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1 식도 - 종격동누공을동반한식도결핵 1 예 1 고신대학교의과대학내과학교실, 2 방사선학교실박은호 1, 장태원 1, 박무인 1, 송준영 1, 최인수 1, 옥철호 1, 정만홍 1, 권진환 2 A Case of Esophago-mediatinal Fistula Due to Esophageal Tuberculosis Eun Ho Park, M.D. 1, Tae Won Jang, M.D. 1, Mu In Park, M.D. 1, Jun Young Song, M.D. 1, In Su Choi, M.D. 1, Chul Ho Oak, M.D. 1, Maan Hong Jung, M.D. 1, and Jin Hwan Kwon, M.D. 2 1 Departments of Internal Medicine and 2 Radiology, College of Medicine, Kosin University, Pusan, Korea The esophagus is a rate site for rarely involved site of tuberculosis. The most common cause of esophageal tuberculosis is secondary involvement from adjacent tuberculous lymphadenitis. Esophago-nodal or esophagobronchial fistulas may be formed when tuberculous lymph nodes erode the adjacent esophageal or bronchial wall. We report a patient diagnosed with esophageal tuberculosis, which was complicated by an esophago-mediastinal fistula, by endoscopy, sputum acid fast bacilli (AFB) stain, chest computed tomography (CT), and an esophagogram. The patient was treated with antituberculous agents and chest CT and endoscopy showed that the fistula had closed completely. (Tuberc Respir Dis 2007; 62: ) Key words: Tuberculosis, Esophagus-mediastinum. 서 결핵에의한식도의침범및이의합병증에의한식도-종격동간누공형성은발생빈도가매우드물고국내에서는 1990년서울대학교병원에서보고된후 1, 최근결핵유병률의감소에따라국내보고는거의없는실정이다. 결핵성식도염의가장흔한원인은인접한결핵성종격동림프절염의침범에의한것으로알려져있지만척추, 폐등으로부터의직접침범, 또는다른장기로부터혈행성으로전파될수있고아주드물게원발성으로식도에발생할수도있다 2-4. 결핵성병변의전형적인내시경적소견은비교적경계가분명한깊고넓은궤양및비후된궤양저가특징적이다 5. 본원에서는약 20일간의연하통이있어시행한내시경검사에서식도결핵이의심되었고이어시행한객담검사및흉부전산화단층촬영에서폐결핵및식 론 Address for correspondence: Tae Won Jang, M.D. Department of Internal Medicine, Kosin University College of Medicine 34 Amnam-dong, Suh-gu, Pusan, , Korea Phone: , Fax: jangtw@ns.kosinmed.or.kr Received: Mar Accepted: May 도-종격동간누공형성이확인된후항결핵약제에성공적으로치료되어문헌고찰과함께보고하는바이다. 증례환자 : 송 O O, 33세남자주소 : 20일간의연하통및고열기왕력, 사회력및가족력 : 특이사항없음. 현병력 : 20일전부터연하통이있어타병원서실시한위내시경검사에서식도궤양성병변이관찰되고식도결핵이의심되어정확한진단및치료위해본원으로전원되었다. 과거력 : 13년전폐결핵으로 1년동안항결핵제복용후완치진찰소견 : 혈압 110/70 mmhg, 맥박수 70회 / 분, 호흡수 22회 / 분, 체온 38.5 였다. 흉부청진등다른진찰소견은모두정상이었다. 검사실소견 : 혈색소 10.9 g/dl, 백혈구 5,300/mm 3, 혈소판 270,000/mm 3 로경한빈혈소견을보였다. 혈청전해질검사및동맥혈가스검사는정상이었고, 간기능검사에서 SGPT 114 IU/L, SGOT 81 IU/L로증가되었다. 흉부후전단순사진에서활동성결핵이의 531

EH Park et al: A case of esophago-mediatinal fistula due to esophageal tuberculosis Figure 1.

