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Esophageal variceal bleeding in a patient with tuberculosis

A 52-year-old male chronic hepatitis B carrier has both type 2 diabetes mellitus and pulmonary tuberculosis, and was being followed in the outpatient clinic. He exhibited progressive thrombocytopenia (platelets: 47 000/ml) and splenomegaly (19 cm detected via sonography). Computed tomography (CT) of the abdomen showed a soft tissue mass (4.2 5.6 5.0 cm) with fibrosis and calcification, encasing the celiac trunk, splenic vein, portal vein, superior mesenteric artery and superior mesenteric vein, contiguous with the pancreas head (Fig. 1A). CT-guided biopsy of the retro-pancreatic tumour revealed chronic granulomatous inflammation with caseous-like necrosis, which was surrounded by epitheloid histocytes and Langhans giant cell infiltration (Fig. 1B). Although tuberculosis polymerase chain reaction was negative, a 12-month anti-tuberculous therapy was administered. Repeat CT scan showed shrinkage of the tumour mass (3.3 5.2 3.6 cm) after completing the anti-tuberculous therapy. One episode of haematemesis was noted and bleeding esophageal varices were observed on endoscopy. The patient was discharged after receiving variceal band ligation and conservative treatment. Two weeks later, massive bleeding recurred and the patient underwent surgery to stop the bleeding (exploratory laparotomy with splenectomy). Gastrointestinal and peritoneal tuberculosis, although rare in North America and Europe, remain common problems in the developing world (1). Abdominal tuberculosis is characterized by its nonspecific protean manifestations, frequently known to mimic myriad intra-abdominal conditions. The possibility of a causal association between oesophageal variceal bleeding and abdominal tuberculosis should be kept in mind after a carefully taken medical history. Follow-up at 4 months and repeat endoscopy revealed the patient to be well.