Tuberculosis of the esophagus

Role of Endoscopy in Esophageal Tuberculosis: A Narrative Review

Esophageal tuberculosis (ET) is a rare infectious disease of the gastrointestinal tract. Awareness of ET is deficient due to its low incidence. Unexplained dysphagia and upper gastrointestinal bleeding are the most common symptoms of ET. The prognosis is generally good if patients are diagnosed properly and receive anti-tubercular treatment promptly. However, ET is difficult to differentiate from other diseases. Endoscopic techniques such as esophagogastroduodenoscopy (EGD), endoscopic ultrasonography (EUS), contrast-enhanced harmonic endoscopic ultrasonography (CH-EUS), elastography, and endoscopic ultrasound--guided fine-needle aspiration (EUS-FNA) improve the diagnosis of ET. Thus, the characteristics of ET and other difficult-to-detect diseases according to EGD and EUS were summarized. Intriguingly, there is no literature relevant to the application of CH-EUS and elastography in ET. The authors' research center was first in introducing CH-EUS and elastography into the field of ET. The specific manifestation of ET based on CH-EUS was discovered for the first time. Correlative experience and representative cases were shared. The role of endoscopy in acquiring esophageal specimens and treatment for ET was also established. In this review, we aim to introduce a promising technology for the diagnosis and treatment of ET.

Oesophageal Tuberculosis: A Systematic Review Focusing on Clinical Management

Oesophageal tuberculosis, an uncommon form of extrapulmonary tuberculosis, has been reported mainly as small case series and the literature is heterogeneous. A systematic review to characterize the clinical presentation, evaluation and management of oesophageal tuberculosis was performed. Electronic databases were searched with keywords: esophagus OR esophageal AND tuberculosis. We included original papers and case series (> 4 patients) with oesophageal tuberculosis. Twenty-two studies reporting 311 patients were included. Mean age in most of the studies was 31-51 years and male gender constituted 50.5% patients. Dysphagia (72.3%), odynophagia (22.4%) and chest pain (31.3%) were predominant symptoms. Mid-oesophagus was the commonest site of involvement (88%). Endoscopic findings included ulcers (59.9%), submucosal bulge (31.7%), extrinsic compression (24.8%) and pseudotumour (5.8%). On endoscopic ultrasound, presence of hypoechoic (69.5%), heteroechoic (47.6%) and matted (86.3%) mediastinal lymph nodes and oesophageal wall involvement (67.3%) were common findings. Computed tomography showed mediastinal lymphadenopathy (76.5%) and oesophageal thickening (52.1%). Diagnosis was confirmed by granuloma (72.3%) and acid fast bacilli positivity (32.5%) in mots patients. Response to antitubercular therapy was excellent; 97.7% patients recovered and 2.3% patients died. Surgery (14.5%) and oesophageal stenting (11.4%) were required infrequently. Oesophageal tuberculosis should be considered in endemic regions as a cause of dysphagia because early treatment is associated with excellent outcomes.

Endoscopic ultrasound in diagnosis of esophageal tuberculosis: 10-year experience at a tertiary care center

Definite diagnosis of esophageal tuberculosis (ET) requires isolation of tubercle bacilli, which is challenging in clinical practice. Difficulty in differentiating ET from other esophageal diseases may well result in a delay in diagnosis. The literature on utility of endoscopic ultrasound (EUS) in diagnosis of ET is insufficient. This study aims to evaluate the role of EUS morphology combined with EUS-guided tissue acquisition in the diagnosis of ET. Data of the 35 patients diagnosed with ET from January 2006 to October 2015 were retrospectively analyzed. After miniprobe and linear echoendoscopic visualization, either linear EUS-guided deep biopsy or EUS-guided fine needle aspiration was performed for tissue acquisition. Histocytopathological results showing caseous necrosis or acid fast bacilli (AFB) or epithelioid granuloma were considered diagnostic. Esophageal wall thickening or mass formation with disruption of the adventitia due to infiltration by adjacent mediastinal lymphadenopathy was typically observed under EUS. Tissue acquisition revealed epithelioid granuloma in 33 patients, caseous necrosis in 13, a positive AFB stain in 14, and nonspecific chronic inflammation in 2. Of the 35 patients, 33 (94.3%) with both characteristic EUS morphology and diagnostic histocytopathology were considered to have an EUS established diagnosis. The remaining two with only nonspecific chronic inflammation received empirical antitubercular chemotherapy based solely on EUS morphology. The two-year follow-up confirmed diagnosis of ET in all patients. While the final diagnosis of ET was based upon two-year follow-up of treatment response to antitubercular medication in addition to caseous necrosis/granuloma/positive-AFB stain revealed by EUS-guided tissue acquisition, an EUS-established diagnosis of ET and medical treatment with long-term follow-up is rational and practical compared with surgery or untreated follow-up.

