Pediatric Radiology
Case note
9 Springer-Verlag 1992 Pediatr Radiol (1992) 22:154
Bronchoesophageal fistula of tuberculous origin in a child R. Bhatia 1, D . K. Mitra 2, S. M u k h e r j e e ~, and M. Berry ~ Departments of Radiodiagnosis and ~ Pediatric Surgery, All India Institute of Medical Sciences, Ansari Nagar, New Delhi-110029, India Received: 7 June 1991; accepted: 26 September 1991
Abstract. Bronchoesophageal fistulas (BEF) are uncommon in children, the etiology being congenital or acquired. Acquired bronchial perforation of tuberculous origin is common in children with pulmonary tuberculosis hut bronchoesophageal perforation secondary to tuberculosis and leading to a fistulous tract formation is rare [i]. To date, there have only been 4 case reorts of BEF of tuberculous origin in children 1]. We present yet another case of an acquired BEF of tuberculous origin in a child who presented with a sudden onset of dysphagia and choking sensation.
~
A 10-year-old boy presented with a sudden choking sensation associated with coughing immediately after swallowing food especially liquids. There was no history of fever, foreign body inhalation, trauma or family history of tuberculosis. On general physical examination there was no anomaly except for occasional bilateral basal crepitations. A chest radiograph showed presence of left tracheobronchial lymphadenopathy and a left perihilar infiltrate (Fig. 1). A barium swallow revealed the presence of a BEF between the esophagus and the left main and lower lobe bronchus with mucosal irregularity and narrowing of the mid third of the esophagus (Fig.2). There were multiple small pseudo-diverticulae in the upper third of the esophagus and in the region of the stricture. There was also evidence of bridging between adjacent pseudodiverticulae producing discrete intramural tracts. In addition, the esophagus was displaced anteriorly and to the left (Fig. 2). Endoscopy revealed esophagitis and ulceration with caseation at about 18 cm distance. Although the biopsy did not reveal tuberculous bacilli, the features were consistent with granulomatous ulcers. A feeding gastrostomy was fashioned and the patient was put on antitubercular treatment. On subsequent follow-up, he had improved physically although his choking sensation persisted. A repeat chest radiograph 3 months later showed progressive clearance of the pulmonary infiltrate. A follow-up esophagogram 6 months later demonstrated a normal esophagus with minimal extrinsic mass effect on its distal third. No fistulous tracts could be demonstrated (Fig.3).
Discussion Primary tuberculous involvement of the esophagus is very rare as compared to secondary involvement which usually results from local extension of tuberculous disease, innoculation of the esophagus by swallowed infected sputum, or hematogenous disseminated tuberculosis [2]. Direct contiguous involvement from adjacent tuberculous lymphadenitis is known to be the
most frequent cause of esophageal tuberculosis. Erosion of these lymph nodes into the adjacent esophageal or bronchial wall results in esophago-nodal or esophago-bronchial fistulas [3]. Esophagorespiratory fistulas of infectious origin are usually due to granulomatous disease, most commonly tuberculosis [4]. Clinically, patients with benign BEF may have symptoms for several days to years before a diagnosis is made. The most common presentation is paroxysmal cough following ingestation of food, particularly fluids. Mediastinal involvement is more prominent in children with primary pulmonary tuberculosis and associated complications oflymphadenitis such as fistula formation and compression of the tracheobronchial structures and the major vessels have been recognized in children with tuberculosis [5], Persistent pneumonia, bronchiectasis, lung abscess are common sequelae [4]. Chest radiography may be normal or show evidence of chronic recurrent infection with infiltrates, bronchiectasis, pleural reaction and enlarged or calcified mediastinal nodes. Esophagography findings are non-specific and include extrinsic compression of the esophagus, BEF, sinus tract formation, mucosal tract irregularity or ulceration. Advanced stage of the disease may reveal stricture formation and development of traction diverticulae. It has been observed that though tuberculous lymphadenitis involves the right paratracheal nodes more common than the subcarinal ones, fistulous communication is more common in the subcarinal area. The rightward preference of the fistulas is also due to the descending thoracic aorta which acts as an anatomic b a r r e r to enlarged nodes [3]. The esophagogram findings in outpatient are similar to those ofLucayaet al. [1] with respect to the leftward location of the fistulous communication.
We conclude, in concordance with previous authors [1, 3] that antitubercular treatmentis the treatment of choice of tuberculous BEF and surgical intervention should not be considered in such cases.
