Esophageal tuberculosis (TB) is a rare diagnosis, found in <1% of autopsies in patients who died with known TB. The majority of cases are secondary, with contiguous spread from mediastinal lymph nodes constituting the most common etiology. Esophageal TB is commonly mistaken for malignancy, as symptoms are similar (dysphagia, weight loss, and fever) and esophagogastroduodenoscopy (EGD) characteristics are comparable. To make a definitive diagnosis, a granulomatous lesion must be present on biopsy of the esophagus or adjacent lymph node. Alternatively, Ziehl-Neelsen stain of the specimen must be positive for tubercle bacilli.
Case Report
A 69-year-old Mexican American man with a history of polysubstance abuse presented to the hospital for persistent fevers and dysphagia of 4 weeks duration. At an outside hospital, computed tomography of the chest showed a large esophageal mass with right hilar and left supraclavicular lymphadenopathy (Figure, A). Given the computed tomography findings and the patient’s history of alcohol and tobacco use, an EGD with biopsy was performed due to concern for esophageal malignancy. The EGD showed a fungating mass in the middle third and lower third of the esophagus, which was thought to be a malignant esophageal tumor (Figure, B). Pathology showed denuded squamous mucosa with no immunophenotypic evidence of malignancy, and was negative for cytomegalovirus, herpes simplex viruses 1 and 2, and fungal and acid-fast bacilli staining. Despite the pathology results, level of suspicion for malignancy was still high and a core biopsy of the enlarged supraclavicular lymph node was performed. Pathology of this second biopsy showed fibrinopurulent exudate but no evidence of malignancy. Again, special stains were negative. As the fever persisted, further infectious work-up was initiated. Urine histoplasma antigen was negative, as was serum cryptococcal antigen, coccidioides antibody, Brucella antibody, and Bartonella antibody. The initial T-SPOT test (Oxford Immunotec, Marlborough, Mass) was borderline, as was a repeat value. At this point, a cell-free DNA sequencing test was sent from tissue of the supraclavicular node biopsy, which returned positive for acid-fast bacilli. One additional EGD was performed, which showed numerous cratered, deep esophageal ulcerations in place of the previous mass (Figure, C). Special stains of the biopsy of this second esophageal specimen were also positive for acid-fast bacilli, and a diagnosis of esophageal tuberculosis was made.
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-Bernard J. Danna, MD, Alexander W. Harvey, MD, Laila E. Woc-Colburn, MD
