Bronchoscopic assessment of the evolution of endobronchial tuberculosis

A Rare Case of Fatal Endobronchial Mucormycosis Masquerading as Endobronchial Tuberculosis

Pulmonary mucormycosis is a relatively rare but often fatal opportunistic fungal infection that occurs mostly in immunocompromised patients. Endobronchial mucormycosis, a distinct clinical form of pulmonary mucormycosis, is very rare, and only a few cases have been reported. The most common bronchoscopic findings in patients with endobronchial mucormycosis are stenosis, erythematous mucosa and airway obstruction. Here, we present a case of fatal endobronchial mucormycosis mimicking actively caseating endobronchial tuberculosis in a young diabetic patient living in a country with an intermediate tuberculosis burden.

Hilar asymmetry in endobronchial tuberculosis patients: An often-overlooked clue

BACKGROUND

Endobronchial tuberculosis (EBTB) is a challenging diagnosis because of its varied clinical and radiological manifestations. Hilar asymmetry on chest radiograph (CXR) may be found in patient with EBTB but is often overlooked, which may lead to delayed diagnosis.

CASE REPORT

We present five cases with EBTB. Clinicians failed to identify unilateral hilar abnormalities on CXR, and these patients were treated initially for pharyngitis, bronchitis, or pneumonia with no improvement. Subsequently, they visited the pulmonary clinic and bronchoscopy revealed endobronchial lesions and microbial/histopathological evidence of tuberculous infection consistent with EBTB. Anti-tuberculosis therapy resulted in complete clinical resolution in four of the five patients; one patient had persistent bronchial stenosis.

CONCLUSION

Hilar asymmetry on CXR may occur with EBTB and may suggest this diagnosis in the appropriate clinical setting. Bronchoscopy has an important role in establishing the final diagnosis.

Pleural effusion resulting from bronchial tuberculosis: A case report

RATIONALE

The clinical manifestations in patients with bronchial tuberculosis (BTB) are nonspecific and may pose a great diagnostic challenge.

PATIENT CONCERNS

Here we describe the case of a 57-year-old man presented with right chest pain, chest tightness, and discomfort for 2 days.

DIAGNOSIS

Bronchoscopic biopsy was performed which revealed subepithelial and epithelioid cell granuloma of Langerhans cell structure. The definitive diagnosis was BTB with pleural effusion.

INTERVENTIONS

Treatment with a quadruple combinational antituberculous therapy was initiated.

OUTCOMES

Two months later, the patient's chest distress and discomfort significantly decreased. Repeat chest radiograph revealed that the pleural fluid had been absorbed. The patient recovered after 15 months of antituberculosis treatment.

LESSONS

The patient exemplifies the difficulty of diagnosing BTB, particularly the low reliability of imaging modalities. The diagnosis of BTB currently relies on bronchoscopy as well as bacteriological or pathological evidence. This report will help to lower the incidences of misdiagnosis of this disease.

A Tuberculosis-associated Endobronchial Polyp That Was Negative for Acid-fast Bacillus

The author reports the case of a patient with a tuberculosis-associated endobronchial inflammatory polyp. Acid-fast bacillus (AFB) staining and culturing of sputum and bronchial washing fluid specimens were negative on three occasions. Biopsy results twice showed chronic inflammation. The patient was finally diagnosed with Mycobacterium tuberculosis based on a polymerase chain reaction (PCR) of a biopsy tissue specimen, along with the finding of chronic granulomatous inflammation. The author herein reports a rare case of a tuberculosis-associated endobronchial inflammatory polyp that was AFB smear- and culture-negative and the patient's clinical course after treatment.

Bronchoplasty for treating the whole lung atelectasis caused by endobronchial tuberculosis in main bronchus

Background

Patients with the whole lung atelectasis caused by endobronchial tuberculosis (EBTB) in main bronchus usually undergo pneumonectomy, which may result in a large number of complications and poor quality of life. In the study, we summarized our experience with bronchoplasty treatment for the whole lung atelectasis caused by EBTB in main bronchus, in which long-term medical therapy failed.

Methods

Eight patients with whole lung atelectasis, who suffered from EBTB in main bronchus, were treated by bronchoplasty: 3 patients were treated by bronchoplasty for the left main bronchus; 2 patients were treated by sleeve resection of right upper and middle lobes; and 3 patients were treated by sleeve resection of left upper lobe. The patients were followed up for a period of time.

Results

All the patients were cured by surgery, were discharged from hospital uneventfully, had anastomotic patency and good lung expansion. Neither bronchopleural fistula nor recurrence was observed.

Conclusions

Bronchoplasty is an effective treatment for atelectasis of the whole lung caused by EBTB in the main bronchus, in which long-term medical therapy failed. Prognosis was favorable.

Endobronchial anthracofibrosis: possibly a new indication of aggressive treatment for active endobronchial tuberculosis

Anthracofibrosis, which was defined as a luminal narrowing associated with overlying anthracotic mucosa on bronchoscopy, has been infrequently reported. Recently, we have identified a case of patient who had a history of pulmonary tuberculosis (TB), manifested left main bronchial stenosis and hyperpigmentation. Despite repeated and multiple cryotherapy, the condition was still progressing. Given to the potential relationship between active endobronchial tuberculosis (EBTB) and anthracofibrosis, the patient received a diagnostic anti-tuberculosis (anti-TB) treatment due to initial failed cryotherapy, resulting in improvement of hyperpigmentation and stenosis of the left main bronchus. Eventually, the patient recovered well with regular anti-TB combined with intermittent cryotherapy. Our study suggests that even without etiological evidence, there might be an indication of therapeutic trial of anti-TB medication in case of repeated bronchial stenosis due to anthracofibrosis in patients with past history of TB and other causes are excluded. Yet, the recommendation of aggressive treatment should reply on the effect of diagnostic treatment and further research.

GeneXpert MTB/RIF for rapid diagnosis and rifampin resistance detection of endobronchial tuberculosis

BACKGROUND AND OBJECTIVE

Delayed diagnosis and treatment of tuberculosis (TB) contribute to poor outcomes, especially for endobronchial TB (EBTB), which typically leads to tracheobronchial stenosis. Finding rapid and accurate diagnostic tools for EBTB is crucial. GeneXpert Mycobacterium tuberculosis (MTB)/rifampin (RIF) was recommended by the World Health Organization (WHO) as a standard molecular biological diagnostic technique for MTB. The aim of this study was to evaluate the efficacy of GeneXpert MTB/RIF for diagnosing EBTB and for evaluating RIF resistance.

