Endoscopic findings and clinical features of esophageal tuberculosis

Esophageal anthracosis occurred after treatment of esophageal tuberculosis secondary to mediastinal tuberculous lymphadenitis: a rare case report

BACKGROUND

Anthracosis is a disease generally considered to be in the lungs resulting from exposure to industrial dust in the workplace. Esophageal anthracosis is a fairly rare phenomenon and shows a strong correlation with tuberculosis. Moreover, esophageal involvement in tuberculosis is also rare. We here present an extremely rare case in which follow-up gastroesophageal endoscopy revealed a mass with a sunken, black area in the center and raised ring-like pattern in the surrounding mucosa resembling malignant melanoma. Uncovering the patient's tuberculosis history finally avoided a misdiagnosis or overtreatment.

CASE PRESENTATION

A 67-year-old male patient was admitted to the hospital due to "repeated chest pain for 1 month". Endoscopic ultrasonography and contrast-enhanced CT scans revealed a mass adjacent to the esophageal wall with unclear boundaries. Aspiration biopsy confirmed that esophageal tuberculosis was caused by nearby mediastinal tuberculous lymphadenitis. After a standard anti-tuberculosis treatment regimen, the patient achieved a favorable prognosis. The follow-up gastroesophageal endoscopy showed a sunken black lesion with elevated peripheral mucosa replacing the original tuberculous mass, which was thought to be anthracosis, a disease that rarely occurs in the esophagus.

CONCLUSION

The diagnosis of tuberculosis should be taken into consideration when a submucosal mass appears in the middle part of the esophagus. Endoscopic ultrasonography can effectively contribute to a definite diagnosis. Moreover, this is the first case of esophageal anthracosis observed only 1 year after the treatment of tuberculosis, indicating esophageal anthracosis can be a short-term disease. The traction of the reduction of tubercular mediastinal lymph nodes after anti-tuberculosis treatment may create a circumstance for pigmentation or dust deposition.

Isolated esophageal tuberculosis: A case report

BACKGROUND

Tuberculosis is endemic in Senegal. While its extra-pulmonary localization is rare, esophageal tuberculosis, particularly the isolated form, is exceptional. We report here a case of isolated esophageal tuberculosis in an immunocompetent patient.

CASE SUMMARY

A 58-year-old man underwent consultation for mechanical dysphagia that had developed over 3 mo with non-quantified weight loss, anorexia, and fever. Upper digestive endoscopy showed extensive ulcerated lesions, suggesting neoplasia. The diagnosis was confirmed by histopathology, which showed gigantocellular epithelioid granuloma surrounding a caseous necrosis. Thoracoabdominal computed tomography scan did not show another localization of the tuberculosis. The outcome was favorable with treatment.

CONCLUSION

Esophageal tuberculosis should be considered when dysphagia is associated with atypical ulcerated lesions of the esophageal mucosa, in an endemic area.

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.

Clinical and endoscopic features of esophageal tuberculosis: a 20-year retrospective study

BACKGROUND

Tuberculosis of the esophagus is a rare clinical entity. There is a paucity of data on esophageal tuberculosis. This study aims to analyze the clinical and endoscopic features of esophageal tuberculosis over the last 20 years.

METHODS

We retrospectively analyzed the data of 14 patients with esophageal tuberculosis between January 1999 to January 2019 at Nanfang Hospital. Tuberculosis was considered diagnostic if histopathological results showing epithelioid granuloma with or without caseous necrosis. Records of clinical features, imaging findings, endoscopic features and outcome of antitubercular treatment were evaluated.

RESULTS

A total of 14 patients with definite esophageal tuberculosis were included. 7 patients (50%) presented with dysphagia, followed by 6 patients (42.86%) had retrosternal pain and another had cough (7.14%). On endoscopy, involvement of esophagus was observed at mid-segment mostly and findings included bulging lesions in 10 patients (71.43%), ulcer in 3 patients (21.43%), and tracheoesophageal fistula in 1 patient (7.14%). Endoscopic ultrasound showed a heterogeneous hypoechoic lesion with indistinct margins or interruption of the five layers structure of esophageal wall. Endoscopic ultrasound demonstrated mediastinal lymphadenopathy adjacent to esophageal pathology in 7/11(63.64%). Antitubercular treatment resulted in a good response with complete remission in all patients.

