Teaching Case

A 25 year-old female attended the outpatient clinic complaining of cough, expectoration and fever. Her sputum analysis showed acid fast bacilli (AFB) positive for Mycobacterium tuberculosis and chest radiograph showed a cavitatory lesion. She was negative for HIV. She was put on antituberculous treatment and was shceduled for follow up.

Her initial chest radiograph showed a cavitatory lesion. Although she was put on antituberculous treatment she discontinued it after one-month initial recovery. She returned with exacerbation of her symptoms and her sputum still showed AFB positive for Mycobacterium tuberculosis. Her CECT thorax (high resolution, 1 mm reconstruction and post processed images) revealed in axial, sagittal and coronal planes multiple thin fibrotic bands with consolidation in right lower lobe basal segments (Figure 1, 2, 3). There were multiple cavities and focal nodular opacities. One large cavity showed suspicious communication with the right lateral wall of oesophagus. Mediastinal lymphnodes were present. She underwent thin barium swallow study, which conclusively showed pooling of contrast in the cavity and presence of bronchoesophageal fistula (Figure 4). Ultrasound (USG) of abdomen was unremarkable. Her follow-up barium swallow was normal suggesting healing of fistulous track without any surgical repair and remarkable recovery both radiologically and clinically.

Tuberculosis is a disease with protean manifestations. It is still a huge burden in terms of prevalence and cost on healthcare in developing countries. In India it has been a challenge to deal with tuberculosis due to non-compliance and socio-economic factors. Despite of several programs and initiatives, results are not satisfactory. With increasing cases of drug resistant tuberculosis and conjunction with HIV cases the situation becomes more confounding [1]. Increasing number of cases with complications in young population is a serious issue [2]. Low socio-economic status, literacy, religious factors make treatment of TB difficult. There are many unusual complications and spectrum of disease that are diagnosed retrospectively [3]. A variety of complications can occur in patients. These include tuberculoma, aspergilloma, bronchiectasis, tracheobronchial stenosis, broncholithiasis, vascular lesions, lymph nodes, esophagomediastinal or esophagobronchial fistula. Scenario becomes complicated due to defaulters and gives rise to drug resistant tuberculosis [4]. The disease becomes more complicated in female patients. Incidence of gastrointestinal and tubercular salpingitis is high in the Indian population. Awareness is a major issue. Social factors are hard to overcome. Indiscriminate use of ATT without confirmation is an area of concern. The incidence of complicated pulmonary as well as extrapulmonary tuberculosis is bound to increase if these issues are not addressed. ATT if taken regularly can avoid complications and obviate surgery in the majority of cases.