Non Tubercular Mycobacterial Infection as a Cause of Non Resolving Aspiration Pneumonia in a Case of Achalasia Cardia: A Case Report

Abstract

Achalasia is an oesophageal motor disorder characterised by the absence of peristalsis and swallowing difficulties, which results in poor clearance of the oesophagus. The Lower oesophageal Sphincter (LES) fails to relax, either partially or completely, with elevated pressures demonstrated monometrically. Hereby, the authors present an interesting case of a 38-year-old male who presented to a tertiary care hospital with high-grade fever, difficulty in breathing, chronic cough with whitish-yellowish sputum, and generalised weakness for one month. He had made multiple hospital visits for similar complaints and was treated as a case of aspiration pneumonia. Upon admission, he was febrile but otherwise had stable vital signs. Initial investigations revealed bilateral inhomogeneous opacities on chest radiography, a total leukocyte count of 25,000/mm3, and haemoglobin of 7 gm%. He was started on empirical antibiotics and antipyretics, and due to difficulty swallowing, a nasogastric tube was inserted under fluoroscopic guidance. High-Resolution Computed Tomography (HRCT) showed a dilated thoracic oesophagus with mild tracheal and Superior Vena Cava (SVC) compression, bilateral mass-like consolidation, and an air-fluid level, raising suspicions of malignancy or lung abscess. Upper gastrointestinal endoscopy revealed a dilated, tortuous oesophagus with white plaques. A 2D echocardiography showed an ejection fraction of 60% with moderate pulmonary arterial hypertension. Despite initial antibiotic therapy reducing the leukocyte count, his cough and fever persisted. Fiber optic bronchoscopy indicated mild tracheal compression and bilateral mucosal congestion, and a transbronchial lung biopsy was performed. Bronchoalveolar Lavage (BAL) samples tested negative for the Cartridge-based Nucleic Acid Amplification Test (CBNAAT) but showed acid-fast bacilli on Gram and Ziehl-Neelsen (ZN) staining. Repeated sputum samples and CBNAAT tests revealed similar results, confirming the presence of Non Tubercular Mycobacteria (NTM), and appropriate treatment was started. The patient gradually improved, with a reduction in fever spikes over a month. He later underwent laparoscopic Heller’s cardiomyotomy with Dor’s fundoplication, the treatment of choice for achalasia cardia. Currently, patient has completed nine months of treatment for NTM with visible clinical and radiographic improvement.

Keywords

• bronchoalveolar lavage
• consolidation
• dysphagia
• oesophagitis
• mediastinal disease