1
|
Andronikou S, Lucas S, Zouvani A, Goussard P. A proposed CT classification of progressive lung parenchymal injury complicating pediatric lymphobronchial tuberculosis: From reversible to irreversible lung injury. Pediatr Pulmonol 2021; 56:3657-3663. [PMID: 34515414 DOI: 10.1002/ppul.25640] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Revised: 06/28/2021] [Accepted: 08/19/2021] [Indexed: 11/10/2022]
Abstract
Lymphobronchial tuberculosis (LBTB) is tuberculous lymphadenopathy affecting the airways, which is particularly common in children with primary TB. Airway compression by lymphadenopathy causes downstream parenchymal pathology, which may ultimately result in irreversible lung destruction, if not treated timeously. Computed tomography (CT) is considered the "gold standard" for detecting mediastinal lymph nodes in children with TB. CT is also the best way of imaging the airways of children with LBTB. The CT findings of the parenchymal complications and associations of LBTB on CT have been described, but no severity classification was provided to aid management decisions. Identifying the parenchymal complications of LBTB and recognizing their severity has clinical relevance. Using prior publications on LBTB and post obstructive lung injury we have used an image bank of CT scans in children with pulmonary TB, presenting with airway symptoms, to create a CT severity staging of lung injury in LBTB. The staging focuses on distinguishing nonsalvageable destruction (nonenhancing or cavitated lung) from salvageable lung parenchymal disease (enhancing and noncavitated) to inform the management decisions, which range from bronchoscopic airway clearance to surgical decompression of the compressing nodes.
Collapse
Affiliation(s)
- Savvas Andronikou
- Department of Pediatric Radiology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Susan Lucas
- Department of Diagnostic Radiology, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Andrea Zouvani
- Faculty of Medicine, University of Glasgow, Glasgow, Scotland
| | - Pierre Goussard
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Tygerberg Hospital, Stellenbosch University, Cape Town, South Africa
| |
Collapse
|
2
|
Invited Commentary. Ann Thorac Surg 2015; 99:1163. [DOI: 10.1016/j.athoracsur.2015.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2014] [Revised: 12/18/2014] [Accepted: 01/05/2015] [Indexed: 11/22/2022]
|
3
|
Goussard P, Gie RP, Janson JT, le Roux P, Kling S, Andronikou S, Roussouw GJ. Decompression of enlarged mediastinal lymph nodes due to mycobacterium tuberculosis causing severe airway obstruction in children. Ann Thorac Surg 2015; 99:1157-63. [PMID: 25725929 DOI: 10.1016/j.athoracsur.2014.12.042] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2014] [Revised: 12/09/2014] [Accepted: 12/16/2014] [Indexed: 10/23/2022]
Abstract
BACKGROUND Large airway compression by enlarged tuberculosis (TB) lymph nodes results in life-threatening airway obstruction in a small proportion of children. The indications, safety, and efficacy of TB lymph node decompression are inadequately described. This study aims to describe the indications and efficacy of TB lymph node decompression in children with severe airway compression and investigate variables influencing outcome. METHODS A prospective cohort of children (aged 3 months to 13 years) with life-threatening airway obstruction resulting from TB lymph node compression of the large airways were enrolled. The site and degree of airway obstruction were assessed by bronchoscopy and chest computed tomography scan. RESULTS Of the 250 children enrolled, 34% (n = 86) required transthoracic lymph node decompression, 29% as an urgent procedure and 71% (n = 63) after failing 1 month of antituberculosis treatment that included glucosteroids. Compression (less than 75%) of the bronchus intermedius (odds ratio 2.28, 95% confidence interval: 1.29 to 4.02) and left main bronchus (odds ratio 3.34, 95% confidence interval: 1.73 to 6.83) were the best predictors for lymph node decompression. Human immunodeficiency virus status, drug resistance, and malnutrition were not associated with decompression. Few complications (self-limiting, 8%) or treatment failures (2%) resulted from the decompression. There were no deaths. CONCLUSIONS In one third of children with TB, severe airway obstruction caused by enlarged lymph nodes requires decompression. Transthoracic decompression can be safely performed with low complication, failure, and fatality rates.
Collapse
Affiliation(s)
- Pierre Goussard
- Department of Pediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Children's Hospital, Cape Town.
