Indian Journal of Tuberculosis

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Clinical profile and diagnosis of extra-pulmonary TB in HIV infected patients: Routine abdominal ultrasonography increases detection of abdominal tuberculosis.
(2013-07) Spalgais, Sonam; Jaiswal, Anand; Puri, Manmohan; Sarin, Rohit; Agarwal, Upasna
Objective: To study the clinical profile and assess the utility of the procedures performed for the diagnosis of extra" pulmonary TB (EPTB) in HIV patients. Design: Prospective observational study of HIV patients suspected to have EPTB. Results: Two hundred and thirty HIV-infected patients were enrolled over 18 months. Of them, 87 cases had active TB, 60 (69%) of whom were of EPTB. Major presenting symptoms were fever (93.3%), weight loss (80%) and cough (61.6%). The most common site of active EPTB was the abdomen (70%), which could be detected due to routine use of abdominal ultrasonography, followed by CT scans in inconclusive cases. Peripheral lymph node (22% ), pleura (15%), CNS involvement (3%) and one case each of psoas abscess and mediastinal lymphadeopathy were the other extra-pulmonary sites seen. Diagnosis of peripheral lymph node and pleural TB was based on cytological and mycobacterial examinations. Direct smear examinations were positive for AFB in 11 of 24 samples and mycobacterial cultures were positive in five of 18 samples. The median CD4 ceH count in our HIV-EPTB cases was 126 cells/ml3 (IQR-79.5-205.75). There was no statistical difference in the baseline CD4 ceH counts in patients with PTB vs EPTB (p-0.70), single vs multiple extra-pulmonary site involvement (p-0.57), and AFB positive vs AFB negative EPTB cases (p-0.51). Conclusions: EPTB is the most common form of TB in HIV patients with low CD4 cell counts. Fever, weight loss and cough are common presenting symptoms of EPTB. Routine abdominal ultrasonography followed by an abdominal CT scan in inconclusive cases can significantly increase the detection of abdominal TB.
Primary tuberculous myositis: a rare clinical entity.
(2013-10) Kulkarni, Sunanda A; Patil, Santosh S; Kulkarnix, Santosh S; Udgaonkar, Usha S; Gadgil, Shubhangi A
Summary: Primary tuberculous myositis without underlying pathology has been sparingly reported in medical literature. We report a case of primary tuberculous myositis of left upper arm in a seven-year-old boy. He presented with gradually increasing swelling on the medial aspect of the left arm. Ziehl Neelsen staining of pus collected revealed acid fast bacilli morphologically resembling Mycobacterium tuberculosis and the same was grown on the culture. Histopathological findings were consistent with tuberculosis. The results were confirmed by Genotype MTBDRpluse line probe assay. He was treated with standard four-drug regimen to which he responded well with complete resolution of the lesion.
Gallbladder tubrculosis mimicking malignancy: A rare case report.
(2013-10) Dutta, Pravati; Santra, Avradip; Manjhi, Rekha; Pothal, Sudarsan; Sahu, Dibakar
Summary: Gallbladder tuberculosis is an extremely rare disorder even in endemic region. It often mimics gallbladder malignancy as both of them share some common presentations. This entity is very rarely diagnosed pre-operatively as neither clinical features nor radiology are pathognomonic of gallbladder tuberculosis. The case reported here presented as chronic calculous cholecystitis with mass at gallbladder neck. Patient underwent laparotomy with suspicion of gallbladder carcinoma, which was eventually diagnosed as a case of gallbladder TB following histopathological examination of the resected specimen. He also had pulmonary TB in association and was completely cured with short course antitubercular chemotherapy.
Tubercular ileal perforation - atypical, acute presentation in a renal transplant recipient - a case report.
(2013-10) Kedlaya, Prashant G; Subramanyam, S G; Raja, H; Divya, P
Summary: Extrapulmonary tuberculosis (TB) is more common than pulmonary TB in immuno-suppressed renal transplant recipients. Atypical presentation of TB and disseminated TB is known in transplant recipients. Usually intestinal TB presents with pain abdomen, intermittent subacute intestinal obstruction, diarrhoea and/or constitutional symptoms like fever and weight loss. Here we report a case of renal allograft recipient on regular hospital follow up, presented with acute abdomen with no previous symptoms of fever, weight loss or abdominal symptoms and was diagnosed to have tubercular ileal perforation on exploratory laporatomy and confirmed by histopathological examination. This patient succumbed to the illness due to sepsis despite timely surgery, broad spectrum antibiotics and antitubercular therapy.