References 1. Lucaya J, Sole S, Badosa J, Manzanares R (1980) A JR 135:525-528 2. Rubinstein BM, Pastrana J, Jacobson HG (1958) Radiology 70:401-403 3. Im JG, Kim JH, Hart MC, Kim CW (1990) J Comput Assist Tomogr 14:89-92 4. Vasquez RE, Landay M, Kilman WJ, et al (1988) Radiology 167:93-96 5. Bloomberg TJ, Dow CJ (1980) Thorax 35: 392-396 Dr. S. Mukherjee Department of Radiodiagnosls All India Institute of Medical Sciences New Delhi-110029, India
Figs. l-3. See text
Case note
9 Springer-Verlag 1992 Pediatr Radiol (1992) 22:154
Bronchoesophageal fistula of tuberculous origin in a child R. Bhatia 1, D . K. Mitra 2, S. M u k h e r j e e ~, and M. Berry ~ Departments of Radiodiagnosis and ~ Pediatric Surgery, All India Institute of Medical Sciences, Ansari Nagar, New Delhi-110029, India Received: 7 June 1991; accepted: 26 September 1991
Abstract. Bronchoesophageal fistulas (BEF) are uncommon in children, the etiology being congenital or acquired. Acquired bronchial perforation of tuberculous origin is common in children with pulmonary tuberculosis hut bronchoesophageal perforation secondary to tuberculosis and leading to a fistulous tract formation is rare [i]. To date, there have only been 4 case reorts of BEF of tuberculous origin in children 1]. We present yet another case of an acquired BEF of tuberculous origin in a child who presented with a sudden onset of dysphagia and choking sensation.
~
A 10-year-old boy presented with a sudden choking sensation associated with coughing immediately after swallowing food especially liquids. There was no history of fever, foreign body inhalation, trauma or family history of tuberculosis. On general physical examination there was no anomaly except for occasional bilateral basal crepitations. A chest radiograph showed presence of left tracheobronchial lymphadenopathy and a left perihilar infiltrate (Fig. 1). A barium swallow revealed the presence of a BEF between the esophagus and the left main and lower lobe bronchus with mucosal irregularity and narrowing of the mid third of the esophagus (Fig.2). There were multiple small pseudo-diverticulae in the upper third of the esophagus and in the region of the stricture. There was also evidence of bridging between adjacent pseudodiverticulae producing discrete intramural tracts. In addition, the esophagus was displaced anteriorly and to the left (Fig. 2). Endoscopy revealed esophagitis and ulceration with caseation at about 18 cm distance. Although the biopsy did not reveal tuberculous bacilli, the features were consistent with granulomatous ulcers. A feeding gastrostomy was fashioned and the patient was put on antitubercular treatment. On subsequent follow-up, he had improved physically although his choking sensation persisted. A repeat chest radiograph 3 months later showed progressive clearance of the pulmonary infiltrate. A follow-up esophagogram 6 months later demonstrated a normal esophagus with minimal extrinsic mass effect on its distal third. No fistulous tracts could be demonstrated (Fig.3).
Discussion Primary tuberculous involvement of the esophagus is very rare as compared to secondary involvement which usually results from local extension of tuberculous disease, innoculation of the esophagus by swallowed infected sputum, or hematogenous disseminated tuberculosis [2]. Direct contiguous involvement from adjacent tuberculous lymphadenitis is known to be the
most frequent cause of esophageal tuberculosis. Erosion of these lymph nodes into the adjacent esophageal or bronchial wall results in esophago-nodal or esophago-bronchial fistulas [3]. Esophagorespiratory fistulas of infectious origin are usually due to granulomatous disease, most commonly tuberculosis [4]. Clinically, patients with benign BEF may have symptoms for several days to years before a diagnosis is made. The most common presentation is paroxysmal cough following ingestation of food, particularly fluids. Mediastinal involvement is more prominent in children with primary pulmonary tuberculosis and associated complications oflymphadenitis such as fistula formation and compression of the tracheobronchial structures and the major vessels have been recognized in children with tuberculosis [5], Persistent pneumonia, bronchiectasis, lung abscess are common sequelae [4]. Chest radiography may be normal or show evidence of chronic recurrent infection with infiltrates, bronchiectasis, pleural reaction and enlarged or calcified mediastinal nodes. Esophagography findings are non-specific and include extrinsic compression of the esophagus, BEF, sinus tract formation, mucosal tract irregularity or ulceration. Advanced stage of the disease may reveal stricture formation and development of traction diverticulae. It has been observed that though tuberculous lymphadenitis involves the right paratracheal nodes more common than the subcarinal ones, fistulous communication is more common in the subcarinal area. The rightward preference of the fistulas is also due to the descending thoracic aorta which acts as an anatomic b a r r e r to enlarged nodes [3]. The esophagogram findings in outpatient are similar to those ofLucayaet al. [1] with respect to the leftward location of the fistulous communication.
We conclude, in concordance with previous authors [1, 3] that antitubercular treatmentis the treatment of choice of tuberculous BEF and surgical intervention should not be considered in such cases.
References 1. Lucaya J, Sole S, Badosa J, Manzanares R (1980) A JR 135:525-528 2. Rubinstein BM, Pastrana J, Jacobson HG (1958) Radiology 70:401-403 3. Im JG, Kim JH, Hart MC, Kim CW (1990) J Comput Assist Tomogr 14:89-92 4. Vasquez RE, Landay M, Kilman WJ, et al (1988) Radiology 167:93-96 5. Bloomberg TJ, Dow CJ (1980) Thorax 35: 392-396 Dr. S. Mukherjee Department of Radiodiagnosls All India Institute of Medical Sciences New Delhi-110029, India
Figs. l-3. See text