Figure 3. Esophagogram shows an irregular barium leakage outline the fistular in mid esophagus. Figure 2.

Contrast enhanced CT scan shows linear or oval gas collections in an enlarged left lower paratracheal lymph node.

calcified right lower lymph node. 심되었고 (Figure 1), 객담검사에서는항산균도말검사양성소견을보였다.

2 EH Park et al: A case of esophago-mediatinal fistula due to esophageal tuberculosis Figure 1. This radiographic study of chest shows multiple no-dular opacities in left upper zone. Perihilar engorgement is suspicious. Figure 3. Esophagogram shows an irregular barium leakage outline the fistular in mid esophagus. Figure 2. A 3 x 2 cm sized roundly deep ulce-rative lesion with fistular opening was noted at 33 cm site from upper incisor. Figure 4. Contrast enhanced CT scan shows linear or oval gas collections in an enlarged left lower paratracheal lymph node. There is a communication between the esophagus and a mediastinal area of air attenuation and peripheral rim enhancement and calcified right lower lymph node. 심되었고 (Figure 1), 객담검사에서는항산균도말검사양성소견을보였다. 위내시경검사에서절치로부터 33 cm 되는곳에원형의깊은궤양과함께누관의개구부가관찰되었고 (Figure 2), gastrografin을이용한식도조영술검사에서마찬가지로식도의중간부위좌측면으로깊은궤양소견을볼수있었다 (Figure 3). 흉부전산화단층촬영에서는커져있는좌측기관옆림프절내로선형또는타원형의공기음영과식도-종격동누공을확인할수있었고, 대동맥하림프절또한중심부는저음영및가장자리는윤상의조영증강소견을보였다 (Figure 4). 기관지내시경은특이소견보이지않았다. 532

Tuberculosis and Respiratory Diseases Vol. 62. No.6, Jun. 2007 Figure 7. Follow up contrast enhanced CT scan show no abnormal air collection in mediastinum. Figure 5.

환자의총금식기간은 20일이었고경구투여는입원후 34일지나가능하였다. 경구투여를시작하고 3일경과관찰후퇴원하였다. 지금은항결핵약제를복용하면서외래경과관찰중이다. 고 찰 Figure 6. A shallow well demarcated defect with tiny fistulous opening was noted.

20일후시행한식도조영술결과식도중간부위에있던궤양의크기가작아지고누공을통한조영제의누출이소실되는등호전소견보여 (Figure 5), 미음부터비위관을통해투여하였다. 7일뒤다시위내시경시행한결과누공및궤양이사라진소견보였고 (Figure 6), 그이후경과관 결핵에의해식도가침범되는경우는매우드문경우로대부분인접한구조물로부터의전파에의해속발성으로발생한다 1-3.

3 Tuberculosis and Respiratory Diseases Vol. 62. No.6, Jun Figure 7. Follow up contrast enhanced CT scan show no abnormal air collection in mediastinum. Figure 5. Shallow ulceration at left lateral wall of mid esophagus. No evidence of mediastinal leakage. 찰위해촬영한식도조영술및흉부전산화단층촬영에서 (Figure 7) 누공이완전히폐쇄되어비위관제거후경구투여시작하였다. 환자의총금식기간은 20일이었고경구투여는입원후 34일지나가능하였다. 경구투여를시작하고 3일경과관찰후퇴원하였다. 지금은항결핵약제를복용하면서외래경과관찰중이다. 고 찰 Figure 6. A shallow well demarcated defect with tiny fistulous opening was noted. Much improving state comparing with previous study. 치료및경과 : 환자는객담검사에서항산균도말양성및흉부전산화단층촬영상식도-종격동누공및발열이있어항생제정주와비위관을통해항결핵제를투여하면서금식하였다. 20일후시행한식도조영술결과식도중간부위에있던궤양의크기가작아지고누공을통한조영제의누출이소실되는등호전소견보여 (Figure 5), 미음부터비위관을통해투여하였다. 7일뒤다시위내시경시행한결과누공및궤양이사라진소견보였고 (Figure 6), 그이후경과관 결핵에의해식도가침범되는경우는매우드문경우로대부분인접한구조물로부터의전파에의해속발성으로발생한다 1-3. 결핵이식도에잘침범되지않는이유는식도는여러층의편평상피세포로구성되어있고, 관구조이며, 점막이타액과점액으로덮여있을뿐만아니라빠른연동운동으로인해결핵균이점막침범을할수있는기회를줄이기때문이다 6. 속발성으로발생하는가장흔한원인은인접한결핵성종격동림프선염에의한것인데, 결핵성종격동림프선염이잘침범되는부위는우측기관옆림프절, 기관기관지림프절, 기관분기하림프절등이고 7,8, 특히기관분기하림프절이침범된경우다른림프절을침범했을때보다식도-종격동누공이잘생기는경향이있다 2. 이는해부학적으로이부위가식도와가장인접해있기때문인것으로추정하고있다. 또한누공은왼쪽보다는오른쪽방향으로더잘생기는데이는하행성 533