CONCLUSIONS

Esophageal tuberculosis is rare and frequently misdiagnosed due to the lack of diagnostic signs. There needs to be a high index of clinical suspicion among patients with dysphagia or retrosternal pain. Endoscopic biopsy and endoscopic ultrasound-guided FNA can help in achieving the correct diagnosis in esophageal tuberculosis.

EUS in the diagnosis of pathologically undiagnosed esophageal tuberculosis

Background

Esophageal tuberculosis (ET) is relatively rare, and the diagnosis is challenging. The aim of this study was to evaluate the clinical features of ET and highlight the role of endoscopic ultrasonography (EUS) in the diagnosis of pathologically undiagnosed ET.

Methods

We retrospectively analysed the clinical features, radiological performances, conventional endoscopic appearances, EUS features, treatment and outcomes of pathologically undiagnosed ET between January 2011 and December 2018. All 9 patients failed to be diagnosed by at least two repeated biopsies (such as routine biopsy, multipoint or deep biopsy, and even or EUS-guided fine-needle aspiration (EUS-FNA)).

Results

Nine patients (66.7% female) with a mean age of 45 years (range 29–59) complained of retrosternal pain or discomfort, or (and) dysphagia. Esophagoscopy demonstrated protruding lesions in the mucosa with central ulcers or erosion in five patients, submucosal bulges with smooth surfaces in one patient, submucosal bulges with diverticula in one patient, ulcers with suspicious fistula formation in one patient, and multiple ulcers in one patient. None of the patients received confirmed histopathological or bacteriological diagnoses by repeated biopsies. However, they were first suspected to have ET based on EUS examination. Because EUS found some characteristic ultrasonographic changes, which were very helpful for the diagnosis of ET when combined with clinical manifestations, the patients subsequently received diagnostic antituberculosis therapy. Finally, the patients recovered or improved with follow-up times ranging from 3 to 10 months.

Conclusions

EUS could help in the diagnosis of ET on basis of EUS features like poorly defined esophageal wall structure, enlarged paraesophageal or mediastinal lymph nodes, hypoechoic lesions of esophageal wall that are linked to the enlarged paraesophageal lymph nodes. However all attempts should be made to obtain histological or microbiological diagnosis.

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.

Primary Esophageal Extranasal NK/T Cell Lymphoma With Biphasic Morphology: A Case Report and Literature Review

We report a case of esophageal extranasal NK/T cell lymphoma with biphasic morphologic features revealed by a deep large piecemeal biopsy. A 40-year-old man present with pharyngalgia, dysphagia, recurrent fever, and 5-kg weight loss for 8 months. Endoscopy demonstrated progressing longitudinal ulcers and mucosal bridges along the esophagus. The first and second biopsies obtained superficial mucosa with scattered bland-looking small lymphocytes. A subsequent large piecemeal snare abscission for biopsy showed atypical lymphoid cells infiltrating into the deep lamina propria and muscularis mucosae, whereas the superficial lamina propria was highly edematous with scant small lymphocytes. Immunohistochemical studies confirmed that both underlying atypical cells and superficial small lymphocytes were neoplastic, sharing an identical immunophenotype: positive for CD2, CD3, CD43, CD8, CD56, TIA-1 and granzyme B. Epstein-Barr virus-encoded small RNAs were found in both cells. The histologic findings were diagnostic of primary esophageal extranasal NK/T cell lymphoma. However, the patient developed bone marrow depression during chemotherapy and died of massive cerebral hemorrhage after the first cycle of chemotherapy. Primary esophageal extranodal NK/T cell lymphoma nasal type is extremely rare. We show the biphasic morphology of this disease, which highlights the importance of deep biopsy for accurate diagnosis.

Tuberculosis presenting as Dysphagia: clinical, endoscopic, radiological and endosonographic features

Objective:

Dysphagia as a presenting manifestation of tuberculosis is rare and there is paucity of data on the clinical, endoscopic and endosonographic features of these patients. We present our data related to the features over last four years.

Methods:

We analyzed retrospectively the clinical, endoscopic, radiological, endosonographic and cytological findings in 14 patients (male: 10; mean age: 37.7 ± 10.4 years) with dysphagia due to tuberculosis presenting to us over last 4 years.

