(1226) TB or Not TB? That Is the Question: Traction Esophageal Diverticulum Rare Presentation of Active TB

Introduction: Traction diverticulum occurs as a rare complication of mediastinitis, in which fibrosis causes mediastinal structures to adhere to and pull the wall of the esophagus. We present a case of incidentally found esophageal diverticulum leading to the diagnosis of active TB infection.

Description: 79-year-old male from Bangladesh visiting family in the US with a history of CVA, HTN, tobacco use initially presented with severe headache. CT and CTA head demonstrated subacute right SDH, chronic occlusion of the left ICA and incidentally found interstitial fibrosis with mass like consolidation in the LUL. Patient was admitted to ICU for further management. A dedicated CT chest showed similar findings along with extensive additional nodular opacities and right apical pulmonary nodule with paratracheal and hilar lymphadenopathy. Differential diagnoses included malignancy, aspiration pneumonia, or inflammatory process. It was then noted that there was invagination of the esophagus appearing as esophageal diverticulum on the CT chest, in speaking with radiology this was likely traction esophageal diverticulum most commonly caused by mediastinitis which is typically associated with histoplasmosis and TB infections. QuantiFERON, Fungitell and galactomannan all came back negative. Bronchoscopy with BAL of LUL was performed and sent for cultures, cytology, and AFB. AFB culture and smear from BAL came back positive for MDR Mycobacterium TB. Appropriate regimen was initiated for the patient and close contacts.

Discussion: Fibrosing mediastinitis is most commonly caused by histoplasmosis in the US and rarely TB, only 10% involve the esophagus. The finding of a traction esophageal diverticulum in this case indicates fibrosing mediastinitis. This case demonstrates the importance of looking at imaging as something such as an esophageal diverticulum could easily be overlooked. It also shows the importance of keeping region specific differentials in mind, for many patients esophageal disease with lung findings typically indicates aspiration. However when taking into account home of origin or travel history such as in this case, Bangladesh which is endemic for TB, the differential broadens and patient care is more personalized. The downstream effects are significant in regard to public health safety as well.