Case report:
A 37-year-old Filipino female presented to the emergency department with
a four-month history of progressive dysphagia to solids and then
liquids. She was otherwise healthy and did not take any prescribed
medication. She denied odynophagia, food bolus obstruction, chest pain,
regurgitation, heartburn, and respiratory symptoms. She had
unintentional weight loss of 3kg over 4 months with no other
constitutional symptoms.
The patient had received BCG vaccination in the Philippines as a child.
Her chest x-ray on Canadian immigration screening in 2009 was negative
for latent or active TB. Her only known TB exposure occurred 14 months
ago when her mother visited Canada and was diagnosed with active
pulmonary TB after returning to the Philippines. Interestingly, she had
a negative TST as a part of her care aide employment screening five
months before her emergency department presentation.
Cardiac, respiratory, and abdominal examinations revealed no
abnormalities with no palpable lymphadenopathy. Complete blood count
with differential showed mild normocytic anemia with hemoglobin of 108
g/L (115-155). WBC was normal at 5.3*109/L (4.0-11.0).
She had a normal neutrophil count of 3.6 *109/L
(2.0-8.0), mildly decreased lymphocyte at 1.1 *109/L
(1.2-3.5), and normal monocyte, eosinophil, and basophil counts.
Electrolytes and hepatic panels were normal. Her chest x-ray in the
emergency department showed no signs of lung scarring.
Esophagogastroduodenoscopy (EGD) revealed a 2 cm ulcerated mass,
abutting the gastroesophageal junction (GEJ) inferiorly on retroflexion
(Figure 1) and a subepithelial lesion in the duodenal bulb with normal
overlying mucosa. The exam was otherwise normal. Mucosal biopsies were
taken from both lesions and histopathology revealed ulcerated mucosa
with acute and chronic inflammatory infiltrates composed of histiocytes,
granulocytes, and lymphocytes (Figure 2). No granulomas were identified.
Ziehl-Neelsen stain was negative for acid-fast bacilli. Although a
lymphoproliferative disorder was not identified, it could not be
excluded in the limited tissue sample.
Additionally, computed tomography (CT) scan of her chest, abdomen, and
pelvis was performed for staging due to suspicion of lymphoma or other
malignancy. This demonstrated infiltrative soft tissue masses at the GEJ
and duodenal bulb, each measuring up to 4.5 cm in size (Figure 3). There
was linear scarring and several discrete nodules at the left lung apex,
the largest 12 mm (Figure 4). No pathologically enlarged lymph nodes
were noted.
Endoscopic ultrasound (EUS) demonstrated an ill-defined, hypoechoic
lesion, involving the GEJ, extending into the region of the celiac axis.
A second lesion, involving the proximal duodenum, was round with
well-defined margins and measured 20 mm x 14 mm (Figure 5). No enlarged
lymph node was seen. EUS-guided fine-needle biopsy of both lesions was
performed, which revealed fragments of necrotizing granulomatous
inflammation (Figure 6). No mycobacteria were seen on Ziehl-Neelsen
stain (Figure 6). Concurrent flow cytometry was completed with a
10-color lymphoma screening panel. The CD45 gated lymphocyte population
accounted for 4% of all events. T-cells were 66% of the lymphocyte
gate and showed normal antigen expression. The CD4/CD8 ratio is 1.7.
Overall, the flow cytometry analysis was not consistent with
lymphoproliferative disorders. Given this finding along with the fact
that previous infectious investigations are not highly sensitive,
infectious etiologies cannot be ruled out and the patient was referred
to the infectious disease team and underwent an IGRA/QuantiFERON assay,
which came back positive. Diagnosis of TB was further confirmed by a
positive TB PCR testing on paraffin block on esophageal biopsies from
index EGD. The patient was subsequently referred to a TB-specialized
clinic and was started on Rifampin, isoniazid, vitamin B6, and
pyrazinamide for 6 months. Given the lack of respiratory symptoms or
active findings on chest imaging, isolation was not required, and her
immediate family members were all screened for TB.