Annual risk of tuberculosis infection in a rural population of South India and its relationship with prevalence of smear positive pulmonary tuberculosis.
(2013-10) Chadha, V K; Anjinappa, Sharada M; Gowda, Umadevi; Srivastava, Ramesh; Ahmed, J; Kumar, Prahlad
Background: We conducted a tuberculin survey to estimate the annual risk of tuberculous infection (ARTI) among children in a sub-division of rural Bangalore district. A TB disease survey was conducted in the same area around the same time and has already been published. DOTS strategy is being implemented in the study area since 2002. Methods: The tuberculin survey was conducted during 2010-2011 among 3838, 5-9-year-old children attending 147 schools selected by simple random sampling. Children were tuberculin tested with 2TU PPD RT23 with Tween 80 and maximum diameter of induration was measured between 48-96 hours. ARTI was computed from prevalence of infection estimated by mirror-image technique. Prevalence of smear positive pulmonary TB estimated during the disease prevalence survey in 2008-10 was used to find out its relationship with ARTI. Results: Using the observed mode of tuberculin reaction sizes at 19 mm, among surveyed children, prevalence of infection was estimated at 7.3% (CI: 6.5-8.1); ARTI was computed at 1.05%. Considering the mean age of children, estimated ARTI most closely approximated to the year 2008. Every one per cent ARTI was found to correspond to a prevalence of 103 sputum smear positive patients of PTB, which was similar to the ratio of 106 found in the same study area during 1960s. Conclusion: There has been no change in the relationship between ARTI and prevalence of smear positive pulmonary TB from the pre-DOTS era and thus in the number of children infected by each adult point prevalent case of smear positive pulmonary TB each year suggesting the need for early case detection and treatment.
Exposure to cetyl pyridinium chloride and loss of integrity of cell wall of mycobacteria.
(2013-10) Sekar, Gomathi; Vanaja, Kumar; Gomathiand, N S; Selvakumar, N
Background: Cetyl pyridinium chloride (CPC) liquefied sputum was shown to reduce AFB smear positivity presumably damaging cell wall of M. tuberculosis. Settings: National Institute for Research in Tuberculosis, Chennai, (Tamil Nadu). Objective: To assess the cell wall damage of mycobacteria in CPC liquefied sputum, by Transmission Electron Microscopy (TEM) and mycobacteriophage adsorption studies. Methods: Pooled sputum sample from smear positive pulmonary TB patients was homogenized and liquefied with CPC. It was examined in TEM daily for four days, to assess cell wall damage of M. tuberculosis, and photomicrographs were taken. M. smegmatis mc2155, treated with CPC, was infected with mycobacteriophage (phAE129) to study phage adsorption on cell wall and plaque formation. CPC untreated sputum and M. smegmatis formed controls. Results: Photomicrographs showed that cell wall of M. tuberculosis was intact in controls and damaged in CPC preserved sputum for 96 hours. Plaque formation was seen and absent respectively in CPC untreated and treated M. smegmatis cells. Conclusion: Exposure to CPC damaged the cell wall of M. tuberculosis within 96 hours. Mycobacteriophage failed to form plaques after M. smegmatis mc2155 was treated with CPC implying inhibition of phage adsorption on damaged cell wall and thus providing a clue for poor staining and smear positivity in microscopy.
Gender differences in health care seeking behaviour of tuberculosis patients in Chandigarh.
(2013-10) Kaur, Manmeet; Sodhi, Suninder K; Kaur, Parampreet; Singh, Jasmik; Kumar, Rajesh
Background: Gender is a social determinant of health. In view of the substantial burden of tuberculosis (TB), it is important to look into the gender issues related to utilization of services. Aims: To find out gender differences in health care seeking behaviour of tuberculosis patients. Methods: A cross sectional study, using integrated mixed method, was conducted in Chandigarh (India). Systematic random sample was used to interview 109 TB patients (54 men and 55 women) from eight randomly selected health institutions. Results: More women (40%) resorted to home remedies or medicines without prescription at the onset of symptoms compared to men (13%). More men (87%) consulted qualified medical practitioners compared to the women (60%). Consultations from private doctors were more common among men. Mean delay in diagnosis was more in men (60 days) than women (33 days). Main reasons for delay, in men and women respectively, were late referral by doctor (37% vs 26%), long distance to health institution (29% vs 28% ), prolonged use of self-medication (30% vs 26%), and financial constraints (7% vs 17%). More women (20.8%) reported missing a prescribed dose of treatment as compared to men (11.1%). However, 10% men were on re-treatment compared to none of the women. Conclusions: Delay in diagnosis was more in men than women. More delay occurred due to delayed referral by doctors among men and due to financial constraints among women. Hence, gender differences in health care seeking behaviour should be kept in mind while selecting programme strategies.
