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Tuberculous esophageal ulcer as the mode of presentation of Pott’s disease (tuberculous spondylitis)

      To the Editor:
      TTuberculosis of the esophagus is uncommon. Vertebral tuberculosis is more frequently observed, although cervical involvement is also unusual, particularly among elderly people (
      • Hsu L.C.S.
      • Leong J.C.Y.
      Tuberculosis of the lower cervical spine (C2 to C7).
      ,
      • Morvan G.
      • Martini N.
      • Massare C.
      • Nahum H.
      Tuberculosis of the cervical spine. Radiological study apropos of a multicenter series of 53 cases [in French].
      ). The coexistence of both vertebral and esophageal tuberculosis is exceptional. We report a patient who presented with dysphagia owing to esophageal involvement of a mediastinal mass that was due to cervical and dorsal Pott’s disease.
      An 82-year-old woman was admitted because of a 3-month history of dysphagia, odynophagia, anorexia, and weight loss. She did not report fever and had no history of previous tuberculosis. She was afebrile, and the results of the physical examination were unremarkable. Hemoglobin level was 139 g/L, leukocyte count was 8.6 x 109/L, and erythrocyte sedimentation rate was 35 mm/h. Routine chemistry was normal, Mantoux test was 20 mm, and chest radiographs were noncontributory. Esophagogastroscopy disclosed a superficial ulcer 20 cm from the tooth row. Biopsy of the lesion revealed necrotizing granulomas and Langhans’ cells, however, culture of the biopsy specimen was negative. An esophagogram ruled out the presence of fistulous tracts connected to the esophagus. Magnetic resonance imaging showed signs of spondylodiscitis in the seventh cervical vertebra and the first and second thoracic vertebrae, an epidural abscess, and a mediastinal mass with small areas of liquid signal involving the esophagus and extending to the posterior wall of the trachea (Figure). The patient was treated with isoniazid, rifampin, and pyrazinamide for 2 months, which led to clinical improvement and rapid disappearance of dysphagia. Treatment with isoniazid and pyrazinamide was continued for another 10 months. Magnetic resonance imaging performed at the end of treatment revealed resolution of the vertebral lesion, the epidural abscess, and the mediastinal mass.
      Figure thumbnail gr1
      FigureMagnetic resonance imaging showing spondylodiscitis of the seventh cervical vertebra and first and second thoracic vertebrae, an epidural abscess with compression of the spinal cord, and a mass infiltrating the esophagus.
      The esophagus may be involved in tuberculosis through infection spreading through the blood or lymphatic system, by swallowing of contaminated saliva or sputum, or by fistulization from contiguous structures such as the pleura, lung, tracheobronchial tree, pericardium, and, especially, the mediastinal lymph nodes (
      • Krakamp B.
      • Leidig P.
      • Chemaissani A.
      • Stolte M.
      Oesophageal ulceration by tuberculosis a rare cause of dysphagia.
      ,
      • Mokoena T.
      • Shama D.M.
      • Ngakane H.
      • Bryer J.V.
      Oesophageal tuberculosis a review of eleven cases.
      ,
      • Moreno Sánchez D.
      • Arévalo Serrano J.
      • Domínguez Franjo M.P.
      • et al.
      Esophageal tuberculosis. Presentation of a case and review of the literature [in Spanish].
      ,
      • Jiménez F.J.
      • Simeón C.P.
      • Pérez C.
      • et al.
      Esophageal tuberculosis [letter].
      ,
      • Sigurdarson S.T.
      • Field F.J.
      • Schlesinger L.S.
      Esophageal tuberculosis a rare but not to be forgotten entity [letter].
      ). The coexistence of Pott’s disease and esophageal tuberculosis is exceptional. A survey of the literature using MEDLINE yielded three cases of esophageal tuberculosis and vertebral involvement, all of which involved the thoracic spine exclusively (
      • David-C haussé J.
      • Dehais J.
      • Bullier R.
      • Leleu J.P.
      Pott’s dorsal disease, mediastinal suppuration, esophageal tuberculosis with cutaneous fistulas, cold thoracic abscesses [in French].
      ,
      • Kingma B.J.
      • van der Berg W.
      • Schuurmans M.M.J.
      • Molenaar A.H.M.
      A patient with back pain and fever.
      ,
      • Bhatnagar M.S.
      • Nanivadekar S.A.
      • Sawant P.
      • et al.
      Asymptomatic spinal tuberculosis presenting as esophageal stricture.
      ).
      Dysphagia is the most common symptom when the esophagus is involved, and is usually accompanied by anorexia, weight loss, malaise, and fever (
      • Krakamp B.
      • Leidig P.
      • Chemaissani A.
      • Stolte M.
      Oesophageal ulceration by tuberculosis a rare cause of dysphagia.
      ,
      • Mokoena T.
      • Shama D.M.
      • Ngakane H.
      • Bryer J.V.
      Oesophageal tuberculosis a review of eleven cases.
      ,
      • Moreno Sánchez D.
      • Arévalo Serrano J.
      • Domínguez Franjo M.P.
      • et al.
      Esophageal tuberculosis. Presentation of a case and review of the literature [in Spanish].
      ,
      • Jiménez F.J.
      • Simeón C.P.
      • Pérez C.
      • et al.
      Esophageal tuberculosis [letter].
      ,
      • Sigurdarson S.T.
      • Field F.J.
      • Schlesinger L.S.
      Esophageal tuberculosis a rare but not to be forgotten entity [letter].
      ,
      • David-C haussé J.
      • Dehais J.
      • Bullier R.
      • Leleu J.P.
      Pott’s dorsal disease, mediastinal suppuration, esophageal tuberculosis with cutaneous fistulas, cold thoracic abscesses [in French].
      ,
      • Kingma B.J.
      • van der Berg W.
      • Schuurmans M.M.J.
      • Molenaar A.H.M.
      A patient with back pain and fever.
      ,
      • Bhatnagar M.S.
      • Nanivadekar S.A.
      • Sawant P.
      • et al.
      Asymptomatic spinal tuberculosis presenting as esophageal stricture.
      ). The diagnosis of esophageal tuberculosis depends mainly on the histological study of biopsies obtained by endoscopy. In our patient, dysphagia was the presenting symptom, which led to an endoscopy that revealed the esophageal ulceration, prompting imaging studies that revealed the mediastinal mass and the vertebral involvement. This sequence was opposite to the presumed temporal sequence of events in this patient, which was primary vertebral involvement with a secondary spread of a cold abscess anteriorly to involve the esophagus, thus leading to an ulceration that resulted in dysphagia. This observation underscores the need to perform a complete investigation of intraluminal esophageal ulcers, including imaging studies of the neighboring structures.

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