S Rahmatulla, A Marshall, S Bhagani, GL Jones and DP Gale
Solid organ transplant recipients are at increased risk of opportunistic infections, including tuberculosis, which may be caused by re-activation of latent disease or acquired de novo. Tuberculosis can affect any organ, present atypically, is diagnostically challenging and potentially fatal. Esophageal tuberculosis is generally rare, and usually secondary to infection in adjacent mediastinal structures. We report a case of esophageal tuberculosis in a simultaneous pancreas-kidney transplant recipient, who presented with symptoms of odynophagia, retrosternal chest pain, weight loss and dry cough, three years post-transplantation. Initial upper gastrointestinal endoscopy revealed non-specific inflammation but no identifiable cause. Repeat endoscopy revealed severe ulceration with a lower esophageal stricture. Multiple esophagealbiopsies taken demonstrated granulomatous inflammation, and evidence of acid-fast bacilli on Ziehl- Neelsen staining. Polymerase Chain Reaction (PCR) assay was specific for Mycobacterium tuberculosis. Computerized tomography (CT) of the patient’s thorax showed evidence of pulmonary disease and fully sensitive Mycobacterium tuberculosis was cultured from the esophageal tissue biopsies, confirming a diagnosis of secondary esophageal tuberculosis.The patient was treated with 6 months of anti-tuberculous therapy, following which she had made a full recovery. This case illustrates firstly an unusual manifestation of tuberculosis in an immunocompromised patient; secondly the importance of thorough and persistent investigation of unexplained symptoms in this group; and thirdly that tuberculosis should always be considered as it may occur even in patients who do not fulfill conventional criteria for prophylactic therapy.