METHODS

Biopsy tissue and bronchial brushings from EBTB patients were prospectively assessed with GeneXpert MTB/RIF. The diagnostic yields of auramine O-stained sputum smears and bronchial brush smears were obtained, and the results were compared with the cultures of sputum and biopsy tissues for MTB.

RESULTS

In 61 confirmed cases of EBTB, the sensitivities of sputum smear, bronchial brush smear, sputum culture and tissue culture to diagnose EBTB were 13.1%, 32.8%, 36.1% and 68.9%, respectively. For bronchial brushings and biopsies, our data showed sensitivities of 57.4% and 63.9%, respectively, and a specificity of 100% for GeneXpert MTB/RIF, and these results were superior to those of sputum smears, bronchial brush smears and sputum culture. GeneXpert MTB/RIF for bronchial brushings and biopsies showed complementarity in its diagnostic performance. Resistance to RIF was identified in 17.4% (8/46) of GeneXpert MTB-positive cases.

CONCLUSION

GeneXpert MTB/RIF may enable more rapid EBTB diagnosis and determination of RIF resistance, which are crucial for timely treatment.

[Surgical Treatment of Bronchial Stricture due to Endobronchial Tuberculosis: Results in 36 Consecutive Cases]

背景与目的

支气管结核是肺结核常见的并发症，本研究目的是探讨支气管结核的临床特点，手术指征及总结外科治疗经验。

方法

对36例诊断明确且造成支气管狭窄或肺不张的支气管结核患者，给予药物及内镜腔内治疗无效而进行外科治疗，术前规律抗结核治疗6个月以上，术后继续抗结核治疗9个月-12个月。其中全肺切除8例，肺叶切除23例，袖状肺叶切除5例。

结果

36例患者均治愈，无手术死亡，6例患者术后出现并发症，给与对应治疗痊愈出院，无支气管胸膜瘘及结核播散。随访1年以上无复发。

结论

对于药物及内镜治疗无效，伴有肺内不可逆病变的支气管结核患者应考虑积极手术。

[Tuberculous pseudotumour, a challenging diagnosis]

INTRODUCTION

The pseudotumorous form of tuberculosis is a rare entity. Whatever its location, it can simulate neoplasia by its radiological and/or endoscopic appearances. We highlight the diagnostic difficulties associated with this type of presentation.

METHODS

We performed a retrospective study of inpatient records from 2003 to 2016 in the pneumology department of La Rabta Hospital to identify cases of thoracic tuberculous pseudo-tumor.

RESULTS

Seventeen patients were identified. The median age was 41 years and their symptomatology was dominated by cough and general debility. All had abnormal radiology with 10 cases of suspect lesions. Fibre-optic bronchoscopy revealed endobronchial abnormalities in 11 cases. The median overall diagnostic delay was 97 days. The diagnosis was confirmed bacteriologically in five cases, histologically in 14 cases and based on clinical presumption in one case. The progression was favourable: 13 patients have been declared cured and four patients are still undergoing treatment.

CONCLUSION

Making a positive diagnosis of thoracic tuberculous pseudotumour can be difficult, as bacteriological samples are often negative. This can lead to a significant delay in diagnosis and treatment.

A Survey of Anxiety and Depressive Symptoms in Pulmonary Tuberculosis Patients With and Without Tracheobronchial Tuberculosis

Background and Objective: Anxiety/depression and tuberculosis are global public health problems. The incidence of psychiatric morbidities is high among tuberculosis patients. However, little is known about the prevalence of anxiety and depression among Chinese pulmonary tuberculosis (PTB) patients, especially those with tracheobronchial tuberculosis (TBTB). The goal of the present study was to explore the prevalence of and associated factors of anxiety and depressive symptoms among PTB patients with and without TBTB. Methods: A cross-sectional survey of PTB patients from three hospitals in Liaoning, China, was conducted using a structured questionnaire. Depression and anxiety were evaluated by using the Hospital Anxiety and Depression Scale (HADS) and the Patient Health Questionnaire-9 (PHQ-9). Results: According to HADS and PHQ-9, 17.73 and 18.13% of 1252 PTB patients, respectively, had significant depressive symptoms and based on HADS scale, 18.37% had significant anxiety symptoms. Approximately 70% of patients with probable depression also had significant anxiety symptoms, and vice versa, and 69.6% patients with anxiety symptoms were also diagnosed with probable depression in our study population. Dyspnea and TBTB were significantly associated with depressive symptoms. Other depressive symptoms-related factors included age, divorce, abnormal body mass index (BMI), and low income. Patients with lower incomes, symptoms of dyspnea, or a combination of ≥3 clinical symptoms had an increased risk of anxiety symptoms, while patients with occasional or frequent alcohol consumption had a reduced risk of anxiety symptoms. Conclusion: Depressive and anxiety symptoms are common among PTB patients, especially those with TBTB. Screening for depression and anxiety is essential for identifying patients who require further psychosocial assessment and support.

Characteristics and clinical role of bronchoscopy in diagnosis of childhood endobronchial tuberculosis

BACKGROUND

Endobronchial tuberculosis (EBTB) is the most frequent complication of primary pulmonary tuberculosis (PTB) in children. The aim of the study was to analyze characteristics and clinical role of bronchoscopy in diagnosis of childhood EBTB.

METHODS

A retrospective, descriptive study was undertaken in 157 children with EBTB undergone flexible bronchoscopy (FB) between January 2006 and June 2014.

RESULTS

The median age of the enrolled patients was 3.4 years, with 73.2% of patients under five years old. The most common subtype was tumorous type (145/157, 92.4%). If only involved bronchus were considered, the common affected sites were right middle lobe bronchus (49/228, 21.5%), left upper lobe bronchus (41/228, 18.0%), right upper lobe bronchus (41/228, 18.0%), right main bronchus (35/228, 15.4%), respectively. Children younger than five years old were at higher risk to have multiple endobronchial lesions (P=0.044), with an odds ratio of 2.313 (95% confidence interval: 1.009-5.299). Before the bronchoscopy, only 16 (10.2%) patients were highly suspected of EBTB, while the others were diagnosed as PTB without EBTB (69.4%), or misdiagnosed as pneumonia or foreign body aspiration (20.4%) on admission.