Results:

Nine patients (64.3%) had Grade 1 dysphagia, 4 (28.6%) patients had Grade 2 and 1 patient (7.1%) had Grade 3. Mid esophagus was the commonest site of involvement. Endoscopic findings were extrinsic bulge (50%), linear ulcers (28.6%) and pol-ypoidal ulcerated lesion (7.1%). Endoscopic biopsies were inconclusive. Endoscopic ultrasound (EUS) demonstrated mediastinal lymph nodes being responsible for endoscopic bulge and their infiltration into esophageal wall leading on to ulcers. EUS-guided fine needle aspiration from these nodes established diagnosis in all patients.

Conclusion:

Dysphagia in tuberculosis is most commonly caused by compression by the surrounding mediastinal lymph nodes. EUS is a useful investigation for assessment of these patients.

Esophageal tuberculosis: A case report and literature review

Esophageal tuberculosis is a rare type of gastrointestinal tuberculosis. Common clinical symptoms of esophageal tuberculosis are reported to be dysphagia and odynophagia. Upper gastrointestinal endoscopy often reveals ulceration or apophysis. Clinically, esophageal tuberculosis is often misdiagnosed as esophageal cancer, Crohn's disease and Behcet's disease. Clinicians showed raise their awareness of this disease.

EUS and EUS-FNA for diagnosis of esophageal tuberculosis

AIM: To summarize the endoscopic ultrasonography (EUS) characteristics of esophageal tuberculosis and evaluate the role of EUS and EUS guided fine needle aspiration (EUS-FNA) in the diagnosis and differential diagnosis of esophageal tuberculosis.

METHODS: The clinical data, EUS and EUS-FNA data for 11 patients with esophageal tuberculosis were collected and analyzed retrospectively.

RESULTS: Eight lesions were found in the middle part of the esophagus and 3 in the upper part. The lesions demonstrated as protrusion in 7 cases and ulceration in 4 cases. The layers of the esophageal wall were unclear or disappeared in some cases, and in some patients low echo occupying lesions inside or outside the esophageal wall were showed by EUS. The internal echo of the lesions was heterogeneous, and strong echo spots could be observed. In most cases, enlarged mediastinal lymph nodes were observed. EUS-FNA was used to take biopsy specimens in 7 cases: caseouse necrosis was found in 2 cases; 3 biopsy specimens suggested tuberculosis; no cancer cells were observed in 2 biopsy specimens.

CONCLUSION: EUS can not only show the morphology and internal echo of the lesions, as well as the relationship between the lesions and esophageal wall, but also allow to observe the lymph nodes outside the esophageal wall. Biopsy specimens can be taken by EUS-FNA. EUS and EUS-FNA have high value in the diagnosis of esophageal tuberculosis.

Esophageal tuberculosis: role of endoscopic ultrasound in diagnosis

Esophageal involvement by tuberculosis is rare and is commonly secondary to mediastinal lymph nodal involvement. Endoscopic ultrasound (EUS) is a good modality for evaluation of both esophageal wall and mediastinal lymph nodes. The objectives were to study the role of EUS in diagnosing esophageal tuberculosis, to differentiate primary from secondary form, and to assess the response. Retrospective analysis of data over 7 years (i.e. from 2003 to 2009) was used. The study was set in a tertiary care referral institute and focused on patients diagnosed with esophageal tuberculosis. Interventions used included endoscopy, EUS, EUS-FNA (fine needle aspiration) followed by antituberculosis treatment. The main outcome measurements were symptoms, endoscopic features, EUS features, pathological yield, and response to treatment. There were 32 cases of esophageal tuberculosis. The primary symptom was dysphagia, and endoscopy showed ulcers in 18/32 (56.25%) and extrinsic bulge in 20/32 (62.5%) in middle one third of esophagus. EUS showed lymph nodes adjacent to esophageal pathology in all cases. Subcarinal region was the most common site of lymphadenopathy and they were matted, heterogeneous with predominantly hypoechoic center. Histopathology of endoscopic biopsy of ulcers and EUS-FNA of lymph nodes provided the diagnosis of tuberculosis in 27/32 (84.35%). All patients were treated with antitubercular treatment and showed good clinical, endoscopic and endosonographic response. This is a retrospective study, and PCR and culture for Mycobacterium tuberculosis were not done. Esophageal tuberculosis does not appear to be a primary disease and is most likely secondary to mediastinal nodal tuberculosis. A conglomerated mass of heterogeneous with predominantly hypoechoic lymph nodes with intervening hyperechoic strands and foci on EUS appears to be characteristic of mediastinal tuberculosis.