4 EH Park et al: A case of esophago-mediatinal fistula due to esophageal tuberculosis 흉부대동맥이해부학적장벽으로작용하기때문인것으로생각된다 1. 본증례의환자에서도식도결핵의원인으로는종격동림프절의침범으로인한속발성인것으로밝혀졌지만일반적인유형과는달리좌측기관옆림프절의침범에의해식도-종격동누공이형성되었고결과적으로왼쪽방향으로발생하였다. 식도결핵에의해나타나는증상은식도를침범한정도와형태에따라다양하게나타날수있는데가장흔한것은연하곤란이다. 이러한연하곤란은대개식도에궤양이형성되었을경우잘나타나지만게실이나협착이형성되었을경우에도유발될수있다 3. 식사를하거나물을마시는중에기침이나면식도-기관누공형성을시사하는소견이고가장드물게나타나는증상은토혈로서이는대동맥-식도누공이형성된경우이다 9. 본증례의경우주로연하통및발열이있었지만식사를하거나물을마시는중에기침이나토혈등의증상은나타나지않았다. 결핵이진행되어종격동림프절을침범하는경우는건락성괴사와육아조직형성에의해림프절이종대되는데흉부전산화단층촬영상에서는중심부저음영을보이면서주변부는윤상의조영증강을보이는것이특징이다 7. 또한결핵성종격동림프절내의괴사물질이식도를통해분출됨으로써종격동내국소성공기음영을발견할수있다 1. 식도결핵의내시경소견은크게궤양성, 비후성, 과립성등 3가지로분류하고이중궤양성이가장흔한병변으로알려져있다 5. 궤양성병변은감염된객담내에들어있는결핵균의식도표면침범에의해발생한다 10. 그리고비후성병변은식도의중간부위를주로침범하고식도내강의협착과폐쇄를유발할수있다 5. 과립성병변은가장드물고속립성결핵에서식도의점막표면을회색의과립으로덮고있는소견을나타낸다 10. 본증례의경우궤양성병변과함께누공의개구가관찰되었는데이는식도외부에서의염증이파급되어관찰되는소견인것으로생각되었다. 식도결핵의진단에있어서위내시경적생검이유용한데 Jain 등 11 은약 50% 에서조직검사시전형적인육아종이나왔다고하였고 25% 미만에서항산균도말검사양성으로보고하였다. 또한한연구에따르면식 도결핵환자중내시경으로조직검사를시행한환자의 60% 에서육아종이관찰되었고항산균도말검사양성은 20% 에불과하다고발표하였다. 따라서결핵의진단에있어서내시경적생검의필요성이점차증가되고있음을알수가있다 12. 본증례의환자에서는내시경조직검사상만성염증소견으로나왔으나객담항산균도말검사에서양성으로나왔기때문에진단을위한추가적인검사는시행하지않았다. 심한구토나손상등에의한식도파열이예후가불량한반면에 13 식도결핵에의한식도천공및식도 -종격동누공의형성은수술없이항결핵제만으로치료가가능하므로예후가양호하다 14. 본증례의환자와같은경우는항결핵제투여후음식물섭취로인해식도-종격동누공을통해서유발될수있는종격동염을예방하기위해 20일정도금식기간이필요하였고 30일정도지나검사한식도조영술및흉부전산화단층촬영에서식도-종격동누공은폐쇄되었음을관찰할수있었다. 요 식도결핵은매우드문질환으로원발성으로발생하는경우는거의없고발생한다하더라도대부분속발성으로발생한다. 가장흔한원인으로는종격동림프절의침범에의해인접해있는식도로전파되는것으로이러한경우식도-종격동누공등의합병증이발생할수가있다. 저자들은식도결핵및이의합병증으로식도-종격동누공이형성된환자를항결핵제투여만으로식도결핵의호전과누공의폐쇄를경험하였기에보고하는바이다. 약 참고문헌 1.Im JG, Kim JH, Han MC, Kim CW. Computed tomography of esophagomediastinal fistula in tuberculous mediastinal lymphadenitis. J Comput Assist Tomogr 1990;14: Williford ME, Thompson WM, Hamilton JD, Postlethwait RW. Esophageal tuberculosis: findings on barium swallow and computed tomography. Gastrointest 534

