CASE REPORTS

Dysphagia as an Uncommon Presentation of Disseminated Tuberculosis: A Case Report BC SHILa, RK BANIKb, SK SAHAc, MR UDDINd, ANM SAIFULLAHe, MMU RASHIDf, I MAHBUBg

Summary: This is a case report of a 57-year old farmer who presented with a 4 months history of and weight loss. Upper gastrointestinal endoscopy revealed submucosal swellings with overlying ulcers at mid to lower part of esophagus. Repeated histopathological evaluation of endoscopic esophageal tissue biopsies showed nonspecific findings. Endoscopic ultrasound showed a hypoechoic mass at submucosal layer with periesophageal . Endosonogram guided FNA materials depicted caseating granulomas. Patient was managed with anti-tuberculosis therapy. Follow up endosonography after therapy revealed resolution of the growth and the mediastinal enlargement and patient was symptomatically improved.

(J Bangladesh Coll Phys Surg 2020; 38: 150-154) DOI: https://doi.org/10.3329/jbcps.v38i3.47063

Introduction: Primary esophageal tuberculosis is very rare, as Esophageal tuberculosis is a rare entity, constitutes 0.3% esophagus has various protective mechanisms such as of gastrointestinal tuberculosis (GI TB).1-2 It may occur mucosal stratified squamous epithelium, covered with in isolation or as a part of disseminated TB. It was first mucus and saliva and rapid transit of food content 5,6,7 described as postmortem diagnosis by Denonvilliers in through the lumen. So esophageal tuberculosis 1837.3 Tuberculosis can involve any part of GIT, usually occurs because of secondary spread from surrounding infected structures like mediastinal nodes, although the terminal ileum, caecum and the peritoneum lung, spine or by hematogenous spread from distant are common sites.4 site.1,2,5-8 a. Dr. Bimal Chandra Shil, Professor & Head, Department of Tuberculosis usually affects the middle third of the 6 Gastroenterology, Sir Salimullah Medical College Mitford esophagus at the carina level. The principle presenting Hospital, Dhaka. symptom is dysphagia but many complain of retrosternal b. Dr. Ranjit Kumar Banik, Associate Professor, Department pain, and weight loss.1,6 Clinical and of Gastroenterology, SSMC MH. endoscopic findings are non-specific and can mimic c. Dr. Shasanka Kumar Saha, Associate Professor, Department carcinoma esophagus. Endoscopic ultrasound (EUS) of Gastroenterology, SSMC MH. may help in diagnosis of esophageal and mediastinal d. Dr. Md. Royes Uddin, Assistant Professor, Department of tuberculosis.5, 6, 8-10 Gastroenterology, SSMC MH. We present one case report of esophageal TB in order e. Dr. A N M. Saifullah, Assistant Professor, Department of Gastroenterology, SSMC MH. to uncover rare presentation, diagnosis and outcome in f. Dr. Md. Mamun-ur Rashid, Resident, Department of management of this disease at tertiary level hospital. Gastroenterology, SSMC. g. Dr. Imteaz Mahbub, Gastroenterology, Resident, Case report: Department of Gastroenterology,SSMC. A 57 years old male got admitted in our hospital with the Address of Correspondence: Dr. Bimal Chandra Shil, Professor presenting complaints of progressive dysphagia to solid & Head, Department of Gastroenterology, Sir Salimullah Medical foods for 4 months, anorexia and weight loss of about College Mitford Hospital, Dhaka. Mobile: 01720038611, Email: 18 kg for 04 months, gradually increasing for the [email protected]. last 03 months. Patient also reported occasional low Received: 21 May, 2019 Accepted: 9 January, 2020