Gastrointestinal Tuberculosis

Gastrointestinal tuberculosis (TB) is a fascinating disease which can be observed both in the clinical context of active pulmonary disease and as a primary infection with no pulmonary involvement. It represents a significant clinical challenge because of the resurgence of TB as well as the diagnostic challenges it poses. A high clinical suspicion remains the most powerful tool in an era of medicine when reliance on diagnostic technology increases. Antimicrobial therapy is the mainstay of therapy, but surgical and endoscopic interventions are frequently required for intestinal TB. Gastrointestinal TB is truly the "great mimic" and continues to require the astute clinical acumen of skillful clinicians to diagnose and treat.

An Interesting Case of Dysphagia in a HIV Patient

Oesophageal tuberculosis is a rare disease. Tuberculosis (TB) can cause dysphagia due to oesophageal ulcers, Tracheo-Oesophageal Fistulas (TOFs) and an extrinsic compression which is caused by the mediastinal lymph nodes. A 33-year-old gentleman was admitted to our hospital for the evaluation of fever, dysphagia and cough. His chest X-ray was suggestive of miliary tuberculosis. A CT scan of his chest revealed miliary tuberculosis, mediastinal lymphadenopathy and pneumomediastinum. His sputum AFB (acid-fast bacilli) test was positive. An upper gastrointestinal endoscopy revealed a large ulcer in the oesophagus with a fistulous opening which was suggestive of a tracheo-oesophageal fistula. A biopsy from the ulcer was positive for AFB. The test for HIV-1 was positive. A nasogastric feeding tube was placed and the Anti Tubercular Therapy ( ATT) was started. The main aim of this case report is to sensitize the clinicians about the fact that Tuberculosis can present with dysphagia, especially in HIV patients.

Tubercular esophagocutaneous fistula

Tubercular esophagocutaneous fistula is a rare entity with only about four cases reported so far. We report here a case in a young female who has a very long tract but responded well to antitubercular treatment.

A solitary tuberculous ulcer in the oesophagus

A 48-year-old woman born in Pakistan was evaluated for dysphagia. Endoscopy showed a solitary ulcerative oesophageal lesion. Cultures were positive for mycobacterium tuberculosis. Additional imaging showed no other manifestations of tuberculosis. Oesophageal tuberculosis is a rare entity, especially as a primary manifestation defined as involvement of the oesophagus without signs of disseminated disease. Therefore, this case was classified as primary oesophageal tuberculosis.

Endoscopic features of esophageal tuberculosis

BACKGROUND

Esophageal tuberculosis is rare. Clinical and endoscopic features are variable, diverse, nonspecific, and poorly described. These findings may be confused with those of esophageal cancer and deep fungal infection.

METHODS

Medical records from a 5-year period (January 1997 to December 2001) were searched for cases of esophageal tuberculosis. For identified cases, the clinical, radiologic, and endoscopic features were evaluated.

OBSERVATIONS

Four cases of esophageal tuberculosis were encountered during the 5-year period studied. Three of the patients presented with dysphagia and weight loss. One patient had aspiration pneumonia and another fatal hematemesis. Endoscopic features included deep and large proximal esophageal ulcers in 2 patients, tracheo-esophageal fistula in one, and nonhealing proximal esophageal ulcer in another patient.

CONCLUSION

The present case series indicates that certain endoscopic features, such as deep and large esophageal ulcers, tracheoesophageal fistula, and nonhealing ulcer, are strongly suggestive of tuberculosis-related esophageal lesions.

Imaging of esophageal tuberculosis: a review of 23 cases

PURPOSE

To evaluate the various radiological abnormalities in patients with proven esophageal tuberculosis.

