Multidrug-Resistant Tuberculous Mediastinal Lymphadenitis, with an Esophagomediastinal Fistula, Mimicking an Esophageal Submucosal Tumor

Abstract

Mediastinal tuberculous lymphadenitis rarely mimics esophageal submucosal tumor, particularly in the case of multidrug-resistant tuberculosis (MDR-TB). Herein, we report the case of a 61-year-old woman who visited a local hospital complaining of odynophagia. An initial esophagogastroduodenoscopy revealed an esophageal submucosal tumor, and subsequent chest computed tomography showed subcarinal lymphadenopathy with an esophagomediastinal fistula. The patient was then referred to Samsung Medical Center, and a second esophagogastroduodenoscopy showed deep central ulceration, as well as a suspicious fistula in the esophageal submucosal tumor-like lesion. A biopsy examination of the ulcerative lesion confirmed focal inflammation only. Next, an endobronchial, ultrasound-guided lymph node biopsy was performed, and TB was confirmed. The patient initially began a course of isoniazid, rifampicin, ethambutol, and pyrazinamide. However, after a drug sensitivity test, she was diagnosed with MDR-TB, and second-line anti-TB medications were prescribed. She recovered well subsequently.

Keywords: Esophageal fistula; Lymphadenitis; Tuberculosis.

Fig. 1.

(A, B) Initial esophagogastroduodenoscopic view of the esophageal submucosal tumor-like lesion (arrow) 27 cm from the upper incisor.

Fig. 2.

Endoscopic ultrasonographic findings 4 weeks after the initial presentation. (A, B) A submucosal tumor-like lesion with ulceration (arrows) can be seen 27 cm from the upper incisors. (C) It shows mixed echogenicity and an irregular margin, and the esophageal wall layer cannot be distinguished on endoscopic ultrasonography.

Fig. 3.

(A, B) Chest contrast computed tomographic scan showing subcarinal lymphadenopathy with a probable fistulous connection to the esophageal lumen (arrows), (C) as well as paratracheal lymphadenopathy (arrow).

Fig. 4.

An initial chest radiograph acquired at our hospital, showing normal chest findings.

Fig. 5.

Chest computed tomography scan 3 months after initial presentation. The extent of mediastinal lymphadenopathy is increased along the (A) subcarinal (arrow), (B) para-aortic (arrow), and (C) paratracheal lymph nodes (arrow), and (D) a new branching nodular lesion can be seen in the left upper lobe of the lung (arrow), which suggests pulmonary tuberculosis.