CONCLUSIONS

The patients under five years old are at high risk to progress to EBTB and have multiple endobronchial lesions. The most frequent subtype of EBTB in children is tumorous type. The lesions are seen in the right bronchial system more frequently. FB should be performed to detect the endobronchial lesions in suspected patients as soon as possible.

Bronchoscopic techniques in the management of patients with tuberculosis

Tuberculosis (TB) is one of the leading causes of morbidity and mortality worldwide. Early diagnosis and treatment are key to prevent Mycobacterium tuberculosis transmission. Bronchoscopy can play a primary role in pulmonary TB diagnosis, particularly for suspected patients with scarce sputum or sputum smear negativity, and with endobronchial disease. Bronchoscopic needle aspiration techniques are accurate and safe means adopted to investigate hilar and mediastinal lymph nodes in cases of suspected TB lymphadenopathy. Tracheobronchial stenosis represents the worst complication of endobronchial tuberculosis. Bronchoscopic procedures are less invasive therapeutic strategies than conventional surgery to be adopted in the management of TB-related stenosis. We conducted a non-systematic review aimed at describing the scientific literature on the role of bronchoscopic techniques in the diagnosis and therapy of patients with TB. We focused on three main areas of interventions: bronchoscopic diagnosis of smear negative/sputum scarce TB patients, endobronchial TB diagnosis and treatment and needle aspiration techniques for intrathoracic TB lymphadenopathy. We described experiences on bronchoalveolar lavage, bronchial washing, and biopsy techniques for the diagnosis of patients with tracheobronchial and pulmonary TB; furthermore, we described the role played by conventional and ultrasound-guided transbronchial needle aspiration in the diagnosis of suspected hilar and mediastinal TB adenopathy. Finally, we assessed the role of the bronchoscopic therapy in the treatment of endobronchial TB and its complications, focusing on dilation techniques (such as balloon dilation and airway stenting) and ablative procedures (both heat and cold therapies).

Update on childhood and adult infectious tracheitis

The trachea is a pivotal organ of the respiratory tract. Rather than a genuine anatomic border, it acts as a crossroad in all respiratory infectious processes. Even though not strictly limited to the trachea, infections such as laryngotracheitis and tracheobronchitis are frequently diagnosed in children, in particular during the winter season. Infectious tracheitis etiologies are diverse and the distinction between viral and bacterial origins, albeit difficult, remains relevant considering the substantial differences in terms of gravity and therapeutic management. This literature review summarizes the microbiological and clinical aspects of community-acquired and nosocomial tracheitis in adults and children, as well as the adequate diagnostic and therapeutic approaches. It also highlights the emergence of fungal tracheitis in immunocompromised patients, of ventilator-associated tracheitis in intensive care medicine, and beyond all that the potential short and long-term consequences of tracheitis.

A bronchoscopic approach to benign subglottic stenosis

Objectives:

Subglottic stenosis is an abnormal narrowing of the tracheal lumen at the level of subglottis (the area in between the vocal cords and the cricoid cartilage). It can cause significant symptoms due to severe attenuation of airflow. We describe our experience in alleviating symptoms by addressing the stenosis using fibreoptic bronchoscopic methods.

Methods:

We report all concurrent cases performed between September 2015 and July 2016. We use a combination of balloon dilation, electro-surgery knife to dilate and incise stenotic segments followed by steroid injection to modulate healing.

Results:

We treated 10 patients in the study period, 8 of which were women. A total of 39 procedures were performed on these patients during this period. Gastro-esophageal reflux was the most common comorbidity associated with stenosis. The majority of the patients required more than 2 therapeutic procedures, but none required more than 4 procedures. There were no complications.

Conclusion:

Tracheal stenosis and in particular subglottic stenosis is a recurrent process and its management requires extensive collaboration amongst treating specialties. Our technique of steroid injection after dilation of the stenosis was effective in symptom control and decreased the number of repeat procedures.

Bronchoscopic diagnostic procedures and microbiological examinations in proving endobronchial tuberculosis

Objective:

To determine the proportional distribution of endobronchial tuberculosis (EBTB) subtypes and to evaluate the types of bronchoscopic diagnostic procedures that can prove granulomatous inflammation.

Methods:

This was a retrospective study of 18 HIV-negative patients with biopsy-proven EBTB treated between 2010 and 2014.

Results:

The most common EBTB subtypes, as classified by the bronchoscopic features, were tumorous and granular (in 22.2% for both). Sputum smear microscopy was performed in 11 patients and was positive for AFB in 4 (36.3%). Sputum culture was also performed in 11 patients and was positive for Mycobacterium tuberculosis in 10 (90.9%). Smear microscopy of BAL fluid (BALF) was performed in 16 patients and was positive for AFB in 10 (62.5%). Culture of BALF was also performed in 16 patients and was positive for M. tuberculosis in 15 (93.7%). Culture of BALF was positive for M. tuberculosis in 93.7% of the 16 patients tested. Among the 18 patients with EBTB, granulomatous inflammation was proven by the following bronchoscopic diagnostic procedures: bronchial mucosal biopsy, in 8 (44.4%); bronchial brushing, in 7 (38.8%); fine-needle aspiration biopsy, in 2 (11.1%); and BAL, in 2 (11.1%). Bronchial anthracofibrosis was observed in 5 (27.7%) of the 18 cases evaluated.

Conclusions:

In our sample of EBTB patients, the most common subtypes were the tumorous and granular subtypes. We recommend that sputum samples and BALF samples be evaluated by smear microscopy for AFB and by culture for M. tuberculosis, which could increase the rates of early diagnosis of EBTB. We also recommend that bronchial brushing be employed together with other bronchoscopic diagnostic procedures in patients suspected of having EBTB.

[Endobronchial tuberculosis]

BACKGROUND/AIM

The endobronchial tuberculosis (EBTB) is an uncommon type of tuberculosis. The respiratory symptoms in EBTB are usually nonspecific and misleading. The aim of the study is to determine the clinical features and diagnostic aspects of EBTB.

PATIENTS AND METHODS

Twenty-eight cases of endobronchial tuberculosis collected from January 2009 to October 2015.

