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.