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Scientific letter
Oesophageal ulcer: An uncommon presentation of tuberculous lymphadenitis mimicking an oesophageal carcinoma
Úlcera esofágica: una infrecuente forma de presentación de una linfadenitis tuberculosa simulando un carcinoma de esófago
Santiago de Cossíoa,
Corresponding author
santiagodecossio@gmail.com

Corresponding author.
, Blas Labradorb, Ramón Yarzac, Laura Corbellad, Mario Fernández-Ruizd
a Servicio de Medicina Interna, Hospital Universitario “12 de Octubre”, Madrid, Spain
b Servicio de Medicina de Aparato Digestivo, Hospital Universitario “12 de Octubre”, Madrid, Spain
c Servicio de Oncología, Hospital Universitario “12 de Octubre”, Madrid, Spain
d Unidad de Enfermedades Infecciosas, Hospital Universitario “12 de Octubre”, Instituto de Investigación Hospital “12 de Octubre” (imas12), Madrid, Spain
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esophageal involvement presenting as esophageal ulcer is rare&#44; with only a few cases previously reported in the literature&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">2&#8211;5</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">A 40-year-old Bolivian male presented to the Emergency Department complaining of upper abdominal pain accompanied by progressive dysphagia and odynophagia over the previous month&#46; Past medical history was remarkable for non-complicated peptic ulcer ten years ago&#46; He denied both alcohol and tobacco consumption or illicit drugs use&#46; The patient reported moderate epigastric burning feeling with further development of non-colicky pain as well as progressive dysphagia&#44; first to solids and later to liquids&#46; The patient eventually suffered from severe odynophagia&#44; for which he had taken occasional acetaminophen without symptomatic relief&#46; Review of systems was unremarkable for nausea&#44; vomiting or halitosis&#46; He had not experienced weight loss&#44; decrease in appetite or fever&#46; On physical examination the patient appeared well-nourished and hydrated&#46; Oral cavity examination excluded the presence of exudates&#46; No cervical lymphadenopathy was noted and cardiopulmonary examination was unremarkable&#46; Laboratory testing showed normal complete blood count and renal and hepatic function tests&#46; Chest X-ray revealed no abnormalities&#46; Further testing for human immunodeficiency and hepatitis B and C viruses was negative&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">As part of the diagnostic approach to progressive dysphagia&#44; the patient underwent upper endoscopic examination which revealed a 1<span class="elsevierStyleHsp" style=""></span>cm size ulcer in the middle third &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>a&#41;&#46; Tissue samples were obtained&#46; A contrast-enhanced computerized tomography &#40;CT&#41; scan revealed the presence of multiple enlarged lymph nodes affecting the left paratracheal &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>b&#41;&#44; left supraclavicular and right paratracheal regions&#46; These nodes caused extrinsic compression of the esophageal structures with subsequent stenosis&#46; Neither parenchymal infiltration within pulmonary or intraabdominal structures nor pleural effusion was noted&#46; Histopathologic findings were consistent with the presence of scattered epithelioid granulomas showing central necrosis surrounded by abundant granulation tissue&#46; A tuberculin skin test &#40;TST&#41; was positive &#40;20<span class="elsevierStyleHsp" style=""></span>mm&#41; and a new endoscopic examination was performed for further microbiological studies&#46; The aforementioned lesion was shown to have progressed&#44; measuring approximately 1&#46;5<span class="elsevierStyleHsp" style=""></span>cm&#46; The patient had no sputum production&#44; and the PCR assay for <span class="elsevierStyleItalic">M&#46; tuberculosis</span> complex &#40;Xpert MTB&#47;RIF&#44; Cepheid&#44; Sunnyvale&#44; CA&#41; in the gastric aspirate was negative&#46; Despite both acid-fast bacilli smear and specific mycobacterial cultures were negative&#44; a diagnosis of tuberculous lymphadenitis was presumptively made given the histological and radiological findings in the presence of a clearly positive TST and compatible epidemiological history&#46; Patient was started on antituberculosis therapy&#46; Symptoms gradually improved over the next weeks&#46; After completing the two-month intensive phase of therapy with four drugs&#44; a follow-up endoscopic assessment showed complete remission of the lesion&#44; whereas a significant reduction in lymph nodes sizes was observed in the CT scan &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>c&#41;&#46; The two-drug continuation phase &#40;isoniazid and rifampicin&#41; was uneventfully maintained for four further months&#44; with complete symptom resolution&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Tuberculosis is a rare cause of dysphagia that should be considered in patients from endemic regions with uncertain esophageal lesions&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">2&#44;3</span></a> In addition&#44; dysphagia may also result from the extrinsic compression of the esophagus by mediastinal or neck lymph nodes &#40;as occurred in the present case&#41; or due to the development of tracheoesophageal fistula&#46; Esophageal ulcer is the most common endoscopic finding&#44; whose appearance is often suggestive of malignancy&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> However&#44; as mentioned above&#44; other endoscopic findings reported in patients with esophageal tuberculosis include esophageal stenosis&#44; tracheoesophageal fistula or exophytic mass&#44; widening the differential&#46; Therefore&#44; histological and microbiological examination plays a crucial role&#46; Culture positivity for <span class="elsevierStyleItalic">M&#46; tuberculosis</span> on tissue samples is uncommon&#44; and the diagnosis is only established by demonstrating clinical&#44; radiological and endoscopic response to anti-tuberculosis treatment&#44; as exemplified by our experience&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> In the absence of culture confirmation&#44; endoscopic ultrasound-guided fine needle aspiration of the lymph node represents a valuable diagnostic tool&#44; particularly taking into account the need of ruling out alternative Follow-up endoscopic assessment is mandatory in order to confirm endoscopic healing of lesions&#44; since malignancy and esophageal tuberculosis may coexist&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> Of note&#44; a case of esophageal tuberculosis diagnosed after an esophagectomy performed due to esophageal stricture with histologic features of high-grade dysplasia has been described&#44; stressing the need of considering tuberculosis in the differential diagnosis&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> In conclusion&#44; the possibility of esophageal ulcer caused by paraesophageal tuberculous lymphadenitis with mucosal involvement should be kept in mind in patients from high-prevalence countries and evidence of esophageal granulomas&#44; even if <span class="elsevierStyleItalic">M&#46; tuberculosis</span> is not isolated in tissue cultures&#46; Anti-tuberculosis therapy is usually curative in this uncommon condition&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflict of interest</span><p id="par0025" class="elsevierStylePara elsevierViewall">The authors declare that there are no conflicts of interest in relation to this work&#46;</p></span></span>"
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