150 (151) 01 - JULY - Vol. - 38, No. - 3, 2020 ol. 38, No. 3, July 2020 ol. 38, No. V . Endoscopic view of esophageal submucosal Endoscopic image of submucosal swelling in

enlarged periesophageal lymph nodes were also seen nodes were also lymph enlarged periesophageal with were consistent 4). Features of EUS (Figure 3, lesion. neoplasm or tubercular esophageal done from the lesion in fanning EUS guided FNA was were prepared. Cytology of FNA pattern. Eight slides (Figure 5) with background materials showed granuloma 6). Cytological finding of FNA caseation necrosis (Figure inflammation suggestive was chronic granulomatous of tuberculosis. swelling with partial narrowing of lumen. Fig.-2: Fig.-1: esophageal wall with ulcer All WBC Ascites uberculin . otal . Repeat T T sonographic endo with lymphocyte 3 . In were Negative. Anti HCV AFB was not found in the fluid. Adenosine deaminase activity (ADA) and hour with normal WBC and platelet count. st sophagus (32- 38 cm) with narrowing of the , non-alcoholic, normotensive and non-diabetic. normotensive , non-alcoholic, ganomegaly was found, testes were normal. ganomegaly was found, testes were normal. view a hypoechoeic soft tissue mass at submucosal layer of esophagus (28 mm X 17mm) invading layer of muscularis mucosa & adventitia was seen. Multiple 151 vitals were within normal limit. On gastrointestinal vitals were within was distended. No systemic examination, or Journal of Bangladesh College of Physicians and Surgeons College of Physicians Journal of Bangladesh had no history of cough, for 03 months. He grade fever non- . He was and hemoptysis, smoker of contact with smear positive There was no history His bowel and bladder habits were tuberculosis patient. normal. patient was ill looking and On general examination, anemic. Jaundice, cyanosis, cachexic. He was mildly leuconychia and edema were clubbing, koilonychia, lymphadenopathy was found. absent. No peripheral count in the fluid was 1700/mm Random blood glucose, and renal functions were Random blood glucose, liver and renal Carcinoem- normal. Carbohydrate antigen (CA) 19.9, protein (AFP) bryonic antigen (CEA) and alpha feto (TSH) was were negative. Thyroid stimulating hormone normal. HBsAg and was present evidenced by . Examination was present evidenced by shifting dullness. of the other systems revealed no abnormality gm/dl, ESR- Investigations revealed hemoglobin - 9.8 40 mm in 1 test was negative. Chest X-ray P/A view was normal. test was negative. Chest X-ray P/A view ascites. Ultrasound of whole abdomen showed moderate Echocardiography was normal (EF: 62%). with serum Ascitic fluid study showed exudative fluid ascites albumin gradient (SAAG) - 0.46 gm/dl. endoscopy and biopsies including PCR were inconclusive. CT scan of chest showed eccentric wall thickening at mid and lower part of esophagus with mild bilateral small pleural effusion and ascites. EUS showed submucosal swelling with mucosal ulcers at 32-38 cm in endoscopic view predominance. was 21.93 U/L submucosal Endoscopy showed moderate size swellings with overlying superficial ulcers at mid to lower part of e lumen (Figure 1 and 2). Comment was suggestive of carcinoma esophagus. Histopathology report revealed acute & chronic inflammatory cells infiltration in mucosa without any granuloma or malignancy Dysphagia as an Uncommon Presentation of Disseminated Tuberculosis: A Case Report BC Shil et al

Fig.-3: Endosonographic Image showing esophageal Fig.-4: Endosonographic Image showing esophageal wall thickening with periesophageal enlarged lymph wall thickening with periesophageal enlarged lymph nodes. nodes.

Fig.-5: Cytology of FNA materials showing granuloma, Fig.-6: Cytology of FNA materials showing lymphocytes groups of epithelioid histiocytes. with background caseation necrosis.

