British Journal of Radiology 75 (2002),1003-1004 © 2002 The British Institute of Radiology
A pain in the neck
A Rajesh, FRCR
D Ramsay, MRCP, FRCR
and
K Jeyapalan, MRCP, FRCR
Glenfield Hospital NHS Trust, Leicester LE3 9QP, UK
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Introduction
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A 26-year-old Asian male presented with neck pain. A cervical spine radiograph led to subsequent investigations. What does this series of investigations (Figures 1–4
) demonstrate? What is the diagnosis and what complications are demonstrated?
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Answer
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The lateral radiograph of cervical spine showed vertebral destruction, prevertebral soft tissue swelling and air (Figure 1
). The water soluble contrast swallow demonstrated contrast medium leaking and extending up to the base of the skull, suggesting an oesophageal tear (Figure 2). Contrast enhanced CT showed vertebral destruction, prevertebral abscess, free air in the mediastinum and fistulous communication with the oesophagus (Figure 3). A diagnosis of spinal tuberculosis (TB) was made. MRI was performed to assess the extent of involvement. Pre- and post-contrast sagittal T1 weighted MRI shows multifocal bone destruction, an enhancing epidural mass and prevertebral abscess with air, suggesting fistulous communication with the oesophagus (Figure 4).
Oesophageal TB is an uncommon condition, usually resulting from direct extension of caseating mediastinal lymph nodes. The clinical diagnosis of this condition can be difficult and histological diagnosis based on oesophageal biopsies are not always definitive [1, 2]. Radiological investigations can often be useful in demonstration of the pathology.
Primary oesophageal TB is rare because stratified squamous epithelium and a rapid transit time protect the oesophagus against implantation of the bacilli [3]. Dysphagia, odynophagia or haematemesis are the usual clinical presenting symptoms. Pre-existing disease such as reflux oesophagitis, inflammation, ulceration, stricture or carcinoma are considered predisposing factors [3]. The secondary form of disease is well recognized and can result from haematogenous or retrograde lymphatic dissemination, although caseating mediastinal lymph nodes are considered the main source of spread. Extension can also occur from disease in the thoracic spine or disseminated miliary TB [4]. Owing to difficulty in diagnosis in the majority of cases, diagnosis is presumed only after response to anti-tuberculous therapy [5]. However, this diagnosis should definitely be considered in patients with predisposing factors, including an immunocompromised state, and known extrapulmonary tuberculosis.
Three pathological forms of oesophageal TB have been described: ulcerative; hypertrophic; and granular [6]. Barium studies demonstrate displacement and distortion of the oesophageal contour. Mucosal irregularity with ulceration and spasm are also seen. Oesophageal TB occasionally leads to fistulous tracts in the mediastinal lymph nodes or the tracheo–bronchial tree [6]. Luminal narrowing, stricture formation and traction diverticula occur as long-term sequelae [6]. CT is useful for demonstrating the extent of mediastinal adenopathy and involvement of the thoracic spine. MRI is essential in evaluating the extent of spinal disease and neurological complications. Spontaneous rupture of the oesophagus is a very rare complication.
Received for publication August 21, 2001.
Accepted for publication August 24, 2001.
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References
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- Gordon AH, Marshall J. Esophageal tuberculosis: defintive diagnosis by endoscopy. Am J Gastroenterol 1990;85:174–7.[Medline]
- Savage PE, Grundy A. Oesophageal tuberculosis: an unusual cause of dysphagia. Br J Radiol 1984;57:1153–5.[Abstract/Free Full Text]
- Rosario MT, Raso CL, Comer GM. Esophageal Tuberculosis. Dig Dis Sci 1989;34:1281–4.[Medline]
- Rubinstein BM, Pastrana T, Jacobson HG. Tuberculosis of the esophagus. Radiology 1958;70:401–3.[Medline]
- Perdomo JA, Naomoto Y, Haisa M, Yamatsuji T, Kamikawa Y, Tanaka N. Tuberculosis of the esophagus. Dis Esophagus 1998;11:72–4.[Medline]
- Williford ME, Thompson WM, Hamilton JD, Postlethwait RW. Esophageal tuberculosis; findings on barium swallow and computed tomography. Gastrointest Radiol 1983;8:119–22.[Medline]
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Introduction
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