Another perspective of the dysphagia due to tuberculosis

We read with interest the article of Rathinam et al. [1]. Tuberculosis was central to the development of the om /ejcts/articlect/32/1/184/451334 by gest on 19 April 2019 specialty of thoracic surgery, [2] and it is unfortunate that complications of this disease are almost completely forgotten in themodern literature. We commend the authors for calling attention to a symptom of tuberculosis that is relatively rare, yet carries important consequences. We are writing to underscore the paper as well as to broaden the professional horizon by drawing attention to the importance of this disease and symptom throughout history. The tuberculotic patient can suffer from swallowing problems starting from the pharynx all down to the lower esophageal sphincter — dysmotility due to peritonitis tuberculosa, for instance. Mediastinal (nodal) involvement is really the most plausible cause. Literature provides us with an early description of a patient suffering from dysphagia due to tuberculosis, although the source is outside the usual medical sources [3]. The patient is Joachim, cousin of the main character, Hans Castorp in Thomas Mann’s novel Magic Mountain (Der Zauberberg). No one who reads this book will fail to list tuberculosis among possible causes of dysphagia. Thomas Mann, who was himself a thoracic surgical patient, having undergone a bilobectomy [4] — gives a brilliant description of the terminal incapacity of swallowing. Although one might initially suspect recurrent nerve palsy from tuberculous mediastinal node involvement as the cause for the hoarseness, in this case, the diagnosis is laryngeal tuberculosis. The patient suffers from increasing hoarseness, aspiration, debilitation and finally succumbs. A broad base of knowledge is important, and the case series reported by Rathinam is a good example. Thomas Mann reminds us that even unusual sources like the humanities can also be useful.