A 38-year-old man presented with progressively increasing mechanical
dysphagia associated with anorexia and weight loss. Clinical examination did
not reveal any significant findings. The hematological and biochemical
investigations were normal. The upper gastrointestinal endoscopy performed at
the referring hospital revealed an eccentric ulcerated lesion in the mid
esophagus ([Fig. 1]), and the histological
examination of endoscopic biopsies was inconclusive.
Fig. 1 Eccentric ulcerated
lesion in the mid esophagus.
Computed tomography (CT) of the chest revealed a thickened
esophageal wall ([Fig. 2]) with enlarged
mediastinal lymph nodes. The patient was referred to us for endoscopic
ultrasound (EUS).
Fig. 2 Computed tomography (CT)
showing thickened esophageal wall (arrow).
EUS revealed multiple enlarged mediastinal lymph nodes; one of the
large subcarinal lymph nodes was noted to infiltrate across the esophageal wall
into the lumen ([Fig. 3 a] and
[3 b]).
Fig. 3 a, b Endoscopic
ultrasound (EUS) showing a subcarinal lymph node eroding into the esophagus
wall (arrows).
This lesion corresponded to the ulcerated lesion noted on endoscopy.
EUS-guided fine needle aspiration cytology (FNAC) from the lesion revealed
epithelioid cell granulomas with numerous polymorphs and lymphocytes, and the
stain for acid-fast bacilli was positive. The patient was initiated on a
four-drug antitubercular therapy with marked improvement in his symptoms.
Esophageal tuberculosis is rare and is often secondary to spread
from adjacent sites such as mediastinal or hilar lymph nodes, pulmonary
infection, infected vertebral bodies, or from extension from the larynx or
pharynx [1]. The usual presentation is due to dysphagia,
retrosternal pain, fever, cough and expectoration, and weight loss
[1]
[2]. Complications may include
hemorrhage from the lesion, development of arterioesophageal fistula,
esophagocutaneous fistula, or tracheoesophageal fistula [1]
[2]. As in the present case, the
middle esophagus is the most common site of involvement. Endoscopic findings
may include ulcer, growth, infiltrative growth, stricture, fistula, or
extrinsic compression [1]
[2].
Tubercular necrotic mediastinal lymph nodes may erode into the esophagus,
leading to hematemesis or fistula formation [3]
[4]. However, mediastinal lymph nodes eroding into the
esophagus and presenting as a polypoidal mass is very rare.
Endoscopy_UCTN_Code_CCL_1AB_2AC_3AZ
