Esophageal Tuberculosis: A Rare but Important Cause of Dysphagia

Difficulty swallowing is usually linked to common problems such as reflux, a narrowing of the oesophagus, eosinophilic oesophagitis or malignancy. Oesophageal tuberculosis (TB) is far less frequent, yet it deserves consideration when dysphagia occurs alongside constitutional symptoms, abnormal chest imaging or risk factors for tuberculosis infection.

Australia has a low incidence of TB compared with many countries, so clinicians may not immediately place it high on the differential diagnosis. A careful history, targeted imaging and tissue sampling can prevent delayed treatment, especially when symptoms are attributed to gastro-oesophageal reflux or a routine benign stricture.

Why oesophageal involvement is unusual

The oesophagus is relatively resistant to infection because swallowed material passes quickly, the mucosa is protected by mucus and the organ has limited lymphoid tissue. Tuberculosis usually reaches it from nearby mediastinal lymph nodes, rather than through direct infection of the inner lining. Less often, organisms spread through the bloodstream or are swallowed from an infected upper respiratory tract.

The middle third of the oesophagus is commonly affected because it lies close to subcarinal and mediastinal lymph nodes. Enlarged nodes may compress the oesophagus from outside, while inflammation or a fistula can damage the wall. These mechanisms explain why dysphagia may develop gradually and why chest symptoms or radiological findings can be more informative than the endoscopic appearance alone.

Recognising the clinical pattern

Progressive dysphagia, initially for solid food and later for liquids, is the most important symptom. Retrosternal pain, odynophagia, weight loss, night sweats, fever and persistent cough may provide additional clues. Some people have pulmonary TB at the same time, although oesophageal disease can occasionally occur without obvious lung involvement.

In Australia, a patient in Sydney, Melbourne, Brisbane or Perth may have been born in a country where TB is more common, lived in a crowded setting, or had previous exposure through household or community contacts. Recent travel, immunosuppression, HIV, diabetes, chronic kidney disease and treatment with biological medicines should be documented. Reflux symptoms are common in everyday practice, but persistent or progressive swallowing difficulty should not be managed as simple heartburn without investigation.

Confirming the diagnosis

Upper gastrointestinal endoscopy may show an ulcer, irregular narrowing, raised lesion, external compression or a fistulous opening. These findings are not specific, and superficial biopsies can miss disease because the infection often lies deeper in the wall or adjacent lymph nodes. Histology may reveal granulomatous inflammation, while acid-fast staining and mycobacterial culture can support the diagnosis.

Computed tomography of the chest is particularly useful for identifying mediastinal lymphadenopathy, pulmonary lesions and complications. Endoscopic ultrasound-guided sampling of an abnormal lymph node may provide better material than an oesophageal biopsy. Nucleic acid amplification testing can speed detection of Mycobacterium tuberculosis and assess rifampicin resistance, but results should be interpreted with culture, histology and the full clinical picture.

Managing treatment and complications

Drug-susceptible disease is generally treated with standard multidrug anti-tuberculosis therapy, commonly an intensive phase containing rifampicin, isoniazid, pyrazinamide and ethambutol, followed by a continuation phase. The exact regimen and duration depend on susceptibility results, disease site, immune status, drug interactions and specialist advice. Pyridoxine is usually prescribed with isoniazid to reduce the risk of peripheral neuropathy.

Treatment requires monitoring for liver injury, visual changes, drug interactions and adherence difficulties. Dysphagia may improve with medical therapy, but severe obstruction, perforation, bleeding or an oesophagobronchial fistula may require endoscopic or surgical management. In Australia, care often involves a respiratory or infectious diseases service, a gastroenterologist, radiology, pathology and local public health authorities.

Public health considerations in Australia

Tuberculosis is a notifiable condition under state and territory public health legislation. Suspected or confirmed cases should be discussed promptly with the relevant public health unit, particularly when pulmonary disease or contact exposure is possible. Contact tracing, respiratory precautions and assessment for drug resistance are essential, even when the main presentation appears to be oesophageal.

Access can differ between metropolitan hospitals and regional or remote communities. Telehealth may support specialist review, but tissue collection, chest imaging and endoscopy still require coordinated local services. Clear communication is also important for people who need interpreters or who face travel, cost and work-related barriers. Information about the ISDE 2021 congress reflects the wider international emphasis on collaboration in oesophageal disease research and education.

Practical recommendations for clinical assessment

A structured approach helps distinguish rare infection from more common causes of swallowing difficulty. The following actions are particularly useful:

• Treat progressive dysphagia, weight loss or odynophagia as alarm features requiring timely endoscopy.
• Ask about country of birth, previous TB exposure, travel, incarceration, homelessness, immunosuppression and prior TB treatment.
• Arrange chest imaging when symptoms, examination or epidemiology suggest tuberculosis.
• Request mycobacterial culture and molecular testing when granulomas, necrosis or suspicious lymph nodes are identified.
• Involve infectious diseases, respiratory medicine and gastroenterology before starting therapy when feasible.
• Notify the appropriate Australian public health unit when TB is suspected or confirmed.
• Monitor treatment toxicity, adherence, nutrition and swallowing function throughout therapy.

Early specialist involvement is valuable because a negative superficial biopsy does not exclude oesophageal tuberculosis. If suspicion remains, repeat sampling, endoscopic ultrasound or image-guided lymph-node biopsy may be safer and more informative than repeated empirical treatment for reflux.

Progressive dysphagia should therefore prompt a broad differential diagnosis, even in a country with low overall TB rates. The immediate next step is to arrange urgent upper endoscopy with chest imaging and ensure that any suspicious tissue is sent for histology, culture and molecular testing.