| | - Robert P Gie
- Department of Pediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Children's Hospital, Cape Town
| | - Jacques T Janson
- Department of Cardiothoracic Surgery, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Children's Hospital, Cape Town
| | - Pieter le Roux
- Department of Anesthesiology and Critical Care, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Children's Hospital, Cape Town
| | - Sharon Kling
- Department of Pediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Children's Hospital, Cape Town
| | - Savvas Andronikou
- Radiology Department, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Gawie J Roussouw
- Department of Cardiothoracic Surgery, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Children's Hospital, Cape Town
| |
Collapse
|
4
|
Lucas S, Andronikou S, Goussard P, Gie R. CT features of lymphobronchial tuberculosis in children, including complications and associated abnormalities. Pediatr Radiol 2012; 42:923-31. [PMID: 22644456 DOI: 10.1007/s00247-012-2399-x] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2011] [Revised: 12/15/2011] [Accepted: 01/13/2012] [Indexed: 11/28/2022]
Abstract
BACKGROUND Lymphobronchial tuberculosis (TB) is tuberculous lymphadenopathy involving the airways, which is particularly common in children. OBJECTIVE To describe CT findings of lymphobronchial TB in children, the parenchymal complications and associated abnormalities. MATERIALS AND METHODS CT scans of children with lymphobronchial TB were reviewed retrospectively. Lymphadenopathy, bronchial narrowing, parenchymal complications and associations were documented. RESULTS Infants comprised 51% of patients. The commonest site of lymphadenopathy was the subcarinal mediastinum (97% of patients). Bronchial compression was seen in all children (259 bronchi, of these 28% the bronchus intermedius) with severe or complete stenosis in 23% of affected bronchi. Parenchymal complications were present in 94% of patients, including consolidation (88%), breakdown (42%), air trapping (38%), expansile pneumonia (28%), collapse (17%) and bronchiectasis (9%), all predominantly on the right side (63%). Associated abnormalities included ovoid lesions, miliary nodules, pleural disease and intracavitary bodies. CONCLUSION Airway compression was more severe in infants and most commonly involved the bronchus intermedius. Numerous parenchymal complications were documented, all showing right-side predominance.
Collapse
Affiliation(s)
- Susan Lucas
- Department of Radiology, Faculty of Health Sciences, University of the Witwatersrand, 7 York Road, Parktown, Johannesburg 2001, South Africa.
| | | | | | | |
Collapse
|
5
|
The chemotherapy of tuberculous lymphadenopathy in children. Tuberculosis (Edinb) 2010; 90:213-24. [PMID: 20627812 DOI: 10.1016/j.tube.2010.05.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2010] [Revised: 04/26/2010] [Accepted: 05/04/2010] [Indexed: 11/23/2022]
Abstract
The chemotherapy of tuberculous lymphadenopthy, the commonest form of extra-pulmonary tuberculosis, is reviewed and a recommendation made for the treatment of this condition in children. Fifteen papers were identified recording the treatment and follow-up of 1133 adults and children with six-month isoniazid and rifampicin based regimens. In 32 (2.8%) cases treatment was recommenced, but in only one case was relapse microbiologically confirmed and in a further four histology was compatible with tuberculosis. Four studies enrolling 484 adults and children, record the follow-up of patients receiving 6-18 months treatment with INH and RMP based regimens; treatment was recommenced in 24 (5%), but in no case was relapse confirmed microbiologically. Five papers describe the treatment and follow-up of 246 adults and children receiving nine-month INH and RMP based regimens and record the recommencement of treatment in 4 (1.6%) cases, but in no case was relapse confirmed microbiologically. Four controlled studies failed to show any advantage for treatment regimens longer than six months. Paradoxical recurrence and worsening of clinical features was common during and following all regimens being recorded in from 3 to 20% of patients. Very seldom were these events accompanied by evidence of culture of Mycobacterium tuberculosis to confirm microbiological failure to respond or relapse. Tuberculous lymphadenopathy in children can be safely treated with six months of INH and RMP with PZA given for the first two months and accompanied by EMB in areas with a high prevalence of drug resistance. Every effort should be made to confirm the diagnosis and possible relapses microbiologically.
Collapse
|
6
|
Conde MB, Melo FAFD, Marques AMC, Cardoso NC, Pinheiro VGF, Dalcin PDTR, Machado Junior A, Lemos ACM, Netto AR, Durovni B, Sant'Anna CC, Lima D, Capone D, Barreira D, Matos ED, Mello FCDQ, David FC, Marsico G, Afiune JB, Silva JRLE, Jamal LF, Telles MADS, Hirata MH, Dalcolmo MP, Rabahi MF, Cailleaux-Cesar M, Palaci M, Morrone N, Guerra RL, Dietze R, Miranda SSD, Cavalcante SC, Nogueira SA, Nonato TSG, Martire T, Galesi VMN, Dettoni VDV. III Brazilian Thoracic Association Guidelines on tuberculosis. J Bras Pneumol 2010; 35:1018-48. [PMID: 19918635 DOI: 10.1590/s1806-37132009001000011] [Citation(s) in RCA: 134] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2009] [Accepted: 08/25/2009] [Indexed: 11/21/2022] Open
Abstract
New scientific articles about tuberculosis (TB) are published daily worldwide. However, it is difficult for health care workers, overloaded with work, to stay abreast of the latest research findings and to discern which information can and should be used in their daily practice on assisting TB patients. The purpose of the III Brazilian Thoracic Association (BTA) Guidelines on TB is to critically review the most recent national and international scientific information on TB, presenting an updated text with the most current and useful tools against TB to health care workers in our country. The III BTA Guidelines on TB have been developed by the BTA Committee on TB and the TB Work Group, based on the text of the II BTA Guidelines on TB (2004). We reviewed the following databases: LILACS (SciELO) and PubMed (Medline). The level of evidence of the cited articles was determined, and 24 recommendations on TB have been evaluated, discussed by all of the members of the BTA Committee on TB and of the TB Work Group, and highlighted. The first version of the present Guidelines was posted on the BTA website and was available for public consultation for three weeks. Comments and critiques were evaluated. The level of scientific evidence of each reference was evaluated before its acceptance for use in the final text.
