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Severe mediastinal tuberculosis complicated by main bronchial and thoracic aortic
compression and long-term esophageal fistulization, in a patient with negative
history and pulmonary signs and symptoms of tuberculosis
Roberto Manfredi, Leonardo Calza
Infectious Diseases, University of Bologna, Italy
Introduction
Tuberculosis is increasing significantly in its frequency, especially among immigrants,
where non-pulmonary localization are of diagnostic-therapeutic concern.
Case Report
A 30-year-old male recently immigrated from Bangladesh, was hospitalized in an Internal
Medicine Department with a mute tuberculosis history, due to a worsening dysphagia and
severe weight loss: a malignancy was initially suspected. Laboratory testing showed an
isolated ESR increase, in absence of positive tumoral markers. A routine chest X-ray
proved normal, but an esophagoscopy showed an extrinsic visceral compression. Later,
an ultrasonographic-endoscopic study and repeated thorax CTs disclosed a mediastinal
mass with a colliquative centre of around three cm diameter which ulcerated the
esophageal lumen, compressed the left bronchus, leaning on the thorax aortic tract.
Multiple sparse lymphnodes undergoing colliquation completed the mediastinal
involvement, while a contrast-enhanced esophagogram showed an extensive fistulization
between the esophagus and the necrotic, colliquated mediastinal abscess. After negative
sputum examinations, the culture diagnosis of tuberculosis was obtained by a
transbronchial bronchoscopy, while the tuberculosis skin test (Mantoux) proved intensely
positive. A well-tolerated foud-drug classical anti-tubercular therapy was performed for
three months,followed by a three-drug combination still ongoing since three more months,
together with proton pump inhibitors to contain dysphagia. At the last chest CT scan and
esophagogram, the mediastinal lesion and the reactive lymph nodes were significantly
reduced in size, calcific lesions substituted colliquative areas, while a narrow esophageal
fistulization was still present.
POSTERS
Discussion
Our rare case of tubercular mediastinal abscess with extensive esophageal fistulization,
treated favourably with conservative medical therapy, reminds that tubercuosis may
mimick multiple pathologic conditions, with diagnosis and treatment often reached
despite the absence of both tuberculosis-compatible history and pulmonary lesions.
The differential diagnosis of tubercular lesions involves a broad spectrum of diseases, and
tuberculosis should be never neglected, even when an evident history and lung
involvement are absent. The recent,explosive rise of tuberculosis among immigrants in
Italy, is a serious epidemiologic and social health concern when summarized with the
increased life expectancy and the greater risk of immunosuppressive conditions in the
general population. A strict monitoring of tuberculosis is strongly needed, in order to plan
adequate diagnostic-preventive measures, and to allocate the needed health care
resources.
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