RESULTS

EBTB was found in 16 females and 12 males. The mean age was 48 years. The history of tuberculosis and tuberculosis contagion were not found in any case. The respiratory symptoms were dominated by cough and dyspnea. Hemoptysis was found in 7 cases. The chest X-ray showed associated pulmonary lesions in 26 cases. Bronchoscopy finded an endobronchial granular lesion in 15 cases, a tumorous pattern in 7 cases; a thickening spurs in 4 cases and ganglio-bronchial fistula in two cases. Bronchial biopsies had found a caseo-follicular tuberculosis in 27 cases. Pleural biopsy confirmed associated pleural tuberculosis in one case. The research of Koch bacillus in the sputum was positive in 13 cases and culture in 6 cases. The antituberculosis treatment was started in all patients and an oral corticosteroids treatment was associated in 5 cases. The evolution was good in 26 cases.

CONCLUSION

This study showed clinical, radiological and endoscopic bronchial tuberculosis polymorphism making its diagnosis difficult and the importance of a bacteriological and/or histological confirmation.

Tracheobronchial tuberculosis: a clinical review

Endobronchial tuberculosis (EBTB) is defined as tuberculous infection of the tracheobronchial tree. The exact pathogenesis is unclear, and it has a heterogenous clinical course. Its diagnosis requires the clinician to have a high index of suspicion based on clinical symptoms and radiological features. Computed tomography and bronchoscopy are useful tools in its evaluation. The goal of treatment is in the eradication of tuberculous bacilli with appropriate anti-tuberculous therapy. Use of corticosteroids is controversial for the prevention of tracheobronchial stenosis. Interventional bronchoscopy or surgical intervention is employed to restore airway patency once significant stenosis occurs.

The concomitant occurrence of pulmonary tuberculosis with bronchial anthracofibrosis

BACKGROUND

Bronchial anthracofibrosis (BAF), diagnosed bronchoscopically, is a clinical entity which is now beginning to emerge from obscurity. This is commonly encountered in elderly females with history of long-standing exposure to biomass fuel smoke in poorly ventilated kitchens. As awareness of BAF has increased in recent times, distinct clinicoradiological and bronchoscopic features of the disease have emerged. Diagnosis is achieved by visualisation of bluish-black mucosal hyperpigmentation along with narrowing/distortion of the affected bronchus on fibreoptic bronchoscopy (FOB). BAF was first recognised nearly a decade ago in India, when a 65-year-old female who presented with a middle lobe syndrome (MLS) was diagnosed with concomitant pulmonary tuberculosis and BAF. Pulmonary tuberculosis, seen in up to one-third of patients with BAF, is now considered to be an associated condition rather than a causative agent, as was initially postulated.

METHODS

Respiratory symptomatics with a history of biomass fuel smoke exposure underwent high-resolution computed tomography (HRCT) of chest as well as FOB to establish a diagnosis of BAF. In patients who were diagnosed with BAF, an association with tuberculosis was also sought for.

RESULTS

Of the 31 patients diagnosed with BAF in one unit, four had an associated diagnosis of tuberculosis. Cough was the most common presenting symptom seen in all four patients. Imaging revealed consolidation in 3/4 subjects, nodular lesions in one and in another one multifocal narrowing on HRCT, a feature characteristic of BAF. One patient had a diagnosis of MLS. FOB, in all four subjects, visualised anthracotic pigmentation along with narrowing/distortion of the affected bronchi with the left upper lobe bronchus being most commonly affected. Stains and cultures of the bronchial aspirate for Mycobacterium tuberculosis were positive in all four patients while GeneXpert performed in three was positive in all. Rifampicin resistance was not detected. One patient had an actively caseating form of endobronchial tuberculosis as evidenced by oedematous, hyperemic mucosa along with whitish cheese-like material affecting the right middle lobe as was seen on FOB.

CONCLUSION

Once a diagnosis of tuberculosis is established in a patient with long-standing exposure to biomass fuel smoke, invasive procedure required for the diagnosis of BAF is usually not considered and the diagnosis would remain confined to pulmonary tuberculosis. This study highlights the need to recognise BAF and to exclude pulmonary tuberculosis in such patients.

Endobronchial tuberculosis-a review

Endobronchial tuberculosis (EBTB) is a tuberculous infection of the tracheobronchial tree with microbial and histopathological evidence. Patients may present with symptoms secondary to disease itself or from the complication of disease like endobronchial obstruction. Diagnosis requires a high index of suspicion. Computed tomography (CT) and bronchoscopy along with microbiological investigations are the most useful diagnostic tools for the confirmation as well as for the evaluation of the tracheobronchial stenosis. The goals of treatment are eradication of tubercle bacilli with anti-tubercular medications and the prevention of airway stenosis. Interventional Bronchoscopic techniques and surgery is required for those patients who develop severe tracheobronchial stenosis that causing significant symptoms including dyspnea, repeated post obstructive pneumonia or bronchiectasis.

Tracheobronchial tuberculosis

Tracheobronchial tuberculosis (TBTB) is reported in approximately 10% to 39% of the patients with pulmonary tuberculosis. It is defined as the tubercle infection of the trachea and or bronchi. Due to its non-specific presentation, insidious onset and normal chest radiography in about 10-20% of the patients, the diagnosis is delayed. Bronchoscopy is the most definite method of diagnosis which provides adequate specimens for microbiological and histopathological diagnosis. Tracheobronchial stenosis is one of the most common long term complications of TBTB resulting in significant morbidity. It is estimated that 90% of patients with TBTB have some degree of tracheal and or bronchial stenosis. In this review article, we will discuss the pathogenesis, symptoms, imaging, bronchoscopic findings, and treatment of TBTB and management of tracheobronchial stenosis.

Tuberculosis exposure, infection and disease in children: a systematic diagnostic approach

The accurate diagnosis of tuberculosis (TB) in children remains challenging. A myriad of common childhood diseases can present with similar symptoms and signs, and differentiating between exposure and infection, as well as infection and disease can be problematic. The paucibacillary nature of childhood TB complicates bacteriological confirmation and specimen collection is difficult. In most instances intrathoracic TB remains a clinical diagnosis. TB infection and disease represent a dynamic continuum from TB exposure with/without infection, to subclinical/incipient disease, to non-severe and severe disease. The clinical spectrum of intrathoracic TB in children is broad, and the classification of clinical, radiological, endoscopic, and laboratory findings into recognized clinical syndromes allows a more refined diagnostic approach in order to minimize both under- and over-diagnosis. Bacteriological confirmation can be improved significantly by collecting multiple, high-quality specimens from the most appropriate source. Mycobacterial testing should include traditional smear microscopy and culture, as well as nucleic acid amplification testing. A systematic approach to the child with recent exposure to TB, or with clinical and radiological findings compatible with this diagnosis, should allow pragmatic classification as TB exposure, infection, or disease to facilitate timely and appropriate management. It is important to also assess risk factors for TB disease progression and to undertake follow-up evaluations to monitor treatment response and ongoing evidence supporting a TB, or alternative, diagnosis.

