstration of normal adjacent pulmonary parenchyma and lymph nodes on a computed tomography scan of the thorax. He showed marked symptomatic improvement with temporary esophageal dilation and stenting which helped in the effective administration of antituberculous therapy as well as attaining nutritional recovery. Our case report emphasizes on this rare scenario of “primary” involvement of esophagus in an otherwise common disease such as TB and its management strategy.

Keywords: Dysphagia, histopathology, primary esophageal tuberculosis, stricture


How to cite this article:
Yewale RV, Ramakrishna B, Damodaran K, Ramakrishna BS. Primary esophageal tuberculosis: A rare presentation of a common disease. Gastroenterol Hepatol Endosc Pract 2022;2:106-9

How to cite this URL:
Yewale RV, Ramakrishna B, Damodaran K, Ramakrishna BS. Primary esophageal tuberculosis: A rare presentation of a common disease. Gastroenterol Hepatol Endosc Pract [serial online] 2022 [cited 2022 Aug 13];2:106-9. Available from: http://www.ghepjournal.com/text.asp?2022/2/3/106/349950




  Introduction Top


India has the world's largest number of tuberculosis (TB) cases, with an incidence of 2.69 million new cases per year as per a WHO report released in 2019. However, tuberculous involvement of the esophagus is a rare entity.[1],[2] TB generally affects the esophagus secondarily with a primary focus elsewhere in the body. Modes of spread may be hematogenous, ingestion of infected sputum, or direct extension from adjacent mediastinal lymph nodes and pulmonary parenchyma, with the latter being the most common mode of involvement.[3] Primary involvement of the esophagus in TB is even rarer with isolated cases reported in the recent past.[4] We present one such case of primary esophageal TB in an immunocompetent young adult.


  Case Report Top


A 20-year-old man presented with complaints of progressive dysphagia for solids for 2 months. There was no history of any loss of weight or appetite, fever, vomiting, regurgitation of food, or heartburn. He did not have any history of TB or exposure with a known TB patient. The clinical examination was normal. Basic laboratory investigations including a complete blood count and erythrocyte sedimentation rate were normal. Upper GI endoscopy revealed a small nodule in the esophagus at 29 cm and a tight stricture at 31 cm from the incisors in the midesophagus [Figure 1], beyond which the adult endoscope could not be negotiated. Barium swallow showed an irregular stricture of the midthoracic esophagus extending for a length of approximately 5 cm [Figure 2]. The stricture appeared to be more severe in its proximal part with deep ulceration and hold up of contrast in the proximal esophagus. Noncontrast computed tomography (CT) scan of the thorax [Figure 3] revealed esophageal wall thickening up to 1.6 cm with luminal narrowing extending up to 5 cm from below the level of the carina. The gastroesophageal junction appeared to be uninvolved with intact periesophageal fat planes and normal adjacent structures. Lung parenchyma showed a normal bronchovascular pattern and no evidence of any axillary, hilar, or mediastinal lymphadenopathy. Histopathological examination from endoscopic biopsies showed predominantly superficial esophageal mucosa with the subepithelial stroma showing discrete and confluent granulomas composed of epithelioid histiocytes and multinucleated giant cells surrounded by dense lymphocytic infiltrates [Figure 4]. Focal minimal central necrosis with nuclear debris and focal ulceration with acute inflammatory exudate were noted. Ziehl–Neelsen stain for acid-fast bacilli and periodic acid–Schiff stain for fungal organisms were negative. At the time of index presentation, serial dilatation of stricture up to 12.8 mm was performed using a bougie dilator. On this background of mid-thoracic esophageal involvement with typical histopathological findings and the absence of a primary focus of TB on CT scan of the thorax, a provisional diagnosis of primary esophageal TB was established. He was started on antituberculous therapy (ATT) regimen with four drugs (rifampicin, isoniazid, pyrazinamide, and ethambutol) on a daily basis as part of the intensive phase therapy. Two weeks later, he reported recurrent dysphagia despite the previous dilatation. Repeat endoscopy confirmed a recurrent stricture and a fully covered 22 mm × 70 mm esophageal self-expanding metallic stent was deployed [Figure 5]. He was asked to continue ATT and follow up after 2 months for reevaluation. On follow-up, he had marked improvement in dysphagia and was able to tolerate a normal solid diet. Repeat endoscopy showed dilated esophagus at the level of previous stricture and scope could be easily negotiated into the stomach. The metallic stent in situ was removed during this session and he was asked to continue T. isoniazid and T. rifampicin for another 7 months as part of the continuation phase. After 9 months of treatment, he achieved complete resolution of symptoms with significant improvement in nutritional status.
Figure 1: Upper GI endoscopy showing a small nodule in the esophagus at 29 cm and a tight stricture at 31 cm from the incisors in the midthoracic esophagus. GI: Gastrointestinal

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Figure 2: Barium swallow showing an irregular stricture of the midthoracic esophagus extending for a length of approximately 5 cm

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Figure 3: Panel of images of noncontrast CT scan of the thorax showing esophageal wall thickening up to 1.6 cm with luminal narrowing and adjacent lung parenchyma showing normal bronchovascular pattern and no evidence of any axillary, hilar, or mediastinal lymphadenopathy. CT: Computed tomography

