A 25 Year old woman, with no premorbid illnesses presented with a history of cough during eating for 3 months duration and mucoid,non blood tinged sputum production for 1 month. She reported an 8 kg weight loss. There was no history of shortness of breath,chestpain,vomiting or choking. There was also no history of foreign body aspiration, ingestion of toxic or corrosive substances or any surgical procedures in past. Her younger sister was detected to have pulmonary tuberculosis 1 yr back and completed antituberculous treatment. She was not evaluated for Tuberculosis at the time of her sister's diagnosis. She had been married for 9 months, had regular menstrual cycles and no history of high risk behaviour.
On examination she exhibited mild pallor. There was no icterus, cyanosis, clubbing or lymph node enlargement. Pulse rate - 86/min, regular; Blood pressure - 110/70 mmHg; respiratory rate - 16/min; and she was afebrile. Cardiovascular,respiratory,gastrointestinal,nervous system examination were within normal limits. Investigations showed WBC 11,200/cmm, with 64% neutrophils and 31% lymphocytes, Hgb - 10 g/dL, platelet count 230,000/cmm and ESR was 55 mm/h. Renal and liver function tests were within normal limits.Retroviral screening and autoimmune markers were negative.Sputum AFB was negative.Tuberculin skin test showed an induration measuring 15 x 15 mm.
Barium swallow showed a fistulous communication between esophagus and bronchial tree (Fig. 1). Esophagoscopy was performed which revealed a 30 mm ulcer with irregular borders with communication into respiratory tract, 25 cm from the oral cavity. Computed tomography scan of thorax with three dimensional reconstruction was done which showed mediastinal lymphadenopathy, with erosion of posterior wall of left main bronchus, with a fistulous tract into anterolateral wall of esophagus (Fig. 2A-C). There was also centrilobular nodules in bilateral lung parenchyma with tree in bud appearance. Bronchoscopy revealed inflamed mucosa which revealed granulomatous inflammation on biopsy.AFB staining of bronchial secretions was negative,but tested positive for M.tuberculosis by PCR. Cultures done on bronchial secretions showed growth of M. tuberculosis.
She was started on antituberculous treatment modified according to weight and nasogastric feeding started. Treatment comprised of an intensive phase for the first two months in which four antituberculous drugs (Isoniazid, Rifampicin, Pyrazinamide, Ethambutol) were given. This was followed by a continuation phase for next four months consisting of two drugs (Isoniazid and Rifampicin). Bronchoscopy was done after completing 4 months of treatment and showed normal bronchial lumen with disappearance of fistulous tract.Computed tomography of thorax showed resolution of lung lesions without any fistula. She completed 6 months of antituberculous treatment and remains asymptomatic till date.