Surgery and pleuro-pulmonary tuberculosis: a scientific literature review

Tuberculosis (TB) is still a major public health concern, mostly affecting resource-constrained settings and marginalized populations. The fight against the disease is hindered by the growing emergence of drug-resistant forms whose management can be rather challenging. Surgery may play an important role to support diagnosis and treatment of the most complex cases and improve their therapeutic outcome. We conducted a non-systematic review of the literature based on relevant keywords through PubMed database. Papers in English and Russian were included. The search was focused on five main areas of intervention as follows: (I) diagnosis of complicated cases; (II) elimination of contagious persisting cavities, despite appropriate chemotherapy; (III) treatment of destroyed lung; (V) resection of tuberculomas; (VI) treatment of tuberculous pleural empyema. Although specific practical guidelines concerning surgical indications and approaches are currently unavailable, a summary of the evidence emerged from the scientific literature was elaborated to help the clinician in the management of severely compromised TB patients. The decision to proceed to surgery is usually individualized and a careful assessment of the patient's risk profile is always recommended before performing any procedure in addition to appropriate chemotherapy.

Tracheobronchopathia Osteochondroplastica: a rare case report of a non-smoker and non-atopic patient, with a long history of wheezing since childhood

Background

Tracheobronchopathia Osteochondroplastica (TBPO) is an uncommon and benign condition characterized by osseous or metaplastic cartilaginous 1–3 mm nodules in the submucosa of the tracheo-bronchial tree. Posterior membranous wall of trachea is typically spared. Ecchondrosis and exostosis nodules can cause chronic inflammation and mucosal metaplasia, stiffness and airway obstruction. The prevalence of this disease, often asymptomatic or associated with nonspecific symptoms, is underestimated, and the mean age at diagnosis is 50 years.

Case presentation

We report a case of a 49 year old male, non-smoker. He was a smith, homeless, born in Romania and reported a diagnosis of asthma since childhood. He was admitted to our Respiratory Unit presenting low-grade fever with profuse sweating, cough, purulent sputum, and ground-glass opacity with irregularity in main bronchi detected by High-Resolution Computed Tomography (HRCT) scan.

Fibrobronchoscopy revealed the presence of mucosal irregularities up to the segmental bronchi entrance. Histological examination showed nodules of osseouscartilaginous nature, consistent with TBPO. Microbiological tests of Bronchoalveolar Lavage fluid also revealed an infection by Pseudomonas Aeruginosa.

Conclusion

TBPO is a rare disease characterized by wheezing, cough, hemoptysis, and recurrent pulmonary infections, with typical onset during adulthood. In the case reported, the symptoms began in childhood, although they had been misinterpreted as asthma. Even if childhood-onset is not reported in literature, it is likely that small changes occur in the first few years of life and become more evident in adulthood. The involvement of segmental and sub-segmental bronchi, usually spared in TBPO, could explain the presence of wheezing and non-productive cough reported by our patient since childhood.

Mechanical complication of endobronchial tuberculosis

A 19-year-old Vietnamese lady was diagnosed with culture positive, left upper lobe pulmonary tuberculosis for which medical treatment was initiated. Four months into treatment, she developed a 'rubber-band-like' stretching sensation in her left chest with wheezing and shortness of breath. Decreased respiratory excursion over the left lung was present on physical-examination. Chest-Xray revealed left-upper-lobe collapse with leftward deviation of the trachea and mediastinum. CT thorax revealed a long segment of stenosis in the left mainstem bronchus. FEV1 was 1.26 L (45% predicted), FVC 1.53 L (49% predicted), FEV1/FVC 82% (95% predicted) indicating airway limitation. Ventilation-perfusion scan noted 9.8% ventilation to the left lung and 92.8% to the right lung and 7.6% perfusion to the left lung and 92.4% to the right lung. Bronchoscopy was notable for pin point stenosis of the left mainstem bronchus beyond which was inflamed mucosa and abnormal cartilage rings in the left upper and middle lobe bronchi. Nine months of medical therapy for tuberculosis along with oral steroid taper was completed successfully; however the patient has required six serial bronchscopies with dilatations without stent placement at four to six week intervals due to partial restenosis, with the last bronchoscopy at four months after completion of tuberculosis therapy.

Endobronchial tuberculosis mimicking malignancy

Endobronchial tuberculosis has a very varied presentation. Diagnosis is often very challenging as typical radiological features are absent and sputum smear for acid-fast bacilli is often negative. However, detection is essential as it may lead to long-term sequelae such as bronchial stenosis. Bronchoscopy is a very useful investigation in such cases. Our case is a rare manifestation of endobronchial tuberculosis as it mimicked malignancy.

A rare case of fibrostenotic endobronchial tuberculosis of trachea

Endobronchial tuberculosis (EBTB) is a sequelae of pulmonary tuberculosis (TB) that extends to the endobronchial or endotracheal wall causing inflammation, edema, ulceration, granulation or fibrosis of mucosa and submucosa. This case depicts a 20 year old foreign-born woman with a history of active pulmonary TB on anti-TB chemotherapy, who presented with worsening stridor, dyspnea, cough and weight loss. The disease state was diagnosed with multiple modalities including, spirometry, CT scan of the neck, and bronchoscopy. The biopsies of the tracheal web revealed fibrotic tissue without any granulomas or malignancy establishing the diagnosis of EBTB. Serial balloon dilations and anti-neoplastic therapy with Mitomycin C was used to accomplish sufficient airway patency to relieve her symptoms. ETBT is a rare consequence of TB, which although has a low incidence in the United States, so physicians should have a high clinical suspicion based on the need for prompt intervention.