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Figure 4: Histopathology from endoscopic biopsy showing esophageal mucosa with occasional discrete and large confluent epithelioid cell granulomas forming a nodular focus surrounded by lymphocytes. H and E, ×100

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Figure 5: Fluoroscopic image showing a fully covered 22 mm × 70 mm esophageal self-expanding metallic stent deployed across the midthoracic esophageal stricture

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  Discussion Top


Tuberculous involvement of the esophagus is a rare extrapulmonary manifestation of TB accounting for 0.2% of total and 2.8% of gastrointestinal TB cases.[5] Most of the cases reported in the literature presented with a lesion in the midthoracic esophagus secondary to pulmonary TB. Our case too presented with a lesion in the midthoracic esophagus. However, unlike other cases of secondary TB, our case did not demonstrate any primary pulmonary parenchymal or mediastinal lymph node involvement which was ruled out by a CT scan of the thorax.[5] Dysphagia is the most commonly reported symptom in esophageal TB, as seen in our patient, followed by odynophagia, retrosternal pain, and other constitutional symptoms.[6],[7] The lack of constitutional symptoms led to the consideration of esophageal malignancy and Crohn's disease as differentials in our case.[8] However, histological findings solved the diagnostic dilemma and ATT could be initiated. However, the sensitivity of identifying typical caseating granulomas on histopathology of endoscopy samples is low, ranging from 25.0% to 60.8%; either due to the low density of tuberculous granulomas in affected tissue or insufficient representation of the submucosal layer, which is the main site of tuberculous granulomas.[7] Acid-fast bacillus staining of the biopsy sample too has low sensitivity.[9] Our case required temporary esophageal metallic stenting after a failed attempt at bougie dilatation of the tight stricture. This not only helped in achieving effective administration of ATT and resolution of dysphagia but also contributed to improvement in nutritional status which is imperative for a faster recovery in TB, irrespective of the site of involvement. Esophageal TB is notorious for complications such as stricture formation, ulceration, perforation, and fistulization; most commonly being tracheoesophageal and aortoesophageal fistula which often require surgical intervention.[10] Our case presented with stricture and escaped other rare complications, probably due to early diagnosis and treatment initiation. Thus, to summarize and conclude, primary esophageal TB although rare, forms an important differential in immunocompetent patients presenting with dysphagia without constitutional symptoms, especially in developing countries. Histological examination of endoscopic biopsy is the investigation of choice for confirming the diagnosis of TB and a CT scan of the thorax is essential to establish whether it is primary or secondary involvement of the esophagus. Conservative management with ATT is the treatment of choice; which if initiated early, helps in achieving nutritional recovery with complete resolution of symptoms and avoids major complications.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Mokoena T, Shama DM, Ngakane H, Bryer JV. Oesophageal tuberculosis: A review of eleven cases. Postgrad Med J 1992;68:110-5.  Back to cited text no. 1
    
2.
Baijal R, Agal S, Amarapurkar DN, Kumar HR, Kotli N, Jain M. Esophageal tuberculosis: An analysis of fourteen cases. J Dig Endosc 2010;1:14-18.  Back to cited text no. 2
    
3.
Khan MS, Maan MH, Sohail AH, Memon WA. Primary esophageal tuberculosis mimicking esophageal carcinoma on computed tomography: A case report. World J Gastrointest Surg 2019;11:373-80.  Back to cited text no. 3
    
4.
Patel N, Amarapurkar D, Agal S, Baijal R, Kulshrestha P, Pramanik S, et al. Gastrointestinal luminal tuberculosis: Establishing the diagnosis. J Gastroenterol Hepatol 2004;19:1240-6.  Back to cited text no. 4
    
5.
Nagi B, Lal A, Kochhar R, Bhasin DK, Gulati M, Suri S, et al. Imaging of esophageal tuberculosis: A review of 23 cases. Acta Radiol 2003;44:329-33.  Back to cited text no. 5
    
6.
Gomes J, Antunes A, Carvalho A, Duarte R. Dysphagia as a manifestation of esophageal tuberculosis: A report of two cases. J Med Case Rep 2011;5:447.  Back to cited text no. 6
    
7.
Welzel TM, Kawan T, Bohle W, Richter GM, Bosse A, Zoller WG. An unusual cause of dysphagia: Esophageal tuberculosis. J Gastrointestin Liver Dis 2010;19:321-4.  Back to cited text no. 7
    
8.
Sharma V, Rana SS, Chhabra P, Sharma R, Gupta N, Bhasin DK. Primary esophageal tuberculosis mimicking esophageal cancer with vascular involvement. Endosc Ultrasound 2016;5:61-2.  Back to cited text no. 8
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9.
Hu Z, Wang X, Gong L, Zhou Y, Meng M, Feng H, et al. Case report: Esophageal tuberculosis presenting as a submucosal tumor. Int J Clin Exp Med 2018;11:1226-32.  Back to cited text no. 9
    
10.
Griga T, Duchna HW, Orth M, Nicolas V, Müller KM, Schultze-Werninghaus G, et al. Tuberculous involvement of the oesophagus with oesophagobroncheal fistula. Dig Liver Dis 2002;34:528-31.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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