Endobronchial Tuberculosis Mimicking Asthma

Asthma and pulmonary tuberculosis: misdiagnosis or coexistence

Asthma and pulmonary tuberculosis (PTB) are disease entities with different pathogenesis. However, endobronchial tuberculosis (EBTB), a peculiar form of PTB, can mimic the symptoms of asthma. Although uncommon, the coexistence of asthma and PTB can appear. We report three cases of PTB. The first two cases with EBTB were misdiagnosed as asthma and the third case with asthma developed PTB four months after high-dose inhaled corticosteroid (ICS) therapy. The first two cases presented with chronic cough up mucopurulent/purulent sputum and localized wheezing which revealed diagnostic clues. The third case presented with dry cough and showed a positive bronchodilator response and the right pulmonary apical fibrosis which could be associated with quiescent tuberculous infection. EBTB should be included in the differential diagnosis of asthma. Although rare, physicians should be aware that PTB can also be developed during the treatment course of asthma.

Performance of the Xpert® MTB/RIF assay in the rapid diagnosis of tracheobronchial tuberculosis using bronchial washing fluid

Objective

To assess the diagnostic value of the Xpert® MTB/RIF (GeneXpert) assay for tracheobronchial tuberculosis (TBTB) using bronchial washing fluid (BWF).

Methods

This retrospective study enrolled patients suspected of having TBTB and patients with non-TB pulmonary disease as controls. BWF were used to undertake acid-fast bacillus (AFB) smears, the GeneXpert assay and the Lӧwenstein–Jensen (LJ) culture method. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were compared among BWF AFB smears, BWF GeneXpert and the BWF LJ culture method.

Results

A total of 130 patients with TBTB and 102 patients with non-TB pulmonary disease were enrolled in the study. Sputum AFB smears were positive in 62 of 130 patients (47.7%) with TBTB. Using the clinical diagnosis of TBTB as the gold standard, the sensitivity, specificity, PPV and NPV of the three methods using BWF were as follows: 93.1%, 99.0%, 99.2% and 91.8% for BWF GeneXpert; 73.1%, 100.0%, 100.0% and 74.5% for BWF LJ cultures; 53.8%, 99.0%, 98.6% and 62.7% for BWF AFB smears. The diagnostic yield of BWF GeneXpert was significantly higher compared with BWF cultures for type III and IV TBTB.

Conclusion

The Xpert® MTB/RIF assay using BWF exhibited higher sensitivity than bacteriological diagnostic methods and was particularly useful for the early diagnosis of smear-negative TBTB.

Confounders of severe asthma: diagnoses to consider when asthma symptoms persist despite optimal therapy

Asthma can often be challenging to diagnose especially when patients present with atypical symptoms. Therefore, it is important to have a broad differential diagnosis for asthma to ensure that other conditions are not missed. Clinicians must maintain a high index of suspicion for asthma mimickers, especially when patients fail to respond to conventional therapy. The purpose of this review is to briefly review some of the more common causes of asthma mimickers that clinicians should consider when the diagnosis of asthma is unclear.

Asthma Mimickers: Approach to Differential Diagnosis

The airway of a child can be easily obstructed because of its small size and there are myriad conditions that may obstruct it. Though asthma is the most common condition causing reversible obstruction of the airway; there are a large number of conditions which can obstruct the airway both reversibly and irreversibly. These asthma mimics can present as clinical problems from the neonatal period through adolescence. This article presents an overview of the clinical situations that must be kept in mind when the child presents with subtly unusual clinical features or a deviant course. This is followed by a brief description of the common mimickers along with clinical clues to their diagnosis. Clinicians will need a high index of suspicion for diagnosing these conditions. Prompt recognition and optimal case management and referral will ensure the best outcomes in these children.

Asthma mimic: Case report and literature review of vocal cord nodule associated with wheezing

Asthma is a heterogeneous disease, usually characterized by chronic airway inflammation. Various clinical conditions can mimic asthma, such as foreign body aspiration, subglottic stenosis, congestive heart failure, diffuse panbronchiolitis, aortic arch anomalies, reactive airway dysfunction syndrome, chronic obstructive pulmonary disease, retrosternal goiter, vocal cord tumors, other airway tumors, and vocal cord dysfunction. Upper airway obstruction can be a life-threatening emergency. Here, we present the case of a 58-year-old female with recurrent hospital visits for wheezing and exacerbations of asthma, who was later found to have a vocal cord nodule confirmed to be squamous cell carcinoma, which was mimicking like asthma.

Case report: Unusual cause of difficulty in intubation and ventilation with asthmatic-like presentation of Endobronchial Tuberculosis

Endobronchial Tuberculosis is hazardous in causing circumferential narrowing of tracheobronchial tree despite the eradication of tubercle bacilli in the initial insult from Pulmonary Tuberculosis. They may present as treatment resistant bronchial asthma and pose challenge to airway management in the acute setting. We present a 25 year-old lady who was newly diagnosed bronchial asthma with a past history of Pulmonary Tuberculosis that had completed treatment. She presented with sudden onset of difficulty breathing associated with noisy breathing for 3 days and hoarseness of voice for 6 months. Due to resistant bronchospasm, attempts were made to secure the airway which led to unanticipated difficult intubation and ventilation. Subsequent investigations confirmed the diagnosis of Endobronchial Tuberculosis and patient was managed successfully with anti TB medication, corticosteroids and multiple sessions of tracheal dilatation for tracheal stenosis. This case highlights the unusual cause of difficulty in intubation and ventilation due to Endobronchial Tuberculosis, which required medical and surgical intervention to improve the condition.

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.