5 Tuberculosis and Respiratory Diseases Vol. 62. No.6, Jun Radiol 1983;8: Devarbhavi HC, Alvares JF, Radhikadevi M. Esophageal tuberculosis associated with esophagotracheal or esophagomediastinal fistula: report of 10 cases. Gastrointest Endosc 2003;57: Lockard LB. Esophageal tuberculosis: a critical review. Laryngoscope 1913;23: Fahmy AR, Guindi R, Farid A. Tuberculosis of the oesophagus. Thorax 1969;24: Gordon AH, Marshall JB. Esophageal tuberculosis: definitive diagnosis by endoscopy. Am J Gastroenterol 1990;85: Im JG, Song KS, Kang HS, Park JH, Yeon KM, Han MC, et al. Mediastinal tuberculous lymphadenitis: CT manifestations. Radiology 1987;164; Amorosa JK, Smith PR, Cohen JR, Ramsey C, Lyons HA. Tuberculous mediastinal lymphadenitis in the adult. Radiology 1978;126: Catinella FP, Kittle CF. Tuberculous esophagitis with aortic aneurysm fistula. Ann Thorac Surg 1988;45: Rubinstein BM, Pastrana T, Jacobson HG. Tuberculosis of the esophagus. Radiology 1958;70: Jain S, Kumar N, Das DK, Jain SK. Esophageal tuberculosis. Endoscopic cytology as a diagnostic tool. Acta Cytol 1999;43: Kochhar R, Sriram PV, Rajwanshi A, Gulati M, Kochhar S, Nagi B, et al. Transesophageal endoscopic fine-needle aspiration cytology in mediastinal tuberculosis. Gastrointest Endosc 1999;50: Lyons WS, Seremetis MG, deguzman VC, Peabody JW Jr. Ruptures and perforations of the esophagus: the case for conservative supportive management. Ann Thorac Surg 1978;25: Lucaya J, Sole S, Badosa J, Manzanares R. Bronchial perforation and bronchoesophageal fistulas: tuberculous origin in children. AJR Am J Roentgenol 1980;135:

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6.Kaes013( ).hwp 갑상선결핵 - 증례보고및문헌고찰 Tuberculosis of the Thyroid Gland - Report of Two Cases and Review of the Literatures Se Yeom Park, M.D., Jong Geun Lee, M.D., Bong Ok Yoo, M.D., Oh Kyoung Kwon, M.D. and Myoung Jin Joo,