Case report: CT Manifestations of Primary Esophageal Tuberculosis

doi:10.21203/rs.3.rs-5010974/v1

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Case Report

Case report: CT Manifestations of Primary Esophageal Tuberculosis

https://doi.org/10.21203/rs.3.rs-5010974/v1

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Background

Primary esophageal tuberculosis is an uncommon manifestation of Mycobacterium tuberculosis infection in Asian adults, often presenting with nonspecific symptoms that can complicate diagnosis. This report details a case of primary esophageal tuberculosis in middle age female, emphasizing the diagnostic value of computed tomography (CT) imaging.

Case presentation

The patient, a 46-year-old female from Sichuan Province, China, experienced recurrent choking and mild retrosternal pain postprandially. She exhibited a weight loss of approximately 1 kg over a week, without additional symptoms such as dysphagia or fever. Esophagoscopy disclosed a small ulcer, and CT imaging revealed esophageal wall thickening with mucosal ulceration. A left thoracic lower and middle esophagectomy was conducted, with postoperative pathology confirming granulomatous inflammation, indicative of tuberculosis.

Conclusions

This case highlights the pivotal role of CT imaging in diagnosing primary esophageal tuberculosis. The imaging modality's ability to delineate subtle mucosal ulcerations and wall thickening provides a crucial diagnostic advantage, facilitating accurate and timely diagnosis of this rare condition.

Primary esophageal tuberculosis

mucosal ulceration

caseous necrosis

computed tomography

Tuberculosis is a chronic infectious disease caused by Mycobacterium tuberculosis complex, which can affect all organs of the body, most commonly the lungs. Esophageal tuberculosis is relatively rare due to its unique anatomical and physiological characteristics, accounting for approximately 0.20–1.00% of all gastrointestinal tuberculosis cases [1]. Esophageal tuberculosis can be classified into secondary and primary types, the incidence of primary esophageal tuberculosis is lower, with only 2 reported cases [2, 6].

The patient, a 46-year-old female from a remote mountainous area in Sichuan Province, China, presented with choking and mild retrosternal pain after eating. Symptoms were recurrent, with a weight loss of approximately 1 kg over the past week, without dysphagia, fever, night sweats, etc. She had no history of tuberculosis exposure. Physical examinations of the lungs and heart were unremarkable, and body temperature was normal. Laboratory tests showed negative special acid-fast staining, and only slight elevation of alanine aminotransferase and aspartate aminotransferase levels of liver function. Blood cell count showed decreased lymphocyte percentage and increased absolute values of neutrophils, monocytes, and eosinophils. Serum tests revealed an elevated calcitonin level, decreased myoglobin, elevated carbohydrate antigens 72 − 4, positive syphilis spirochete specific antibodies. The toluidine red unheated serum test was also positive. However, tests for human immunodeficiency virus antibody, carcinoembryonic antigen, alpha-fetoprotein, and blood glucose were negative. Urine examination showed increased leukocytes, bacteria and erythrocytes.

Esophagoscopy findings revealed a small ulcer formed at approximately 26–29 cm from the incisors, in the 12 o'clock direction, with clear boundaries. Figure 1.

Imaging examinations including chest X-ray, whole-body bone scan under PET-CT, non-contrast and contrast-enhanced CT scans showed no significant abnormalities. Contrast-enhanced CT scan of the chest revealed a lesion located in the middle segment of the esophagus with a rough outline, which was attached to the esophageal wall with a broad base, with gradual thinning of the surrounding normal esophageal wall. Figure 2A. Small concavities were observed on the inner edge of the thickened esophageal wall, suggesting ulcer formation. Figure 2.The largest ulcer had an opening diameter of 10mm and a depth diameter of 5mm, with an irregular base, and The outer margin of the esophageal wall appeared blurred with the boundaries of the neighboring fat. In addition, the right anterior wall of the esophagus showed uneven and obvious thickening, appearing fan-shaped or heart-shaped, with a maximum interface of approximately 25mm × 20mm and a CT value of approximately 34HU.Contrast-enhanced CT scan showed obvious uneven enhancement with scattered small dot-like areas of reduced enhancement inside. Figure 2C. Through the Analysis of CT reconstructed images in the coronal, we found that the main body of the lesion was located in the right anterior wall of the esophagus, gradually spreading to the adjacent esophageal wall, presenting a gradual "wrapping" appearance rather than a single compression and displacement. Figure 2D.

Left thoracic lower and middle esophagectomy and gastric substituting esophageal anastomosis were performed. Intraoperatively, edema of the esophageal wall was found adjacent to the tracheal prominence under the aortic arch, and a shallow ulcer was visible on the posterior wall, with a size of approximately 0.5×1.0cm. Necrotic tissues were observed in the lesion, and biopsies were taken from some of the tissues at the margins of the ulcer. Postoperative pathology: esophagus granulomatous inflammation, tuberculosis considered. Figure 3.