MATERIAL AND METHODS

The case records of 23 patients with proven esophageal tuberculosis were evaluated retrospectively for various radiological abnormalities. Twenty-two patients had secondary involvement of esophagus in the form of direct extension of mediastinal and pulmonary tuberculosis or spinal tuberculosis. Only 1 patient had primary involvement of the esophagus with no evidence of disease elsewhere. The diagnosis was confirmed by endoscopic and CT-guided biopsy/aspiration cytology in 7 and 6 cases, respectively. Diagnosis was made on the basis of surgical biopsy of lymph node and autopsy in 1 patient each. In the remaining 8 patients the diagnosis was based on radiological and endoscopic findings and the response to antituberculous treatment.

RESULTS

Chest radiography (CXR) was abnormal in 65% patients. While the findings were non-conclusive for esophageal tuberculosis, characteristic lesions of tuberculosis in lungs or spine were suggestive of tuberculous etiology. In 15 patients, CT of the chest confirmed the corresponding CXR findings and also showed additional findings of mediastinal lymphadenopathy when CXR was normal. Fourteen patients showed mediastinal lymphadenopathy on CT of the chest. In all these patients, more than one group of lymph nodes was involved. The characteristic hypodense center of lymph nodes suggestive of tuberculosis was seen in 12 patients. Radiological abnormalities seen in barium swallow examination were extrinsic compression, traction diverticula, strictures, sinus/fistulous tracts, kinking and pseudotumor mass of esophagus in decreasing order of frequency. The middle third of the esophagus was found to be the most frequent site of involvement.

Esophageal tuberculosis associated with esophagotracheal or esophagomediastinal fistula: report of 10 cases

BACKGROUND

Esophageal tuberculosis is rare but appears to be increasing, especially in endemic areas and in immunosuppressed individuals. The esophagus is involved by spread from adjacent structures. The natural history, complications, and treatment of this condition are unclear.

METHODS

Experience with 10 cases of esophageal tuberculosis encountered from 1995 to 2000 is described.

OBSERVATIONS

Esophageal tuberculosis was always associated with spread from adjacent structures such as mediastinal or cervical lymph nodes and the spine. Dysphagia or coughing on eating were the predominant symptoms. Esophageal ulcers with undermined edges were the most common finding, followed by esophageal sinuses or fistulous openings. One patient died of disseminated disease; the remaining 9, including 4 with esophagotracheal or esophagomediastinal fistulas, recovered by treatment with antituberculous drugs alone.

CONCLUSION

Esophageal tuberculosis almost always is associated with mediastinal lymphadenopathy. In half of the cases, it is associated with an esophagotracheal fistula or an esophagomediastinal sinus. Despite these complications, patients can be treated safely with antituberculous drugs alone.

Pseudoazygos lobe caused by lymph node pneumatocele

In patients with AIDS, the relatively high incidence of pulmonary tuberculosis places them at risk for more severe esophageal tuberculosis (including fistula formation), and tuberculous esophagitis in the setting of AIDS may be more common than had been thought. Tuberculous esophageal fistulae have long been described and are well known. Air tracking from the esophagus into a mediastinal lymph node is very rare and reported previously to collect in small pockets in either of two patterns: irregular (or "amorphous") or peripheral and curvilinear. Complete filling of a large lymph node by air has not previously been reported. Reported here is a case of tuberculous mediastinal lymphadenopathy in an AIDS patient in whom CT scans demonstrated fistula development between a large lymph node and adjacent esophagus; this was accompanied by total replacement of the apparently necrotic content of the node with air, surrounded by the relatively thin, smooth, residual wall of the node. A lymph nodal pneumatocele was thereby created, which has not been previously described, and is the first feature of this case. On frontal chest radiography, the lateral wall of the lymph nodal pneumatocele produced an appearance falsely akin to an azygos fissure, creating the second feature: a previously unreported cause of false appearance of an azygos lobe. It is important to consider tuberculosis when a fistula to the esophagus is demonstrated in an AIDS patient, to be aware that even a large lymph node may "shell out" entirely in that setting, and not to confuse the final resulting appearance with the normal variant it may resemble.

Tuberculous involvement of the oesophagus with oesophagobroncheal fistula

Tuberculous involvement of the oesophagus is a rare disease. Even if it is suspected, diagnosis is often difficult though dysphagia and chest pain are the most common symptoms without any other specific signs of tuberculosis. The diagnosis is based on oesophagography, oesophagoscopy, bronchoscopy, and computed tomographic scan. Suspected tuberculosis can be confirmed with histology, smear, and culture. The two most common differential diagnoses are Crohn's disease and carcinoma. The case is reported of a female patient with tuberculous involvement of the oesophagus, who developed an oesophagobroncheal fistula during steroid treatment started for suspicion of Crohn's disease. The patient was immunocompromised due to treatment with azathioprine that she was receiving for multiple sclerosis. The fistula was successfully treated by antituberculous chemotherapy alone.

