ELECTRONIC IMAGE OF THE MONTH An Unusual Cause of Dysphagia Surinder S. Rana, Vishal Sharma, and Deepak K. Bhasin Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
38-year-old man presented with progressively increasing dysphagia of 3 weeks’ duration. It was associated with weight loss and loss of appetite, but there was no fever. The clinical examination was normal, and his hemogram and biochemical test results including liver and kidney function tests were normal. Upper gastrointestinal endoscopy showed narrowing in the midesophagus with a black mass obstructing the lumen (Figure A). Closer inspection showed it to be a lymph node eroding into the esophagus (Figure B; arrows show the edge of the esophageal breach). Multiple endoscopic biopsy specimens from the lesion showed findings suggestive of a necrotic lymph node with no granulomas and acid-fast bacilli. The biopsy specimens from the adjacent esophagus showed nonspecific ulcerations. Contrast-enhanced computed tomography showed large mediastinal lymph nodes (Figure C; arrow). An endoscopic ultrasound (EUS) scope could not be negotiated across the narrowing and EUS was performed from the mouth of the narrowing. It showed multiple mediastinal lymph nodes, with EUS elastography showing a mixed elastographic pattern (Figure D). EUS-guided, fine-needle aspiration from the soft areas showed
A
caseous material (Figure E) and the cytologic examination confirmed it to be necrosis. The tuberculin test was positive. The patient was started on 4-drug antitubercular therapy and he had marked improvement in his symptoms. The endoscopy repeated 2 weeks after starting antitubercular therapy showed resolution of the findings with a small ulcerated depressed area seen at the site of lymph node erosion (Figure F). Tuberculosis can present with dysphagia because of various reasons such as compression and/or erosion by the surrounding tubercular peri-esophageal lymph nodes, associated mediastinal fibrosis, ulceration, and/or polypoidal lesions in the esophagus, or altered motility.1,2 Because of a lack of specific signs, symptoms, and endoscopic as well as radiologic findings, esophageal tuberculosis closely mimics malignancy. The erosion of mediastinal lymph nodes into the esophagus usually leads to ulcerations with a extrinsic bulge. This case showed an endoscopic appearance of a lymph node protruding into the esophagus as a large black mass.1,2 EUS is an excellent tool for detection for mediastinal lymph nodes as well as to obtain specimens for cytology from these lymph nodes using fine-needle aspiration.3 Clinical Gastroenterology and Hepatology 2015;13:e43–e44
ELECTRONIC IMAGE OF THE MONTH, continued References 1.
Rana SS, Bhasin DK, Rao C, et al. Tuberculosis presenting as dysphagia: clinical, endoscopic, radiological and endosonographic features. Endosc Ultrasound 2013;2:92–95.
2.
Rana SS, Bhasin DK, Sharma V, et al. Dysphagia as the first manifestation of tuberculosis. Endoscopy 2011;43(Suppl 2):E300–E301.
3.
Fritscher-Ravens A, Ghanbari A, Topalidis T, et al. Granulomatous mediastinal adenopathy: can endoscopic ultrasound-guided
e44
fine-needle aspiration differentiate between tuberculosis and sarcoidosis? Endoscopy 2011;43:955–961.
Conflicts of interest The authors disclose no conflicts. © 2015 by the AGA Institute 1542-3565/$36.00 http://dx.doi.org/10.1016/j.cgh.2015.01.016
38-year-old man presented with progressively increasing dysphagia of 3 weeks’ duration. It was associated with weight loss and loss of appetite, but there was no fever. The clinical examination was normal, and his hemogram and biochemical test results including liver and kidney function tests were normal. Upper gastrointestinal endoscopy showed narrowing in the midesophagus with a black mass obstructing the lumen (Figure A). Closer inspection showed it to be a lymph node eroding into the esophagus (Figure B; arrows show the edge of the esophageal breach). Multiple endoscopic biopsy specimens from the lesion showed findings suggestive of a necrotic lymph node with no granulomas and acid-fast bacilli. The biopsy specimens from the adjacent esophagus showed nonspecific ulcerations. Contrast-enhanced computed tomography showed large mediastinal lymph nodes (Figure C; arrow). An endoscopic ultrasound (EUS) scope could not be negotiated across the narrowing and EUS was performed from the mouth of the narrowing. It showed multiple mediastinal lymph nodes, with EUS elastography showing a mixed elastographic pattern (Figure D). EUS-guided, fine-needle aspiration from the soft areas showed
A
caseous material (Figure E) and the cytologic examination confirmed it to be necrosis. The tuberculin test was positive. The patient was started on 4-drug antitubercular therapy and he had marked improvement in his symptoms. The endoscopy repeated 2 weeks after starting antitubercular therapy showed resolution of the findings with a small ulcerated depressed area seen at the site of lymph node erosion (Figure F). Tuberculosis can present with dysphagia because of various reasons such as compression and/or erosion by the surrounding tubercular peri-esophageal lymph nodes, associated mediastinal fibrosis, ulceration, and/or polypoidal lesions in the esophagus, or altered motility.1,2 Because of a lack of specific signs, symptoms, and endoscopic as well as radiologic findings, esophageal tuberculosis closely mimics malignancy. The erosion of mediastinal lymph nodes into the esophagus usually leads to ulcerations with a extrinsic bulge. This case showed an endoscopic appearance of a lymph node protruding into the esophagus as a large black mass.1,2 EUS is an excellent tool for detection for mediastinal lymph nodes as well as to obtain specimens for cytology from these lymph nodes using fine-needle aspiration.3 Clinical Gastroenterology and Hepatology 2015;13:e43–e44
ELECTRONIC IMAGE OF THE MONTH, continued References 1.
Rana SS, Bhasin DK, Rao C, et al. Tuberculosis presenting as dysphagia: clinical, endoscopic, radiological and endosonographic features. Endosc Ultrasound 2013;2:92–95.
2.
Rana SS, Bhasin DK, Sharma V, et al. Dysphagia as the first manifestation of tuberculosis. Endoscopy 2011;43(Suppl 2):E300–E301.
3.
Fritscher-Ravens A, Ghanbari A, Topalidis T, et al. Granulomatous mediastinal adenopathy: can endoscopic ultrasound-guided
e44
fine-needle aspiration differentiate between tuberculosis and sarcoidosis? Endoscopy 2011;43:955–961.
Conflicts of interest The authors disclose no conflicts. © 2015 by the AGA Institute 1542-3565/$36.00 http://dx.doi.org/10.1016/j.cgh.2015.01.016
