Olson Dylan, Liu Kevin C, Merza Anthony P, Tilahun Ermias, Aziz Aadam A
Department of Medicine, Northwestern University, Feinberg School of Medicine, 251 E Huron St, Chicago, IL, 60611, USA.
Division of Gastroenterology and Hepatology, University of Arizona College of Medicine, Tucson, AZ, USA.
BMC Gastroenterol. 2022 Mar 22;22(1):131. doi: 10.1186/s12876-022-02211-2.
Patients can present for a wide variety of etiologies for dysphagia, and it is important to consider less common causes once common etiologies have been ruled out. Extrapulmonary Mycobacterium tuberculosis (TB) presentations are rare to see in the western populations due to relative lack of TB exposure and overall less immunocompromised populations, but should be considered for at-risk patients. Gastrointestinal (GI) TB is rare, and the GI tract is considered only the sixth most frequent site of extrapulmonary TB (EPTB).
This is a case report of a 35-year-old Ethiopian male presenting with dysphagia and retrosternal odynophagia who was found to have infiltration of mediastinal lymphadenopathy into the esophageal wall secondary to TB. This patient underwent an upper endoscopy, which revealed a linear 2 cm full thickness mucosal defect in the middle esophagus concerning for an infiltrative process with full thickness tear. Computed tomography (CT) of the chest demonstrated a subcarinal soft tissue mass that was inseparable from the esophagus. He was referred to thoracic surgery and underwent an exploratory mediastinal dissection. A mediastinoscopy scope was inserted and the mediastinal dissection was made until the subcarinal nodes were identified and removed. Biopsy results showed necrotizing and non-necrotizing granulomas, and acid-fast bacilli (AFB) culture from the surgically removed lymph node showed Mycobacterium TB complex growth. He had no known TB exposures and did not have any TB risk factors. He then followed up in infectious disease clinic and was managed with anti-tuberculosis treatment (ATT) with complete resolution of symptoms.
Our patient was ultimately found to have esophageal TB secondary to mediastinal invasion into the esophageal wall from lymphadenopathy associated with TB. This is an extremely rare presentation in western populations due to diminished exposure rates and overall less immunocompromised populations compared to impoverished countries with increased TB exposure and human immunodeficiency virus (HIV) infection rates. Although TB is not as commonly seen in western populations, it should be considered on the differential for any atypical presentations of GI diseases for patients with clinical or geographic risk factors.
患者因吞咽困难前来就诊的病因多种多样，在排除常见病因后，考虑不太常见的病因很重要。由于西方人群相对缺乏结核杆菌暴露且免疫功能低下人群总体较少，肺外结核分枝杆菌（TB）表现较为罕见，但对于高危患者应予以考虑。胃肠道（GI）结核罕见，胃肠道仅被认为是肺外结核（EPTB）的第六大常见部位。
这是一例35岁埃塞俄比亚男性的病例报告，该患者因吞咽困难和胸骨后吞咽痛就诊，经检查发现因结核导致纵隔淋巴结肿大浸润食管壁。该患者接受了上消化道内镜检查，结果显示食管中段有一个2厘米长的线性全层黏膜缺损，提示存在全层撕裂的浸润性病变。胸部计算机断层扫描（CT）显示隆突下有一个与食管无法区分的软组织肿块。他被转诊至胸外科并接受了探索性纵隔清扫术。插入纵隔镜进行纵隔清扫，直至识别并切除隆突下淋巴结。活检结果显示有坏死性和非坏死性肉芽肿，手术切除淋巴结的抗酸杆菌（AFB）培养显示有结核分枝杆菌复合群生长。他没有已知的结核杆菌暴露史，也没有任何结核风险因素。随后他在传染病诊所进行随访，并接受抗结核治疗（ATT），症状完全缓解。
我们的患者最终被发现患有食管结核，继发于与结核相关的淋巴结肿大侵犯食管壁。与结核暴露率和人类免疫缺陷病毒（HIV）感染率增加的贫困国家相比，由于暴露率降低和免疫功能低下人群总体较少，这种表现在西方人群中极为罕见。尽管结核在西方人群中不常见，但对于有临床或地理风险因素的患者，在鉴别任何非典型胃肠道疾病表现时都应考虑到结核。
