Patient information: a 55-year-old woman without medical history presented to the hospital with progressive dysphagia, primarily for solid foods then for both liquids and solids. The patient reported 10 kg weight loss, loss of appetite and intermittent fever. She did not report chest pain, dyspnea, coughing episodes, nausea, vomiting or hematemesis.
Clinical findings: the clinical examination found a temperature of 37.8 C, blood pressure at 130/80 mm Hg, a heart rate of 80 beats per minute. The abdomen was soft without any palpable masses or hepatosplenomegaly. The rest of the examination was normal.
Timeline of the current episode: the symptomatology began 3 months before her admission.
Diagnostic assessment: blood investigations revealed lymphocytosis with an elevated erythrocyte sedimentation rate. Esophagogastroduodenoscopy (EGD) showed a large ulcer measuring 3 cm in diameter in the middle third of the esophagus with a fistula opening in the center of the ulcer (Figure 1). Multiple biopsies were taken from the lesion. Histopathological examination revealed epithelioid cell granulomas without caseous necrosis. No evidence of malignancy and no acid-fast bacilli have been seen. We completed with computed tomography (CT) scan of the chest which revealed a fistula of the middle third of the esophagus without signs of mediastinitis, multiple mediastinal necrotic adenopathies and diffuse pulmonary micronodules suggesting miliary tuberculosis (Figure 2). Sputum examination for acid-fast-bacilli was positive. The patient tested negative for Human immunodeficiency virus (HIV).
Diagnosis: the diagnosis of miliary tuberculosis with secondary esophageal involvement in an immunocompetent patient was retained.
Therapeutic interventions: we started the treatment combining isoniazid, rifampicin, pyrazinamide, and ethambutol for 2 months initially and followed by a period of six months with two drugs (isoniazid and rifampicin).
Follow-up and outcome of interventions: the clinical course was favorable with weight gain and resolution of the dysphagia after three months from the start of treatment. The EGD was carried out after stopping treatment. It revealed the cicatrization of the esophageal ulcer. Computed tomography scan showed the regression of the mediastinal and pulmonary involvement. The patient has been followed up regularly and she is currently doing well, two years after the diagnosis.
Patient perspective: she was satisfied with the diagnostic and the proposed care.
Patient consent: she has given her consent for her images and other clinical informations to be reported in the journal. The patient understands that her name and initials will not be published.