Tuberculous Tracheobronchial Strictures Treated with Balloon Dilation: A Single-Center Experience in 113 Patients during a 17-year Period

PURPOSE

To evaluate the safety and effectiveness of balloon dilation in the treatment of tuberculous tracheobronchial strictures (TTBSs) in a series of 113 patients at a single institution.

MATERIALS AND METHODS

The institutional review board approved the study and waived the requirement to obtain informed consent. Between 1997 and 2014, under bronchoscopic and fluoroscopic guidance, a total of 167 balloon dilation sessions were performed in 113 consecutive patients (14 male and 99 female patients; mean age, 37 years [age range, 17-73 years]), with a range of one to eight sessions per patient (mean, 1.5 sessions). Outcomes were number and/or frequency of balloon dilations, technical success, primary and secondary clinical success, improvement in respiratory status, airway patency rate, and alternative treatment after balloon dilation. A two-tailed paired t test and the Kaplan-Meier method were used to evaluate the improvement in respiratory status and airway patency rate after balloon dilation, respectively.

RESULTS

Dilation was successful in 82 patients (73%) after single (n = 67) or multiple (n = 15) balloon dilations, with a mean follow-up of 30.3 months. Clinical failure occurred in 31 patients (27%). In these 31 patients, symptoms recurred 1 day to 113 months (mean, 13 months) after repeat balloon dilations. These 31 patients required alternative treatment, including temporary stent placement (n = 12), cutting balloon dilation (n = 12), radiation-eluting balloon dilation (n = 3), and surgery (n = 4). Before, immediately after, and 1 month after the procedure, pulmonary function test results showed significant improvements in mean forced vital capacity (P < .001), forced expiratory volume in 1 second (P = .001), forced expiratory flow in the midexpiratory phase (P = .020), and peak expiratory flow (P = .005).

CONCLUSION

Balloon dilation of TTBSs is a safe, minimally invasive primary treatment that relieved symptoms in a large percentage of patients (73%). In patients with TTBSs refractory to balloon dilation, temporary stent placement, cutting balloon dilation, or radiation-eluting balloon dilation can be an alternative treatment.

Multinodule abnormalities of the tracheobronchus: bronchoscopy findings and clinical diagnosis

BACKGROUND AND AIMS

Bronchoscopy is an important method for diagnosing respiratory disease. Multiple tracheobronchial nodules are rarely reported and their causes remain unclear.

OBJECTIVES

The aim of this study was to describe the clinical characteristics of multiple nodule tracheobronchial abnormalities found under bronchoscopy caused by different diseases.

METHODS

Eighty-seven patients with multiple tracheobronchial nodules were enrolled in this study. The characteristics of the multinodule lesions and the patient were diagnosed based on the pathology findings in our hospital. Chest computed tomography images were retrospectively reviewed by pulmonologists and radiologist.

RESULTS

In 55 patients with definite pathological diagnosis, 16 (29%) patients were diagnosed as tuberculosis (TB) granuloma; 23 (41.8%) cases were diagnosed as malignant disease; 12 (21.8%) cases were diagnosed as tracheobronchopathia osteochondroplastica; 2 (3.6%) cases were diagnosed as sarcoidosis; and one case (1.8%) was diagnosed as lymphoma and one case (1.8%) as fungal infection. There were 32 cases of chronic inflammation. There was no relationship between nodule distribution and the pathological diagnosis. Malignant nodules usually smaller with a pale outlook, while nodules with larger size and smooth and intact mucosa usually turn out to be granuloma of unknown reason.

CONCLUSION

The major causes of mutinodule lesions observed using bronchoscopy are tumor and TB. The presence of multiple endotracheobronchial nodules suggest that pulmonary lesion is present, and biopsy should be performed. Malignant nodules can be diagnosed by appearance and biopsy. Pathology results of TB, sarcoidosis and fungal infection can turn out to be granuloma of unknown reason. Further diagnosis needs other clinical materials.

Tracheobronchial Tuberculosis Without Lung Involvement

Endotracheal tuberculosis (ETTB) is an infrequent form of tuberculosis whose major feature is the infection of the tracheobronchial tree by Mycobacterium tuberculosis. This case presents a 73-year-old man admitted to our hospital with fatigue, weakness, dry cough and weight loss. His chest X-ray was normal but the high resolution computed tomography (HRCT) showed normal parenchyma images with mediastinal and hilar lymphadenopathy. There was inflammation of the tracheal wall and infiltrates in pavement epithelium; however, the tracheal biopsy for acid-fast bacilli was negative. He was finally diagnosed by endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) of the lymph nodes. Four drugs were prescribed and symptoms improved. EBUS-TBNA contributed to prompt diagnosis. The patient was treated and evolved without complications, such as tracheal stenosis.

Concurrent central nervous system and endobronchial tuberculosis mimicking a metastatic lung cancer

BACKGROUND AND AIMS

Early diagnosis and treatment of central nervous system tuberculosis are important because of high mortality and morbidity. Airways must be carefully evaluated in differential diagnosis.

METHODS

We present a rare case of intracranial-endobronchial tuberculosis mimicking lung cancer with brain metastasis.

RESULTS

A vegetative mass lesion, confirmed as necrotic granulomatous inflammation, originating from the entrance of the right upper lobe entry, was coagulated and extracted by argon plasma coagulation and cryotherapy to prevent permanent upper lobe atelectasis. Mycobacterium tuberculosis complex was detected in bronchoscopic material. A four-drug initial anti-tuberculous treatment regimen was given in 2 months. The upper lobe atelectasis was resolved at the fourth month of therapy despite upper lobar bronchus patency. The patient was doing well and completed the two-drug maintenance therapy of 7 months with complete resolution.

CONCLUSION

In such cases, tissue diagnosis should be achieved as early as possible and anti-tuberculous treatment was commenced along with advanced interventional techniques.

Endobronchial tuberculosis presented as multiple endobronchial vesicular lesions

Endobronchial tuberculosis (EBTB) is a tuberculous infection of the tracheobronchial tree with microbiological and histopathological evidence, with or without parenchymal involvement. EBTB commonly presents as acute or insidious onset cough, wheeze, low grade fever, and constitutional symptoms. In elderly patients, other differentials like malignancy and pneumonia may lead to misdiagnosis. Hence, bronchoscopy is essential for confirmation of EBTB. Here we report a rare presentation of EBTB in a 65 year old patient who presented with 3 months history of fever and cough and have multiple endobronchial vesicular lesions on bronchoscopy.

