Rügamer J, Kaaden R
Innere Medizin - Gastroenterologie, Krankenhaus Grafenau.
Dtsch Med Wochenschr. 2012 Mar;137(11):529-32. doi: 10.1055/s-0031-1298978. Epub 2012 Mar 6.
The patient, a 36-year-old man from Somalia, who had moved to Germany a year before, was referred for a diagnostic work-up of an ulcerating tumour. He suffered from thoracic tightness for the last weeks albeit without any further symptoms. There were no pre-existing illnesses. No further pathological signs were found during a preliminary physical examination.
After ruling out any malignancies by means of an analysis of biopsy samples, further differential diagnostic measures were undertaken. Besides mechanical and chemical factors, an infectious genesis of the esophageal lesion was considered and investigated further through histological, immunohistochemical, laboratory and microbiological tests.
DIAGNOSIS, TREATMENT AND COURSE: Mycobacterium tuberculosis was detected in cultures sampled from biopsy material. This strain turned out to be responsive to medical treatment. Further diagnostics regarding a potential primary pulmonary tuberculosis were negative. Histological analysis of a liver biopsy confirmed noncaseating epithelioid cellular granuloma as typically seen in granulomatous hepatitis without any direct evidence of mycobacteria. Thus, tuberculosis of the liver appeared most likely considering the differential diagnosis of a granulomatous hepatitis. The patient underwent standard treatment using antituberculous drugs over six months. Endoscopic control after two months showed a significant reduction of the ulcerating lesion.
Ulcerating tumors of the esophagus are primarily classified as potential malignancies. Crohn's disease is an important differential diagnosis. Apart from mechanical and chemical causes, infectious diseases should be taken into consideration. However, tuberculosis is one of the most relevant differential diagnoses, particularly in patients immigrating from TB-prone countries, pre-existing immune deficiency or environmentally induced elevated infection risk.
患者为一名36岁的索马里男子，一年前移居德国，因溃疡性肿瘤接受诊断性检查。过去几周他一直感到胸部发紧，但无其他症状。既往无疾病史。初步体格检查未发现其他病理体征。
通过活检样本分析排除任何恶性肿瘤后，采取了进一步的鉴别诊断措施。除了机械和化学因素外，考虑食管病变的感染性病因，并通过组织学、免疫组织化学、实验室和微生物学检查进一步调查。
诊断、治疗与病程：从活检材料中采集的培养物检测出结核分枝杆菌。该菌株对药物治疗有反应。关于潜在原发性肺结核的进一步诊断结果为阴性。肝活检的组织学分析证实为非干酪样上皮样细胞肉芽肿，这在肉芽肿性肝炎中很常见，但没有任何结核分枝杆菌的直接证据。因此，考虑到肉芽肿性肝炎的鉴别诊断，肝结核似乎最有可能。患者接受了为期六个月的抗结核标准治疗。两个月后的内镜检查显示溃疡性病变明显缩小。
食管溃疡性肿瘤主要归类为潜在恶性肿瘤。克罗恩病是一个重要的鉴别诊断。除了机械和化学原因外，还应考虑传染病。然而，结核病是最相关的鉴别诊断之一，特别是在来自结核病高发国家的移民、既往免疫缺陷或环境导致感染风险升高的患者中。