Antitubercular therapy was started accordingly. Patient Discussion was followed up; he was improved symptomatically with Tuberculosis (TB) results in death of 3 million people 12 kg weight gain in 02 months. Dysphagia was totally globally in each year. An estimated 1 billion people improved. In subsequent follow up after completion of will be infected by the year 2020 and 35 million will anti-tubercular therapy, patient was clinically well. die from tuberculosis, if control is not Follow up ultrasonogram showed no ascites. strengthened.11 152 (153) 01 - JULY - Vol. - 38, No. - 3, 2020 e initiated a W . Furthermore, ol. 38, No. 3, July 2020 ol. 38, No. V o 7 months. 16-18 Ascites disappeared after ymph node, and the patient was . proved. gan tissue may be low e available diagnostic methods. Early In the present case, repeated endoscopy and In the present case, 16-18 completion of therapy Conclusion Dysphagia is one of the presenting features of esophageal tuberculosis. This condition should be considered as a differential diagnosis in populations of high prevalence countries and who are at risk such as immunocompromised. The diagnostic confirmation of the disease may be hampered and delayed by the low sensitivity of th diagnosis and therapy are critical for the disease outcome. The undue delay in the diagnosis can lead to complications, which might require surgical intervention. standard treatment in our patient, and advised to standard treatment in our patient, and months. In continue the treatment over a period of nine ultrasound two follow-up endoscopy and endoscopic was complete months after therapy initiation, there remission of the tuberculous esophageal lesion and the enlarged mediastinal l symptomatically im Endoscopic biopsies are useful for the diagnosis of for the diagnosis biopsies are useful Endoscopic classic caseation TB which reveals esophageal of in 25% to 60.8% in endoscopy samples granulomas cases. biopsy were inconclusive and the diagnosis of the biopsy were inconclusive was delayed. The diagnostic esophageal tuberculosis herein are in line with previous difficulties as reported case series of patients with case reports or gastrointestinal tuberculosis. FNAC (eight slides) from the In our patient, EUS guided lymph nodes were needed to lesion and surrounding granulomas. This is related finally detect tuberculous granulomas to the fact that the density of tuberculous in the infected or submucosal tuberculous granulomas are located in the represented in layer that frequently is not adequately the need of endoscopic tissue biopsies, highlighting patients with multiple and deep tissue samples in The suspected esophageal or intestinal tuberculosis. TB was present study demonstrated that esophageal lymph caused by secondary spread from surrounding nodes. drugs. The treatment of esophageal TB is anti-tubercular is A 6 to 9 months course of anti TB chemotherapy first line drugs sufficient to treat the patient with four Pyrazinamide) regimen (Rifampicin, INH, Ethambutol and phase with for initial 2 months and then continuation Rifampicin, INH for further 4 t , 2 A 2,7 14,15 scan of . However In this case, mild bilateral gram does not s and anorexia to lower part of 7 In our case, the 8 s disease, moniliasis, s disease etc. CT contrast esophago CT image is also helpful to detect A 7 Other symptoms include odynophagia, Other symptoms include 2,3,7 In our case, dysphagia and weight loss were . 12-13 . hypertrophic growth may mimic esophageal A differential diagnosis of esophageal TB includes esophageal carcinoma, Crohn’ actinomycosis and esophageal injury secondary to ingestion of caustic materials. endoscopic finding was moderate size submucosal swellings with overlying superficial ulcers at mid to lower part of esophagus (at 32- 38 cm) causing luminal narrowing hypertrophic growth may also be present. 153 Journal of Bangladesh College of Physicians and Surgeons College of Physicians Journal of Bangladesh rare, TB is involvement of disseminated Esophageal suspicion is needed. degree of clinical hence high is no primary when there TB is considered Esophageal tubercular site and secondary other detectable spread from adjacent structure. esophageal TB due to Symptoms are related to the extent of infection but Symptoms are related with dysphagia (>90% of cases). patient usually present It is usually because of esophageal ulcers but may also It is usually because compression and diverticula. be due to stricture, extrinsic present with esophagobronchial Occasionally patients symptoms like cough on fistula producing swallowing. like retrosternal pain and constitutional symptoms evening rise of temperature, weight los etc. cancer thickening chest of this patient showed eccentric wall at mid and lower part of esophagus with small pleural effusion and ascites. is the key An endoscopy and biopsy from the lesion It can involve investigation in evaluation of dysphagia. any segment of esophagus but middle third just proximal to carina is commonly involved due to increased number of lymph node around the carina. esophageal involvement was at the mid esophagus. The most common macroscopic finding on endoscopy is an esophageal ulcer the presenting symptoms. patients with A plain chest X-ray should be done for apical dysphagia. If it shows any abnormality particularly or mediastinal lesion suggestive of present or past TB TB should be nodes, the possibility of esophageal strongly suspected. as perforation, complication of esophageal TB such pneumomediastinum and Pott’ demonstrate extra luminal lesion, for which CT scan of demonstrate extra luminal lesion, for which secondary thorax and/or EUS is required to document nature of diagnosis. Dysphagia as an Uncommon Presentation of Disseminated Tuberculosis: A Case Report BC Shil et al

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