Spinal tuberculosis; A study of the disease pattern, diagnosis and outcome of medical management in Sri Lanka.
(2013-10) Yasaratne, B M G D; Wijesinghe, S N R; Madegedara, R M D
Background: Sri Lanka has an intermediate burden of tuberculous disease. Most patients with spinal tuberculosis (STB) are managed with medical treatment alone as advanced surgical facilities are not freely available. Objective: To describe the clinico-demographic and imaging pattern of STB and to assess the outcome of medical treatment in the local setting. Design: Descriptive case series. Methods: All patients diagnosed with definite or probable STB, had their symptomatology and investigations recorded. They were followed up with anti-TB treatment (ATT) according to standard guidelines. An initial six-week tapering course of steroid was given when there was an evidence of neural involvement. Results: Of 32 patients with STB, backache was the commonest presenting feature (92%). Nine had lower limb neurological deficits. Uni-focal upper lumbar involvement was the commonest disease pattern noted in the series. High ESR (84%) and Mantoux positivity (53%) were frequent. 72% had end-plate changes on imaging. 53% had paraspinal soft tissue components. The triad of backache, high ESR and end-plate and/or paraspinal disease on CT/MRI showed a diagnostic sensitivity of 81.2%. Response to ATT was satisfactory in 87%. Poor neurological response was seen among some with large paraspinal collections or extensive vertebral damage at diagnosis. Conclusion: This study showed that backache over one month, high ESR and specific CT/MRI features helped diagnosis of STB, in the absence of definitive evidence. Medical management alone, comprising a prolonged course of ATT with an initial steroid cover when indicated, appeared to be safe and effective in the local setting for uncomplicated STB.
Tuberculosis in HIV co-infected patients- a study at tertiary care hospital, Amritsar (India).
(2013-10) Bhushan, Bharat; Kajal, N C; Maske, Anil; Nadia; Bharti, Heena; Singh, Jaswant
Background: The dual epidemic of tuberculosis and HIV is a significant problem in the developed and developing countries. Tuberculosis is the most common human immunodeficiency virus related opportunistic infection in India and caring for patients with both diseases is a major public health challenge. Aim: The aim of the present study was to record the different clinical patterns of tuberculosis in HIV co-infected patients as a function of CD4+T cell count. Material and Methods: The study was a retrospective analysis of the HIV-TB co-infected patients admitted in the Chest and TB Hospital, Government Medical College, Amritsar (Punjab) during the calender year 2011. Results: Out of total 47 HIV sero-positive patients (n=47), 36 were males (76.59%) and 11 females (23.41%) of age group 14 to 51 years. Cough was the most common presenting symptom (72.34%).A large number of patients were diagnosed as having pulmonary tuberculosis (48.94%). The other diagnoses were tubercular meningitis (n=4), pleural effusion (n=4), tubercular lymphadenopathy (n=2), pneumothorax (n=2), hydropneumothorax (n=2) and abdominal tuberculosis (n=2). A total of 34 (72.34%) patients were having a CD4+T cell count of < 200. Conclusion: The manifestations of tuberculosis in HIV infected patients are quite varied and generally show a different pattern as a function of CD4+ T cell count. Co-infection with HIV infection leads to difficulties in both diagnosis and treatment of tuberculosis. High degree of suspicion of tuberculosis, with astute clinical and laboratory evaluation is the key for early diagnosis and management.
Vitamin D receptor polymorphism and active Tuberculosis.
(2013-10) Arora, V K; Jaiswal, Ashish K
Tuberculosis of Rectum simulating malignancy and presenting as rectal prolapse - A case report and review.
