Primary esophageal tuberculosis mimicking esophageal cancer with vascular involvement.

A 30-year-old female presented with progressively increasing dysphagia associated with loss of appetite and weight. Upper gastrointestinal endoscopy revealed a polypoidal and ulcerated lesion in the mid esophagus with endoscopic biopsies being inconclusive [Figure 1]. An endoscopic ultrasound (EUS) revealed asymmetrical thickening of the esophageal wall with loss of the wall stratification [Figure 2] as well as loss of fat planes with right pulmonary artery [Figure 3]. No mediastinal lymphadenopathy was noted. EUS guided fine-needle aspiration (FNA) [Figure 4] yielded caseous material and cytology revealed epithelioid cell granuloma with a giant cell and caseation necrosis [Figure 5] with presence of acid-fast bacilli [Figure 6]. The patient was initiated on weight based four drug anti-tubercular therapy (rifampin, isoniazid, pyrazinamide, and ethambutol). At 1 month of follow-up the patient had gained 5 kg of weight with complete resolution of dysphagia.

Figure 1

Polypoidal and ulcerated lesion in mid esophagus

Figure 2

Endoscopic ultrasound: Asymmetrical thickening of the mid esophagus

Figure 3

Loss of fate planes with right pulmonary artery

Figure 4

Endoscopic ultrasound fine-needle aspiration of the lesion

Figure 5

Epithelioid cell granuloma with a giant cell and caseation necrosis (Pap, ×40)

Figure 6

Ziehl–Neelsen stain showing acid-fast bacillus (×100)

Esophageal tuberculosis is usually secondary to mediastinal lymphadenopathy causing extrinsic narrowing or secondarily due to infiltration of the esophageal wall.[12] Primary esophageal tuberculosis, as in our case, is uncommon. Except a few, most such reports are from the pre-EUS era where the mediastinal lymphadenopathy may have been missed.[3] It is unusual for esophageal tuberculosis to result in vascular involvement although this has been described in relation to the pancreatic tuberculosis.[4] EUS-FNA has emerged as an important tool to diagnose the esophageal tuberculosis.[12]