Spontaneous oesophageal perforation due to mediastinal tuberculous lymphadenitis - atypical presentation of tuberculosis.C Desai, KS Kumar, P Rao, V Thapar, AN Supe
Department of Surgery, Seth G.S. Medical College and K.E.M. Hospital, Parel, Mumbai, India., India
Spontaneous non-traumatic oesophageal perforation secondary to bursting of a mediastinal tuberculous abscess into the oesophagus is rare. The diagnosis is delayed, as perforation remains localised due to mediastinal lymph nodes. Patient can be effectively managed by paraoesophageal drainage of the mediastinal abscess and oesophageal diversion.
Keywords: Adult, Case Report, Esophageal Perforation, etiology,Human, Male, Mediastinal Diseases, complications,Tuberculosis, Lymph Node, complications,
Spontaneous non-traumatic oesophageal perforation is extremely rare and is usually the result of severe retching (Boerhaave's syndrome) or local carcinoma,. Perforation of oesophagus in tuberculosis is secondary to bursting of a mediastinal tuberculous abscess into the oesophagus is even rarer,,. As the perforation is localised due to mediastinal lymph nodes, the diagnosis is delayed. We report a patient with such a perforation with the problem of delayed diagnosis and management.
A 32-year-old-man presented with high-grade fever and chills for 10 days; he had been treated with antimalarials drugs, antipyretics and analgesics. He had mild chest pain and developed dysphagia for two days, without cough, weight loss or history of upper gastro- intestinal instrumentation. There was no history of trauma.
Clinical examination revealed high-grade fever, severe tachycardia (pulse rate of 110/min) and intense tachypnoea. Chest x-ray showed mediastinal widening with hilar lymphadenopathy. Barium swallow demonstrated leak in the middle third of oesophagus [Figure - 1]. Contrast enhanced computerised tomography (CECT) scan showed moderate mediastinal lymphadenopathy [Figure - 2]. Endoscopy was not possible due to poor general condition of the patient. Emergency oesophagostomy and gastrostomy was done.
Oesophagostomy was carried out by taking a left lateral neck incision (5 cm) parallel to clavicle. Oesophagus was identified by dissecting in anterior compartment of neck and retracting thyroid. After mobilising oesophagus on both the sides a finger was passed inferiorly in paraoesophageal mediastinum. The abscess cavity was accessed and mediastinal pus was drained by paraoesophageal finger dissection; pus showed presence of acid-fast bacilli. Biopsy from the mediastinal abscess cavity was not possible as the cavity was deep in mediastinum. A loop of cervical oesophagus was mobilised to construct a lateral loop oesophagostomy. A corrugated drain was kept in paraoesophgeal abscess cavity. Distal loop of oesophagus was packed to achieve complete diversion. Intercostal drain was not inserted as the cavity was localised.
Post-procedure chest X-ray did not show any pneumothorax. Anti tuberculous therapy was started. Cervical lymph node biopsy also established the diagnosis of tuberculous inflammation. The patient was asymptomatic within a few weeks. In view of loop, lateral oesophagostomy, he was fed orally. Patient was asked to compress at the time of swallowing. Though there was initial some leak, gradually oesophagostomy closed on its own within two weeks. Follow-up barium study showed complete closure of the oesophageal wall. The patient was resumed on full oral diet and is in good general condition 6 months later.
Oesophageal tuberculosis is a rare clinical entity,,. Isolated or primary tuberculosis of oesophagus has been restricted to case reports in literature. Spontaneous perforation secondary to oesophageal tuberculosis has not been reported. The common cause of oesophageal perforation in tuberculous disease is mediastinal abscess bursting into the oesophagus,.
Tuberculosis lymph nodes may lead to erosion and eventual perforation by pressure necrosis in combination with the inflammatory reaction. Spontaneous oesophageal perforation in the absence of vomiting and without a known cause is rare. Less than 50% of cases are diagnosed within 24 hours, and the delay significantly increases the mortality.
In our case barium swallow and CECT had diagnosed the leak. CECT also helped to diagnose mediastinal lymph nodes. Emergency endoscopy within first 12 hours has also recommended, but we avoided in view of delayed presentation and the risk of disturbing localisation of the disease.
Operative intervention in the form of primary suturing is recommended when spontaneous oesophageal perforation is diagnosed early. However, in a patient with mediastinal lymph node mass and perforation, this is extremely difficult. Diversion of oesophagus and stomach was chosen in our patient and four-drug anti-tuberculous regimen was started empirically. The diagnosis of tuberculosis was later confirmed on smear of pus and also by biopsy of cervical lymph node.
The common cause of mortality in delayed diagnosis is spread of contamination in the mediastinum. In our case the disease was localised by inflammed lymph node mass, and hence though there was a delay in diagnosis, the patient survived.
In conclusion, it is important to consider oesophageal perforation due to mediastinal lymph nodes in endemic areas of tuberculosis; the patient can be managed by simple diversion with anti-tuberculous drug therapy and without removing the oesophagus.
[Figure - 1], [Figure - 2]