結核性縦隔リンパ節炎の食道穿破による食道結核の1例

Esophageal Tuberculosis, Report of a Case

要旨　患者は30歳台，男性．嚥下時胸痛と嚥下困難で他院を受診，上部消化管内視鏡検査で中部食道に粘膜下腫瘍様の隆起性病変を指摘され当科紹介受診となった．食道X線検査では気管分岐部直下Mt前壁に管外圧排による粘膜下腫瘍様の隆起がみられ，表面には潰瘍を形成していた．潰瘍形態に不整はなく，周堤様の辺縁隆起も表面平滑であり正常上皮に覆われ，さらに潰瘍面には瘻孔開口部が認められた．胸部CT，EUSでは気管分岐部近傍のリンパ節は腫大し，食道と隣接していた．生検病理組織では類上皮細胞肉芽腫と多角巨細胞が認められた．結核菌や乾酪性肉芽腫は認めなかったが，ツベルクリン反応は中等度陽性であり各種画像所見から食道結核と診断した．抗結核剤による治療で症状は速やかに改善し経過良好であった．

　The patient was a 39-year-old man who had been examined at another hospital for chest pain during swallowing and dysphagia. When a protruding submucosal tumor-like lesion was discovered in the mid-esophagus by upper GI endoscopy, he was referred to our department and examined. Esophagography revealed a submucosal tumor-like protrusion due to external displacement in the anterior wall of midthoracic esophagus (Mt) directly below the tracheal bifurcation, and an ulcer had formed on its surface. There were no irregularities in the shape of the ulcer. The prominent embankment-like border around it had a smooth surface and was covered with normal epithelium, and a fistula opening was observed in the ulcer surface. CT of the chest and EUS showed lymph node enlargement in the vicinity of the tracheal bifurcation, and the nodes were located adjacent to the esophagus. Histopathological examination of a biopsy specimen revealed epithelioid cell granulomas and multinucleated giant cells. No tubercle bacilli or caseous granulomas were observed, but the tuberculin test was moderately positive, so, based on the diagnostic imaging findings, a diagnosis of esophageal tuberculosis was made. The symptoms rapidly improved in response to treatment with antitubercular agents, and the patient's course has been uneventful.