(2013-07) Patil, Salil; Shah, A G; Bhatt, Hardik; Nalawade, Nikhil; Mangal, Akshaykumar
Summary: Tuberculosis of the gastrointestinal tract (GIT) occurs as a primary lesion or secondary to a focus of tuberculosis elsewhere in the body, most commonly in the lungs. Tuberculosis can affect any part of the GIT from the oesophagus to the anal canal. Two main types are – the tuberculous ulcer and the rarer hypertrophic type which is generally found at the ileocecal junction, less commonly in the colon or rectum. Tuberculosis of bowel distal to ileocecal junction is rare and is seldom considered as a differential diagnosis of rectal stricture (2%).1,6 We report a case of rectal tuberculosis presenting with rectal prolapse and masquerading as malignancy, clinically, radiologically as well as on colonoscopy. The diagnosis was confirmed by repeated histopathological examination. The patient underwent definitive surgery along with anti-tuberculous therapy.
Cryptococcal meningitis associated with tuberculosis in HIV infected patients.
(2013-07) Singh, Urvinderpal; Aditi; Aneja, Pooja; Kapoor, B K; Singh, S P; Purewal, Sukhpreet Singh
Summary: Opportunistic infections are common complications of advanced immuno-deficiency in individuals with Human Immunodeficiency Virus (HIV) infection. Following involvement of the lung, the central nervous system (CNS) is the second most commonly affected organ. We report two cases of concurrent cryptococcal meningitis and tuberculosis (TB) in HIV infected persons. A high suspicion of multiple opportunistic infections should be kept in mind in HIV seropositive individuals.
Post-operative sinus formation due to Mycobacterium abscessus: A case report.
(2013-07) Haider, Mehvash; Banerjee, Priyanka; Jaggi, Tavleen; Husain, Jasmin; Mishra, Bibhabati; Thakur, Archana; Dogra, Vineeta; Loomba, Poonam
Summary: Mycobacterium abscessus is ubiquitously found rapidly growing mycobacteria. Although it is an uncommon pathogen, it has been known to cause cutaneous infection following inoculation, minor trauma or surgery. This communication reports an immuno-competent patient developing multiple sinuses due to Mycobacterium abscessus in the post- operative period.
Trends in the prevalence of Pulmonary Tuberculosis over a period of seven and half years in a rural community in south India with DOTS.
(2013-07) Kolappan, C; Subramani, R; Radhakrishna, S; Santha, T; Wares, F; Baskaran, D; Selvakumar, N; Narayanan, P R; Adult
Setting: Tiruvallur district In Tamil Nadu where DOTS was implemented by the State Government as the tuberculosis control measure in 1999, and monitored by the National Institute for Research in Tuberculosis for over five years. Objective: To estimate trends in TB prevalence in a rural community with DOTS. Design: Surveys of pulmonary tuberculosis were undertaken in representative samples of subjects aged >15 years (N = 83,000 – 92,000), initially and after two and half, five and seven and half years of implementation of DOTS. Sputa were collected from those with abnormal radiograph and/or presence of chest symptoms, and examined by direct smear and culture. Results: The prevalence of culture-positive tuberculosis was 607, 454, 309 and 388 per 100,000 in the four surveys, and that of smear-positive tuberculosis was 326, 259, 168 and 180. In the first five years; annual decrease was 12.4% (95% CI 10.4 - 14.4%) for culture-positive tuberculosis, and 12.2% (95% CI 8.0–16.2) for smear-positive tuberculosis. This was, however, followed by a significant increase in the next two and half years. The average new smear-positive case-notification rate was 75 per 100,000 during first four years but declined to 49 in subsequent years. There were no methodological differences during this period and information on changes in socio-economic indicators and nutritional standards was unavailable. Conclusion: Despite the average annual success rate (78%) in this tuberculosis unit being lower than the expected rate of 85%, the implementation of DOTS was followed by a substantial decrease in the prevalence of pulmonary tuberculosis over the seven and half year period. Our findings suggest that sustaining the high effectiveness of DOTS programme needs vigilant supervision.
Psychosocial trauma of diagnosis: A qualitative study on rural TB patients' experiences in Nalgonda district, Andhra Pradesh.
