대한흉부영상의학회 Korean Society of Thoracic Radiology GuerBet

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대한흉부영상의학회 Weekly Case 검색
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Weekly Chest CasesArchive of Old Cases

Case No : 109 Date 1999-11-27

  • Courtesy of Jae-Woo Song, M.D. / Seoul City Boramae Hospital, Korea
  • Age/Sex 76 / M
  • Chief ComplaintRecurrent attacks of pneumonia during last two years
  • Figure 1
  • Figure 2
  • Figure 3
  • Figure 4
  • Figure 5
  • Figure 6

Diagnosis With Brief Discussion

Diagnosis
Esophagobronchial Fistula due to Tuberculosis
Radiologic Findings
Subcarinal and right hilar lymph node enlargement,
Deformity of esophagus and irregular esophageal wall thickening,
Deformed esophageal gas with some feature of cleft,
Ill-defined airspace consolidation, ground-glass attenuation, and centrilobular nodules in RLL (aspiration pneumonia).

The following esophagogram shows an irregular fistulous tract between the dilated esophagus and the bronchus.
Brief Review
Tuberculous mediastinal lymphadenopathy is an infrequent occurrence (about 4.4%) in adults, because aquired resistance enhances the ability of subjects to confine organisms to the site of infection. There is some female preponderance of 2~3:1. Right sided mediastinal lymph nodes are more commonly involved because the preferential lymph flow of entire right lung and left upper lung to right tracheobronchial and paratracheal nodes as well as the higher frequency of right lung pulmonary tuberculosis involvement. The involved lymph nodes show necrotic central low attenuation area and enhanced peripheral portion due to inflammatory hypervasculaity on enhanced CT scan.

Esophageal involvement by tuberculosis usually occurs in the late stages of tuberculosis secondary to pulmonary, mediastinal, or disseminated disease. Direct contiguous involvement from adjacent tuberculous lymphadenitis is known to be the most frequent cause of esophageal tuberculosis. On contrast enhanced CT, these lymph nodes typically show central low density with peripheral rim enhancement representing caseation necrosis and hyperemic granulation tissue, respectively. Necrotic material within the tuberculous mediastinal lymph node can be extruded through an esophageal and/or tracheobroncheal fistula, resulting in a localized gaseous collection within the mediastinum. Even though tuberculous lymphadenitis involves right paratracheal nodes more commonly than subcarinal nodes, as the diseased right paratracheal nodes have less chance to contact the esophagus than the subcarinal nodes, fistulous communication is more prone to occur in the subcarinal area.

In contrast to the poor prognosis associated with esophageal rupture by forceful vomiting or by other trauma, esophageal perforation by tuberculous esophagomediastinal fistulas tends to close uneventfully during anti-tuberculous therapy.
References
1. JG Im, KS Song, HS Kang, et al. Mediastinal tuberculous lymphadenitis: CT manefestations. Radiology 1987;164:115-119
Keywords
Lung, Esophagus, Infection, Bacterial infection, tuberculosis,

No. of Applicants : 23

▶ Correct Answer : 13/23,  56.5%
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  • - 源€
  • - 諛곗žъ
  • - 寃쎈
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  • - 源€
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  • - 怨
  • - 怨
  • - 源€
  • - Seoul National University Hospital Jung-Gi Im
  • - Pol. S.Orsola-Malpighi, University of Bologna. Bologna, Italy Maurizio Zompatori
▶ Semi-Correct Answer : 2/23,  8.7%
  • - Stedelijk OLV Ziekenhuis Mechelen, Belgium Pilate Ivan
  • - Univ. of Colorado Health Sciences Center Jin Seong Lee
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Current Editor : Sung Shine Shim, MD, PhD. Email : sinisim@ewha.ac.kr

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