Collapse
|
7
|
Pezzella AT, Fang W. Surgical Aspects of Thoracic Tuberculosis: A Contemporary Review—Part 2. Curr Probl Surg 2008; 45:771-829. [DOI: 10.1067/j.cpsurg.2008.06.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
|
8
|
Abstract
Lymph gland involvement of the airways is common in young children with pulmonary tuberculosis. This lymph gland involvement leads to lymphobronchial tuberculosis, which presents with varying degrees of airway obstruction. These children are best assessed by fibreoptic bronchoscopy and are treated with the normal anti-tuberculosis regimens to which corticosteroids are added for a month and then weaned off over the next month. If, after a month, the children remain symptomatic, they must be re-evaluated by bronchoscopy and chest computed tomography. Surgery must be considered in children with severe airway obstruction still present at the time of the second evaluation. Surgical intervention consists of endoscopic or transthoracic enucleation of the lymph nodes. Only a small percentage of those with lymphobronchial tuberculosis will require surgery to relieve their airway obstruction.
Collapse
Affiliation(s)
- Pierre Goussard
- Department of Paediatrics and Child Health, Faculty of Health Sciences, Stellenbosch University, Tygerberg, South Africa.
| | | |
Collapse
|
9
|
Wong JSW, Ng CSH, Lee TW, Yim APC. Bronchoscopic management of airway obstruction in pediatric endobronchial tuberculosis. Can Respir J 2006; 13:219-21. [PMID: 16779468 PMCID: PMC2683283 DOI: 10.1155/2006/278680] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The present report describes a case of severe airway obstruction caused by endobronchial tuberculosis in an 11-year-old girl who was successfully treated by bronchoscopic balloon dilation. This case illustrates the insidious presentation and the increasingly important role of bronchoscopic intervention in the management of endobronchial tuberculosis. In addition, a brief literature review of the condition in the pediatric age group is included.
Collapse
Affiliation(s)
| | | | | | - Anthony PC Yim
- Correspondence: Dr Anthony PC Yim, Division of Cardiothoracic Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, New Territories, Hong Kong. Telephone 852-2632-2629, fax 852-2647-8273, e-mail
| |
Collapse
|
10
|
Abstract
Airway obstruction associated with Pott's disease is rare. We present a case of severe airway obstruction caused by an extensive paravertebral mediastinal abscess in a 3-year-old boy with tuberculosis of the thoracic spine.
Collapse
Affiliation(s)
- Theresa J Ochoa
- Department of Pediatrics, Universidad Peruana Cayetano Heredia, Lima, Perú.
| | | | | | | |
Collapse
|
11
|
Goussard P, Gie RP, Kling S, Beyers N. Expansile pneumonia in children caused by Mycobacterium tuberculosis: clinical, radiological, and bronchoscopic appearances. Pediatr Pulmonol 2004; 38:451-5. [PMID: 15376332 DOI: 10.1002/ppul.20119] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
A cohort of 24 children with expansile pneumonia caused by Mycobacterium tuberculosis is described in mostly HIV-noninfected children (n = 22). The children presented with nonresolving pneumonia and a swinging fever (83%). On chest radiography, they had dense opacification with bulging fissures mainly in the upper lobes (75%). On computed tomography, the lobes are consolidated, with areas of liquefacation. Other features visible are enlarged mediastinal lymph adenopathy with ring enhancement (100%), cavities (63%), and tracheal compression (71%). On bronchoscopy, bronchi were obstructed by more than 75% in 20 (83%) of cases. Lymph gland enucleation was required in 42% of cases. Phrenic nerve palsy was present in 3 children, of whom 2 underwent diaphragmatic plication. The children received standard antituberculous therapy, to which prednisone (2 mg/kg/day) was added for 1 month. The mortality was 4% after 6 months of therapy.
Collapse
Affiliation(s)
- P Goussard
- Department of Paediatrics and Child Health, Stellenbosch University, PO Box 19063, Tygerberg 7505, South Africa.
| | | | | | | |
Collapse
|
12
|
Abstract
The natural history of tuberculosis is complex. Primary infection, the initial phase, occurs in people without specific immunity, generally normal children and young adults who have not previously been exposed to Mycobacterium tuberculosis. The initial infection can occur at any time during childhood, but adolescence is the peak time of risk. Primary disease develops within 5 years of the initial infection, which stimulates specific immunity, demonstrated by the development of a positive skin response to purified protein derivative of tuberculin. Although symptoms of primary disease may be few, early detection and treatment are important for both preventing the development of immediate complications, which carry a high risk of morbidity and mortality, and preventing spread of infection following later reactivation of disease. Our understanding of the host's immune response to the primary infection is increasing, and it is hoped this will lead to improved possibilities for vaccines in the future.
Collapse
Affiliation(s)
- H J Milburn
- Department of Respiratory Medicine, Guy's & St Thomas' Hospital and GKT School of Medicine, London, UK.
| |
Collapse
|