(2013-07) Venkatraju, B; Prasad, Sheela
Background: The current tuberculosis (TB) control strategy in India largely ignores psychosocial needs of the patients. The present study was prompted by the recognition that, if TB treatment is to be culturally sensitive and effective, the psychosocial problems and issues need to be recognized and addressed. Aims: The main aim of this study was to explore psychosocial problems and issues among rural patients being diagnosed with TB. Methods: 110 respondents who had known about their TB diagnosis less than two months prior to conducting the interviews were recruited purposively from two selected rural TB units at Yadagirigutta and Chintapally in Nalgonda district in Andhra Pradesh (A.P.). Semi-structured interview schedule was used for the collection of primary data. A qualitative content analysis method was employed to analyze and interpret the data. Data analysis was carried out following multi-step procedure that consisted of data reduction, coding and identification of dominant themes. Results: The diagnosis of TB was generally seen as a shocking and demoralizing experience, and raised a host of social and psychological problems among the patients. Six prominent themes emerged from the in-depth interviews with the respondents: i) worry, ii) disbelief, iii) embarrassment, iv) fear of death, v) fate, and vi) relief. Conclusion: Effective care for TB requires a much broader approach beyond focusing on anti-tuberculosis drugs and diagnostic techniques. For medical care to be most effective and acceptable to patients, general practitioners should treat both illness and disease in their patients at the same time. Knowledge of the nature of psychosocial problems is crucial for the design of new approaches and methods to improve the quality of life of TB patients.
Initial drug resistance pattern among Pulmonary Tuberculosis patients.
(2013-07) Gupta, Harshita; Kant, Surya; Jain, Amita; Natu, S M; Ahluwalia, Savita
Background: Drug resistant tuberculosis (DRTB) is an emerging problem that adversely affects treatment outcomes and public health in the developing world. Objective: To determine the initial drug resistance pattern among pulmonary tuberculosis patients registered under the Revised National Tuberculosis Control Programme. Study Design: A cross-sectional study design. Setting: Two urban Directly Observed Treatment Supervised (DOTS) centres in Lucknow District of Uttar Pradesh. Methods: The present study consisted of newly diagnosed sputum smear-positive for acid-fast bacilli (AFB) cases at the time of registration under the tuberculosis control programme. All sputum smear positive cases were subjected to culture and drug-susceptibility testing by 1% proportion method on Lowenstein-Jensen (LJ) medium. Results: A total of 185 newly diagnosed sputum smear positive for AFB in pulmonary tuberculosis patients were subjected to culture and drug sensitivity test. Among 185 isolates, 170 (91.4%) isolates were culture positive. Of these 170 isolates, 169 (99.4%) were M. tuberculosis and one (0.5%) was Mycobacterium other than tuberculosis (MOTT). Out of 99.4% M. tuberculosis positive isolates, 21.3% were resistant to at least one drug. Resistance pattern of 21.3% strains of M. tuberculosis showing resistance to single, double, triple, and quadruple drugs were 5.9%, 10.7%, 2.4% and 2.4% respectively. Multi-drug resistance (MDR) was observed in 4.7% isolates. Conclusion: The present study highlights the high rate of drug resistance pattern among the new sputum smear positive pulmonary tuberculosis patients and also high MDR tuberculosis. Routine surveillance of drug resistance profile of patients provides useful information for adopting new strategies of effective treatment within National Tuberculosis Control Programmes in order to combat the threat of MDR-TB in the general population.
Heat fixed but unstained slide smears are infectious to laboratory staff.
(2013-07) Kumar, Parveen; Rufai, Syed Beenish; Singh, Sarman
Background and Aim: In a clinical microbiology laboratory, heat fixed slide smears are commonly transported from one place to another for staining with different stains and also for onsite proficiency testing of laboratory technicians for accreditation of the laboratories. These smears are frequently handled without gloves by the staff in developing countries. Therefore, this study was conducted to check the survivability of tubercle bacilli on smears after physical and chemical treatments. Methods: A total of 196 AFB positive smears were analyzed. Of these, 116 were stained with Ziehl Neelsen (ZN), 60 with cold Kinyoun and 10 were unstained but heat fixed and 10 were neither stained nor heat fixed. The last 20 smears served as controls. The ZN and Kinyoun stained smears were 0-1.5-year-old and stored at room temperature in slide boxes, while control smears were freshly prepared. All smears were prepared from sputum samples positive for acid fast bacilli. All four sets were subjected to slide culture to see if mycobacteria could survive and grow in any. For slide culture, a new and safe device was used, which is designed for three in one purpose: cell cultivation, direct observation of the growth under microscope and cell harvesting inside the closed tube. The slide smears were directly dipped into this tube that contained liquid culture medium. The tubes were incubated at 370C for four weeks. The growth, if any, was confirmed by MPT-64 rapid test and subculture on LJ slants. Results: No growth was observed in ZN and Kinyoun stained slide smears. However, significant growth was observed in both control sets; the unstained non heat fixed as well as heat fixed slide smears. Conclusions: The results of our study indicate that tubercle bacilli remain viable even after heat fixation and carry risk of infection by contact. However, stained smears are safe for handling and storage.
