Oesophageal Tuberculosis: Initial Manifestation of an Immunocompromised State

Oesophageal tuberculosis (TB) is a rare manifestation of gastrointestinal TB, usually secondary to spread from adjacent mediastinal lymph nodes or bronchi. It is extremely rare as an initial presentation of advanced HIV infection. We report a 58-year-old female presenting with 15 days of progressive dysphagia, weight loss, and low-grade fever. Upper gastrointestinal endoscopy revealed ulcerated mucosa with suspected fistulous tracts in the mid-oesophagus. Histopathology of biopsy specimens demonstrated acid-fast bacilli, confirming TB. HIV testing was positive with a CD4 count of 17 cells/mm³. Initial first-line anti-tubercular treatment (ATT) caused drug-induced liver injury and was temporarily replaced with a liver-sparing regimen. Standard drugs were reintroduced stepwise as per BTS guidelines, followed by initiation of antiretroviral therapy two weeks later, along with prophylaxis for opportunistic infections. The patient showed rapid symptomatic improvement, complete resolution of dysphagia, and weight gain. Oesophageal TB, although rare, should be suspected in immunocompromised patients presenting with dysphagia. Early diagnosis and timely initiation of ATT can result in excellent outcomes and prevent the need for surgical intervention.