Tuberculous esophagocutaneous fistula

Esophagocutaneous fistula due to tuberculosis is a distinctly rare entity, with only two cases reported over the past 25 years. We report this unusual complication in an 85-year-old, human immunodeficiency virus-negative man and review the relevant literature.

Sepsis syndrome induced by tuberculous perforation of the esophagus

Perforation of the esophagus induced by tuberculosis with no evidence of HIV infection is an extremely unusual presentation of the disease. We report on a 41-year-old man presenting with an esophageal perforation who developed a sepsis syndrome characterized by multiple organ dysfunction. The perforation was covered endoscopically with a tube, the patient recovered from cardiovascular, renal and pulmonary dysfunction under intensive care treatment, including antimycobacterial therapy. In response to endoscopic and medical treatment the size of the lesion decreased and disappeared 56 days after diagnosis. The patient could be discharged 2 months after admission and remained asymptomatic after a 12 month follow-up examination.

Localized tuberculosis of the oesophagus: a rare condition

This report describes the case of a male patient with progressive dysphagia, epigastric pain, odynophagia, generalized weakness and a mid-oesophagus ulceration in which biopsies showed acid-fast bacilli and histological evidence of tuberculosis. Culture of the biopsies and the sputum revealed mycobacterium tuberculosis. There were no respiratory symptoms, and radiographs did not reveal evidence of pulmonary tuberculosis. The patient responded well to antituberculous therapy and he is alive and well 7 years later, without any signs of relapse. The involvement of the oesophagus as the only demonstrable localization of tuberculosis is an extremely rare condition, which should always be considered as differential diagnosis in dyspepsia of unknown origin.

Esophagoaortic fistula caused by esophageal tuberculosis: report of a case

We report herein the case of a 73-year-old woman who was urgently admitted to hospital with severe hematemesis. An emergency endoscopy revealed a protruding lesion 36 cm from the incisors; however, respiratory insufficiency precluded surgery and despite aggressive medical treatment, the patient's respiratory status continued to deteriorate, leading to death on the 36th hospital day. An autopsy revealed the source of the hemorrhage to be a fistula connecting the esophagus and the descending aorta. Histopathologic studies showed that this fistula was caused by esophageal tuberculosis.

Mediastinal histoplasmosis presenting with esophageal involvement and dysphagia: case study

Esophageal involvement with histoplasmosis is uncommon, but has been recognized in two clinical settings. Most commonly, the esophagus becomes involved as a result of contiguous mediastinal lymphadenopathy. Such patients usually present with dysphagia secondary to midesophageal compression or stricture. The esophagus can also be involved in cases of disseminated histoplasmosis. Esophageal ulcers or nodular lesions are the usual clinical manifestations in this setting. We report a case of mediastinal histoplasmosis with esophageal narrowing and mucosal ulceration that presented with dysphagia. The diagnosis was established at thoracotomy by the histologic finding of necrotizing granulomas and a positive fungal stain. The case was successfully treated with amphotericin B. The literature on esophageal and gastrointestinal histoplasmosis is reviewed.

Esophageal infections: risk factors, presentation, diagnosis, and treatment

Infections of the esophagus are unusual in the general population and strongly imply immunodeficiency, although immunocompetent individuals are not exempt. HIV infection is predominant among risk factors for infectious esophagitis. For all immunocompromised patients, the most frequently identified esophageal pathogens are Candida, CMV, and HSV. Peculiar to HIV-infected patients are idiopathic esophageal ulcers as well as unusual bacteria and parasites. Patterns of presentation differ with each infecting organism, and clinical features should be used as a guide in achieving a correct diagnosis. For example, a patient with AIDS presenting with esophageal symptoms and thrush, along with abdominal pain, nausea, vomiting, and fever, is unlikely to resolve all symptoms with empiric antifungal therapy alone. Parsimony of diagnosis does not hold among immunodeficient patients in whom concurrent infections are common. Accurate and timely diagnoses are essential as effective treatments are available for particular etiologies. Finally, among immunocompromised patients, all esophageal symptoms are not necessarily due to an infection, and possible diagnoses of pill esophagitis, acid-peptic injury, or structural and functional abnormalities should not be overlooked.