ELISA protocol for rapid screening of potential antitubercular drugs based on antigenic reactivity of mycobacterial ES-31 serine protease - a drug target supported by axenic culture of Mycobacterium tuberculosis H37 Ra strain in the presence of inhibitor.
(2013-07) Hutke, Vinita; Wankhade, Gauri; Waghmare, Pranita J; Harinath, B C
Background: Mycobacterial ES-31 serine protease has been reported to be a drug target using protease and lipase inhibitors in axenic and macrophage cultures. Simple screening techniques are needed for rapid testing of anti-tubercular drugs. Aim: To demonstrate the usefulness of ELISA protocol based on antigenic reactivity of mycobacterial serine protease by indirect ELISA for detecting anti-tubercular activity. Material and Methods: Indirect ELISA for assessment of antigenic reactivity of mycobacterial ES-31 serine protease was standardized using ES-31Ag and anti-DSS-goat-serum and assessed the inhibition of the antigenic reactivity by isoniazid, an anti-tubercular drug and serine protease inhibitor and orlistat, a lipase inhibitor. Results: Optimal antigenic reactivity of mycobacterial ES-31 serine protease was observed at 5μg/well of ES-31 antigen and at 1:25 dilution of anti-DSS-goat-serum. Isoniazid showed 42% inhibition of ES-31 serine protease at 0.4μg/well, while orlistat showed inhibition of 60% at 0.5μg/well. Inhibition of Mtb H37Ra bacilli is further confirmed in axenic culture. 35% and 29% inhibition by isoniazid at 0.4μg/well and orlistat at 0.5μg/well were observed respectively on bacterial growth. Conclusion: Simple ELISA protocol based on assay of antigenic reactivity of mycobacterial ES-31 serine protease, a drug target, has been standardized for rapid screening of potential anti-tubercular drugs.
Bio-safety precautions in tuberculosis laboratory.
(2013-07) Singh, Sarman
Tuberculosis of the Duodenum: Clinical presentation, diagnosis and outcome.
(2013-04) Puri, Amarender S; Sachdeval, Sanjeev; Banlml, Ameet; Sakhuja, Puja
Buck&round: Duodenal tuberculosis accounts for <2% of abdominal tuberculosis and usually manifests with recurrent vomiting. Existing guidelines suggest surgery as the mainstay for both obtaining a definitive diagnosis as well as for therapy. Aims: The aim of this prospective study was to describe the clinical presentation and usefulness of endoscopic techniques in the diagnosis and treatment of duodenal tuberculosis. Methods: Data of patients diagnosed to have duodenal tuberculosis over a three-year-period were analysed for age, presenting symptoms and outcome of therapy. Diagnosis was based on histological evidence of granulomatous inflammation along with unequivocal improvement in vomiting and other symptoms over six-eight weeks following a combination of anti-tubercular drug therapy and endoscopic balloon dilatation. Results: Ten patients with recurrent vomiting (median age 27 years) were diagnosed to have duodenal tuberculosis. Significant narrowing was seen at endoscopy in nine patients with post bulbar area being the commonest site in five patients. Histological diagnosis of granulomatous duodenitis was possible in nine (90%) patients. Balloon dilatation achieved resumption of normal diet at a median duration of seven days (range 2-40). Symptomatic improvement was substantiated by a median increase in BMI of 5 kg/m2 over the baseline value. Surgical intervention was not required in any patient. Conclusions : Recurrent vomiting due to gastric outlet obstruction is the commonest presentation of duodenal tuberculosis. Endoscopically, a histological diagnosis of granulomatous inflammation can be achieved in most of the patients. Endoscopic balloon dilatation coupled with anti-tubercular drug therapy is safe and effective treatment for this uncommon disease.

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