Esophageal tuberculosis manifests in various clinical presentations and exhibits geographic variations in incidence, with the highest incidence rates in India, sub-Saharan Africa, the Micronesian Islands, and Southeast Asian islands [3], followed by Pakistan in South Asia, and Senegalese region in West Africa, but it was rarely reported in the literature in East Asia, especially in China. No abnormalities were found in the chest CT examinations of patients with esophageal tuberculosis in South Asia and West Africa. This discrepancy may stem from differences in tuberculosis pathogenesis between these regions and East Asia, particularly China. In the former, underlying esophageal conditions such as esophagitis or severely compromised immune systems, which are associated with higher rates of Human Immunodeficiency Virus infection, could be contributing factors. In these cases, ingestion of food contaminated with TB bacteria and subsequent swallowing of a large amount of bacteria can result in their retention in damaged esophageal mucosa, leading to the development of esophageal tuberculosis [4]. The latter may be related to esophageal mucosal protective factors, mucus, saliva, etc., as well as the initial inoculation following ingestion of infectious substances [5].

The preoperative examinations for primary esophageal tuberculosis in this case were relatively comprehensive. In addition to laboratory tests, pathological examination, imaging studies include chest X-rays, non-contrast and contrast-enhanced CT scans (covering the brain, neck, chest, and entire abdomen), and whole-body bone scans under PET-CT, all of which did not reveal any lesions beyond the esophagus. This provided strong evidence supporting the diagnosis of primary esophageal tuberculosis.

According to literature review, esophageal tuberculosis lesions are commonly located in the middle- third of the thoracic segment of the esophagus, at the level of the tracheal prominence, which is consistent with this case[6]. From a pathogenetic perspective, esophageal tuberculosis presents similarly to tuberculosis in other parts of the digestive tract, and it begins in the submucosal lymphoid tissue, with caseous necrosis occurring within 2 to 4 weeks, resulting in a unique histopathological manifestation of tuberculosis. However, these lesions may be too small to be detected, showing only localized thickening of the esophageal wall on CT, caseous necrotic lesions may not be visualized [3, 7, 8]. In this case, contrast-enhanced CT revealed scattered areas of decreased enhancement within the thickened esophageal wall, suggestive of caseous necrosis upon retrospective analysis. Additionally, CT imaging of this case revealed details of the location, size, and margins of the ulcer, which had not been reported in previous literature. Combined with histopathology, it also suggested tuberculous ulceration with granulomatous formation. The presence of ulcers indicated the lesion was in a progressive stage [8].

In conclusion, this case highlights the relative specificity of carefully observing the surroundings of the esophageal wall in CT diagnosis. In this case, the boundaries between the outer wall of the esophagus and the adjacent fat were blurred, indicating chronic inflammation, congestion, and edema, which was helpful for differentiating from neoplastic lesions. Combined with the signs of caseous necrosis, the possibility of tuberculosis should be considered preoperatively.

In addition to consideration of the factors such as geographical environment and immune function status, CT examination holds an irreplaceable advantage in the diagnosis of esophageal tuberculosis. The internal and external characteristics, enhancement patterns, adjacent relationships, and especially the subtle structures of ulcers of esophageal tuberculosis can be accurately and meticulously identified, which provide reliable evidence for the accurate diagnosis of lesions. Moreover, complications such as esophageal fistula and perforation can also be detected on CT. Therefore, the diagnostic value of CT examination in primary esophageal tuberculosis should be fully recognized and appreciated, in order to enhance the understanding and accuracy in diagnosing this disease.

CT Computed tomography

PET-CT Positron Emission Tomography-Computed Tomography

TB Tuberculosis

Ethics approval and consent to participate

This study was approved by the ethics committee of the Hospital of Traditional Chinese Medicine in Qijiang District, Chongqing municipality. The patient signed informed consent to use identified medical information for research purposes was obtained from the patient at initial evaluation and retained within the medical records system.

Consent for publication

No applicable.

Availability of data and material

The data that support the findings of this study are available from the corresponding author upon reasonable request.

Competing interests

All of authors have no competing interests.

Funding

No finding involved.

Author contributions

Z. W. design and revised manuscript. Z.H. and S.Z. collect the data and draft manuscript. R.L. diagnose the case and prepared figures 1-3. All authors reviewed the manuscript.

Acknowledgments

The all of authors thank patient for assisting with the analysis and reporting of the patient-provided sample.

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No competing interests reported.

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You are reading this latest preprint version

Case report: CT Manifestations of Primary Esophageal Tuberculosis

Status:

Version 1

Abstract

Background

Case presentation

Conclusions

Figures

Introduction

Case presentation

Discussion and conclusions

Abbreviations

Declarations

References

Additional Declarations

Status:

Version 1