A 33-year-old pulmonologist from Southern India, with no known co-morbidities, had a history of COVID-19 infection in January 2022. Following this, he developed an intractable dry cough, which did not settle with the administration of routine cough syrup. Suspecting lung parenchymal involvement, he self-medicated with oral steroids for around 3 months. He developed mid-thoracic back pain in the first week of July, mainly in the paraspinal regions, not associated with any local swelling. There was a history of an evening increase in temperature (maximum temperature of 37.7 C), associated with night sweats, which started along with back pain. There was no history of weight loss, swallowing or breathing difficulty, myalgia, headache, or bowel or bladder disturbances. The patient's history was negative for any IV drug use or high-risk sexual behaviours.
A CT scan (without contrast) of the chest was conducted in a nearby hospital and the results were notable for reticular interstitial thickening in the left perihilar region and multiple lytic lesions in various ribs (images unavailable). The differentials given were sarcoidosis and a metastatic neoplasm with an unknown primary. An FDG PET CT scan of the whole body conducted in the outside hospital was notable for metabolically active asymmetric mural thickening in the distal thoracic oesophagus with mild luminal narrowing. A few metabolically active mediastinal left hilar and para oesophageal lymph nodes were present. The PET CT scan also revealed multiple focal areas of metabolically active, lytic, sclerotic lesions in a few bilateral ribs, multiple vertebrae, the sacrum, bilateral pelvic bones and left proximal femur. Pathological fractures were present in some of the bilateral ribs with lytic lesions. There was no evidence of significant pulmonary nodules or metabolically active disease anywhere else in the body (Fig. 1). The patient was referred to our centre for further evaluation and management in August 2022.
On examination, the patient was well built and his vital signs including temperature, pulse rate, blood pressure, oxygen saturation, and respiratory rate were well within normal limits. Systemic examination was unremarkable. Laboratory work-up was significant for a white blood cell count of 8.99x103/mm3 (4.0-11x103/mm3) and haemoglobin of 15.8 g/dl (12.0-16.0 g/dl) with an elevated erythrocyte sedimentation rate of 42 mm/hr (0-20 mm/hr). His chest x-ray did not reveal any significant abnormalities. Serum calcium and acetyl cholinesterase levels were within normal limits. Cancer biomarkers such as alkaline phosphatase, carcinoembryonic antigen, alpha fetoprotein and beta-HCG were not elevated. Serum protein electrophoresis did not reveal any M-protein bands.
A medical gastroenterology consultation was obtained and the patient underwent an oesophagogastroduodenoscopy (OGD). OGD was notable for two fistulous openings in the oesophagus, the first one at 29 cm and the other at 35 cm from the incisor (Fig. 2). A biopsy from the edge of a tracheoesophageal fistula (TEF) was sent for histopathological examination and Xpert  MTB/RIF Ultra assay. Since the specimen was scanty, it could not be sent for bacterial and mycobacterial cultures. The Xpert  MTB/RIF Ultra assay was negative. Histopathology revealed granulomatous inflammation with rare acid-fast bacilli (AFB) consistent with mycobacterial infection (Fig. 3).
It was decided to manage the patient conservatively and he was started on first-line antitubercular therapy (ATT) with once daily oral isoniazid 300 mg, rifampin 600 mg, ethambutol 1200 mg and pyrazinamide 1000 mg, along with daily pyridoxine supplementation. He was discharged with the advice of completing 12 months of treatment with regular monthly follow-ups with liver function tests.