Incidence and clinical predictors of endobronchial tuberculosis in patients with pulmonary tuberculosis

BACKGROUND AND OBJECTIVE

Incidence and predictors of endobronchial tuberculosis (EBTB) remain unknown because of the lack of prospective studies. Our objective was to assess the incidence and predictors of concomitant EBTB in patients with active pulmonary tuberculosis (PTB).

METHODS

We prospectively performed routine bronchoscopic examination in all patients with PTB to detect EBTB. Clinical and bronchoscopic findings were analyzed to elucidate predictors of EBTB.

RESULTS

Bronchoscopies of 429 PTB patients were performed at a tertiary referral hospital in Korea. Among those, 233 patients (54.3%) had EBTB. Female gender (odds ratio (OR) 4.35, 95% confidence interval (CI) 1.78-10.63), longer symptom duration (>4 weeks; OR 1.86, 95% CI 1.05-5.46), and no previous history of tuberculosis (OR 4.16, 95% CI 1.22-14.18) were found to be the independent predictors of concomitant EBTB in patients with active PTB. Most of the EBTB/PTB patients had mild stenosis, and more than 20% of them had severe stenosis at the time of diagnosis. Patients with EBTB had follow-up bronchoscopy to evaluate persistent airway stenosis. Persistent bronchostenosis with the lumen narrowed by more than one third occurred in 20.7% (30/145) of patients. The involvement length and decreased forced expiratory volume in 1 s were the risk factors for persistent bronchostenosis.

CONCLUSIONS

In patients with active PTB, 50% or more have EBTB. Female gender and longer duration of symptoms are the main predictors of concomitant EBTB. Immediate diagnostic bronchoscopy in patients with active PTB should be considered in selected patients for detection of brocnhostenosis.

Endobronchial tuberculosis

Endobronchial tuberculosis refers to tuberculous infection of the tracheobronchial tree. Diagnosis requires a high index of suspicion since symptoms are attributed to co-existing pulmonary tuberculosis and airway lesions are not detectable on chest radiograph. While computed tomography and bronchoscopy are useful for the evaluation of tracheobronchial stenosis or obstruction, goals of treatment remain in the eradication of tubercle bacilli and prevention of airway stenosis. Corticosteroids may halt progression of active disease to fibro-stenotic stage, however if tracheobronchial stenosis causing post-obstructive pneumonia, atelectasis and dyspnea has occurred, airway patency must be restored mechanically by surgery or bronchoscopic techniques.

Clinical Aspects of Adult Tuberculosis

Tuberculosis (TB) in adults can present in a large number of ways. The lung is the predominant site of TB. Primary pulmonary TB should be distinguished from postprimary pulmonary TB, which is the most frequent TB manifestation in adults (70%-80% cases). Cough is common, although the chest radiograph often raises suspicion of disease. Sputum sampling is a key step in the diagnosis of TB, and invasive procedures such as bronchoscopy may be necessary to achieve adequate samples for diagnosis. Extrapulmonary involvement, which may present many years after exposure, occurs in a variable proportion of cases (20%-45%). This reflects the country of origin of patients and also the frequency of associated human immunodeficiency virus (HIV) coinfection. In the latter case, the presentation of TB is often nonspecific, and care needs to be taken to not miss the diagnosis. Anti-TB therapy should be given in line with proven (or assumed) drug resistance. In extrapulmonary TB, adjunctive therapeutic measures may be indicated; although in all cases, support is often required to ensure that people are able to complete treatment with minimal adverse events and maximal adherence to the prescribed regimen, and so reduce risk of future disease for themselves and others.

Balloon Dilatation of a Case of Tuberculous Tracheobronchial Stenoses during the Course of Antituberculous Treatment

We report a case of posttuberculosis (TB) tracheobronchial stenoses presented with progressive exertional dyspnea during the course of anti-TB treatment. An 83-year-old Japanese man was admitted for progressive dyspnea; chest X-ray and CT showed stenosis of distal trachea and left main bronchus. Pulmonary function test revealed reduction of FEV1. Balloon dilatation without stent insertion was the choice for this patient for multiple reasons with marked improvement of symptoms.

Endobronchial tuberculosis: two case reports and review of the literature

Endobronchial tuberculosis commonly affects young patients and presents as acute or insidious onset cough, wheeze, low grade fever, and constitutional symptoms. Although endobronchial lesions usually result in sputum positivity for acid fast bacilli (AFB), a false negative sputum or absence of radiological lesions may result in delayed diagnosis. On the other hand, sputum positivity with presence of signs on chest radiology may lead to consideration of parenchymal TB as the primary diagnosis and the coexistence of endobronchial lesions may be missed until sequelae of the latter ensue. Besides, in elderly patients, consideration of other differentials like malignancy and pneumonia may lead to misdiagnosis. Hence, bronchoscopy is essential for confirmation of endobronchial TB. We hereby report two cases of endobronchial TB which stress the importance of bronchoscopic diagnosis for timely institution of treatment and prevention of permanent sequelae, respectively.

Challenges in endobronchial tuberculosis: from diagnosis to management

Despite the rapid advancement in diagnostic and therapeutic modalities, endobronchial tuberculosis (EBTB), defined as tuberculous infection of the tracheobronchial tree, continues to remain challenging for clinicians. Nonspecific respiratory symptoms along with normal chest radiograph in 10–20% of cases may be alleged for the diagnostic delay. Variable diagnostic yield with sputum microscopy might further compound the problem. In such cases, high resolution computed tomography (HRCT) works as a more sensitive tool and demonstrates involvement of tracheobronchial tree described classically as “tree-in-bud” appearance. Bronchoscopic biopsy is considered the most reliable method for confirmation of the diagnosis with 30% to 84% positivity in different series. Evolution of the disease is also unpredictable with frequent progression to bronchostenosis, therefore requiring regular follow-up and early intervention to halt the natural course. This review article elaborates various aspects of the disease with specific focus on diagnostic dilemma and recent advances in interventional bronchoscopy. In addition, this discussion evokes optimism for further research and introduction of innovative therapeutic modalities.

