A case report of esophageal tuberculosis in a patient from united states

Introduction/Background Gastrointestinal (GI) tuberculosis (TB) is rare in the United States and is the sixth most frequent site of extra pulmonary involvement of TB overall. It can involve any site along the GI tract, however, esophageal TB is uncommon. Dysphagia is the most common presenting symptom of esophageal TB and misdiagnosis is frequent given its rarity. We present a unique case of a 57-year-old male with progressive dysphagia, found to have presumed esophageal TB. Case Presentation A 57-year-old Hispanic male, employed as factory worker, with past medical history of newly diagnosed diabetes mellitus (HbA1c of 10.5), presented with two-week history of subjective fever, chills, headache, nasal congestion, sore throat and twelve-pound weight loss. Patient was originally from Mexico, but has resided in the United States for the past 20 years. Computed tomography scan of the neck was obtained at outside hospital, revealing a 4.9 × 3.3 × 4.2 cm superior mediastinal mass with lateral esophageal displacement; necessitating transfer to our facility for further evaluation. Initial laboratory work-up was notable only for leukocyte count of 16.9 thou/mcL. During admission patient's symptoms advanced to dysphagia and odynophagia, initially with solids then progressing to liquids, and ultimately difficulty with secretions. Patient was started on empiric antibiotic therapy and underwent laryngoscopy, which was negative for any mass. Upper gastrointestinal endoscopy (EGD) was then performed, which revealed an extrinsic high-grade compression/mass lesion in the cervical esophagus that appeared submucosal, with significant purulent drainage from esophageal wall. Pathology report from EGD demonstrated extensively ulcerated squamous mucosa with acute inflammatory exudate, with immunostains for CMV and HSV negative and GMS stain negative for fungal organisms. A whole-blood interferongamma assay (QuantiFERON) was obtained and returned positive, although review of esophageal biopsy did not show any evidence of granulomas. AFB stain and TB-polymerase chain reaction (TB-PCR) of esophageal biopsy were negative, along with stool TB-PCR. Patient continued to clinically improve and completed a total three-week course of antibiotic therapy with piperacillin-tazobactam for presumed abscess. However, on subsequent follow-up visit, repeat computed tomography imaging of the chest, abdomen, and pelvis with contrast was obtained demonstrating gastroesophageal wall thickening and punctate calcifications in the medial right lung base, anterior wall of proximal esophagus, and anterior to C7 vertebral body, highly concerning for TB in setting of positive Quanti-FERON. Work-up is currently ongoing for patient to undergo repeat EGD and possible endoscopic ultrasound for definitive diagnosis and ultimately treatment of presumed esophageal TB. Discussion Esophageal TB is rare, accounting for only 0.2-1% of all reported gastrointestinal TB cases overall, with majority of published case reports documented from developing countries. It is typically secondary to tuberculosis from another site in the body, most commonly pulmonary. Typically, esophageal involvement occurs from direct extension from mediastinal lymph nodes or lung cavity, although it may also spread via blood, lymphatic drainage, or from swallowed sputum. In our patient, it is postulated that he had a paraesophegal lymph node from TB that reactivated and subsequently affected the esophagus. Furthermore, the diagnosis of esophageal TB is difficult, as sensitivity of tests including AFB and PCR are variable and radiographic/biopsy results can be ill defined. In the case of our patient, positive QuantiFERON is concerning for possibility of esophageal TB in setting of suspicious punctate calcifications noted on repeat imaging. While initial esophageal AFB and TB-PCR were negative, as noted in Dahale et al., initial esophageal biopsies were diagnostic only 57% of the time. Repeat EGD with biopsy or endoscopic ultrasound is oftentimes necessary for definitive diagnosis, as is planned with our patient. If left untreated, esophageal TB can lead to numerous complications, including bleeding, fistula formation, and esophageal strictures.