Characteristics and risk factor analysis of 410 cases of tracheobronchial tuberculosis

The present study analyzed the characteristics and risk factors associated with tracheobronchial tuberculosis (TBTB) in 410 patients with TBTB. Retrospective analysis was performed on the clinical features, bronchoscopy performance, bacteriological examination, imaging and treatment of 410 patients who were diagnosed with TBTB using bronchoscopy. Among the 410 patients, 10 patients underwent chest X-ray which revealed two cases of atelectasis, eight cases of patch or spot shadows, three cases of cavity, one case of nodule and one case with no abnormalities. The remaining 400 patients underwent computed tomography chest scans and/or airway reconstruction examinations. Among all the lesion types, the cavity type was found to be the most likely to cause bronchial stenosis or obstruction, with statistically significant differences when compared with the congestion, stenosis or scar lesion types (P<0.01). Moreover, for the cavity type, there were 194 sites of obstruction prior to therapy; however, only 23 sites of obstruction remained following therapy. Furthermore, there were 34 sites without stenosis prior to therapy and 205 sites without stenosis following therapy. The number of sites of obstruction was significantly decreased and the number of sites without stenosis was increased upon therapy. These findings suggest that the cavity type is the most sensitive type to therapy among the five types of TBTB lesion.

Non-malignant central airway obstruction

The most common causes of non-malignant central airway obstruction are post-intubation and post-tracheostomytracheal stenosis, followed by the presence of foreign bodies, benign endobronchial tumours and tracheobronchomalacia. Other causes, such as infectious processes or systemic diseases, are less frequent. Despite the existence of numerous classification systems, a consensus has not been reached on the use of any one of them in particular. A better understanding of the pathophysiology of this entity has allowed us to improve diagnosis and treatment. For the correct diagnosis of nonspecific clinical symptoms, pulmonary function tests, radiological studies and, more importantly, bronchoscopy must be performed. Treatment must be multidisciplinary and tailored to each patient, and will require surgery or endoscopic intervention using thermoablative and mechanical techniques.

Characteristics of endobronchial tuberculosis patients with negative sputum acid-fast bacillus

OBJECTIVE

Endobronchial tuberculosis (EBTB) is defined as a tuberculous infection of the tracheobronchial tree with microbial and histopathological evidence, with or without parenchymal involvement. In this study, clinical, radiological and bronchoscopic characteristics of cases diagnosed to have EBTB were evaluated.

METHODS

Sixteen patients with at least three negative sputum examinations for acid-fast bacillus (AFB) and diagnosed as having EBTB on the histopathological examination of bronchoscopically obtained specimens showing granulomatous structures with caseation necrosis and/or positive AFB-culture on the microbiological examination of bronchoscopically obtained specimens were included in our study. Age, sex, symptoms, tuberculin skin test (TST), microbiological examination results and radiological findings were recorded. Bronchoscopical lesions were classified according to Chung classification.

RESULTS

EBTB was found to be more common in females. Most common symptoms were cough (100%), sputum (75%), weight loss (62.5%), hemoptisis (37.5%), chest pain (25%) and dyspnea (12.5%). Radiological examination findings revealed consolidations/infiltrations (87.5%), nodular lesions (37.5%), cavitary lesions (25%), unilateral (43.7%) or bilateral hilar widening (31.2%) and atelectasia (25%). Middle lob syndrome was seen in three cases. Most common lesions observed bronchoscopically were active caseous lesions, granular lesions, edematous hyperemic lesions, tumorous lesions, fibrostenotic lesions respectively. In all cases "granulomatous inflammation showing caseation" was shown in the histopathological examination of biopsy specimens.

CONCLUSIONS

EBTB can cause various radiological and bronchoscopical findings. In most of the cases distinct response is seen to antituberculous treatment. Bronchial stenosis is an important complication. Treatment should be given as soon as possible to avoid it.

Childhood bronchial tuberculosis: report of one case and literature review

OBJECTIVE

To explore the early diagnosis of childhood bronchial tuberculosis (BTB).

METHODS

The clinical data of a 9-year-old boy with long-term chronic cough were retrospectively analyzed, and the relevant literature was reviewed.

RESULTS

The pediatric patient was suspected to be with bronchial asthma due to long-term chronic cough, and was confirmed to be with "nasopharyngeal tuberculosis" during surgery. Purified protein derivative (PPD) (5 IU) showed moderately positive results. Chest X-ray showed the atelectasis of left lower lobe, which was suspected to be caused by bronchial tuberculosis. Chest CT and three-dimensional airway reconstruction showed atelectasis of left lower lobe, increased air volume of the left upper lung, left deviation of the mediastinum, bronchiolitis obliterans in the left lower lobe, and narrowing of the left upper lobe bronchus, suggesting the presence of bronchial tuberculosis. The bronchoscopy showed necrosis of the left main bronchus and mucosal congestion and edema, and then bronchial tuberculosis was confirmed. In addition to the systemic anti-TB treatment, transluminal interventions including local drug injection and balloon angioplasty under bronchoscope were applied routinely and achieved good effectiveness.

CONCLUSIONS

Patients with long-term chronic cough should be cautiously managed in clinical settings. Examinations including PPD test, chest CT, three-dimensional airway reconstruction, and bronchoscopy should be performed as early as possible to confirm the potential existence of bronchial tuberculosis. Meanwhile, appropriate interventional treatment under bronchoscopy should be promptly applied to provide optimal protection of bronchi and lung, restore the damaged lung function, and minimize the complications.

Tracheal wall thickening is associated with the granulation tissue formation around silicone stents in patients with post-tuberculosis tracheal stenosis

PURPOSE

Tracheal restenosis due to excessive granulation tissue around a silicone stent requires repeated bronchoscopic interventions in patients with post-tuberculosis tracheal stenosis (PTTS). The current study was conducted to identify the risk factors for granulation tissue formation after silicone stenting in PTTS patients.

MATERIALS AND METHODS

A retrospective study was conducted between January 1998 and December 2010. Forty-two PTTS patients with silicone stenting were selected. Clinical and radiological variables were retrospectively collected and analyzed.

RESULTS

Tracheal restenosis due to granulation tissue formation were found in 20 patients (47.6%), and repeated bronchoscopic interventions were conducted. In multivariate analysis, tracheal wall thickness, measured on axial computed tomography scan, was independently associated with granulation tissue formation after silicone stenting. Furthermore, the degree of tracheal wall thickness was well correlated with the degree of granulation tissue formation.

CONCLUSION

Tracheal wall thickening was associated with granulation tissue formation around silicone stents in patients with post-tuberculosis tracheal stenosis.