50 endobronchial tuberculosis cases based on bronchoscopic diagnosis

The epidemiology of extrapulmonary tuberculosis in China: A large-scale multi-center observational study

Tuberculosis (TB) remains a serious global public health problem in the present. TB also affects other sites (extrapulmonary tuberculosis, EPTB), and accounts for a significant proportion of tuberculosis cases worldwide. In order to comprehensively understand epidemiology of EBTB in China, and improve early diagnosis and treatment, we conducted a large-scale multi-center observational study to assess the demographic data and the prevalence of common EPTB inpatients, and further evaluate the prevalence of EPTB concurrent with Pulmonary tuberculosis (PTB) and the associations between multiple EPTB types and gender-age group in China. All consecutive age≥15yr inpatients with a confirmed diagnosis of EPTB during the period from January 2011 to December 2017 were included in the study. The descriptive statistical analysis included median and quartile measurements for continuous variables, and frequencies and proportions with 95% confidence intervals (CIs) for categorical variables. Multinomial logistic regression analysis was used to compare the association of multiple EPTB types between age group and gender. The results showed that the proportion of 15–24 years and 25–34 years in EPTB inpatients were the most and the ratio of male: female was 1.51. Approximately 70% of EPTB inpatients were concurrent with PTB or other types of EPTB. The most common of EPTB was tuberculous pleurisy (50.15%), followed by bronchial tuberculosis (14.96%), tuberculous lymphadenitis of the neck (7.24%), tuberculous meningitis (7.23%), etc. It was found that many EPTB inpatients concurrent with PTB. The highest prevalence of EPTB concurrent with PTB was pharyngeal/laryngeal tuberculosis (91.31%), followed by bronchial tuberculosis (89.52%), tuberculosis of hilar lymph nodes (79.52%), tuberculosis of mediastinal lymph nodes (79.13%), intestinal tuberculosis (72.04%), tuberculous pleurisy (65.31%) and tuberculous meningitis (62.64%), etc. The results from EPTB concurrent with PTB suggested that females EPTB inpatients were less likely to be at higher risk of concurrent PTB (aOR = 0.819, 95%CI:0.803–0.835) after adjusted by age. As age increasing, the trend risk of concurrent PTB decreased (aOR = 0.994, 95%CI: 0.989–0.999) after adjusted by gender. Our study demonstrated that the common EPTB were tuberculous pleurisy, bronchial tuberculosis, tuberculous lymphadenitis of the neck, tuberculous meningitis, etc. A majority of patients with pharyngeal/laryngeal tuberculosis, bronchial tuberculosis, tuberculosis of hilar/mediastinal lymph nodes, intestinal tuberculosis, tuberculous pleurisy, tuberculous meningitis, etc. were concurrent with PTB. Female EPTB inpatients were less likely to be at higher risk of concurrent PTB, and as age increasing, the trend risk of concurrent PTB decreased. The clinicians should be alert to the presence of concurrent tuberculosis in EPTB, and all suspected cases of EPTB should be assessed for concomitant PTB to determine whether the case is infectious and to help for early diagnosis and treatment.

Bronchoscopic sampling techniques in the era of technological bronchoscopy

Flexible bronchoscopy is a key diagnostic and therapeutic tool. New endoscopes and technologically advanced navigational modalities have been recently introduced on the market and in clinical practice, mainly for the diagnosis of mediastinal lymph adenopathies and peripheral lung nodules. Bronchoscopic sampling tools have not changed significantly in the last three decades, with the sole exception of cryobiopsy. We carried out a non-systematic, narrative literature review aimed at summarizing the scientific evidence on the main indications/contraindications, diagnostic yield, and safety of the available bronchoscopic sampling techniques. Performance of bronchoalveolar lavage, bronchial washing, brushing, forceps biopsy, cryobiopsy and needle aspiration techniques are described, focusing on indications and diagnostic accuracy in the work-up of endobronchial lesions, peripheral pulmonary abnormalities, interstitial lung diseases, and/or hilar-mediastinal lymph adenopathies. Main factors affecting the diagnostic yield and the navigational methods are evaluated. Preliminary data on the utility of the newest sampling techniques (i.e., new needles, triple cytology needle brush, core biopsy system, and cautery-assisted transbronchial forceps biopsy) are shown. TAKE HOME MESSAGE: A deep knowledge of bronchoscopic sampling techniques is crucial in the era of technological bronchoscopy for an optimal management of respiratory diseases.

Endobronchial Tuberculosis: A Rare Presentation

Endobronchial tuberculosis (EBTB) is an infection of the tracheobronchial tree by Mycobacterium tuberculosis. It is common among young females. Patient can present with fever, cough, wheeze, with or without any constitutional symptoms. It presents as a diagnostic dilemma, as patient sputum smear can be false negative. CT scan may or may not show any abnormality, or any endobronchial lesion. Bronchoscopy with bronchoalveolar lavage and biopsy offers the diagnostic choice. We hereby report a case of a young immunocompetent Asian female who was found to have endobronchial pathology, leading to diagnosis and timely therapy. 

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).

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-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.

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.

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.

Endobronchial tuberculosis: histopathological subsets and microbiological results

BACKGROUND

Endobronchial tuberculosis (EBTB) is defined as a tuberculous infection of the tracheobronchial tree with microbial and histopathological evidence, with or without parenchymal involvement. Bronchoscopic appearances of EBTB have been divided into seven subtypes: actively caseating, edematous-hyperemic, fibrostenotic, tumorous, granular, ulcerative, and nonspecific bronchitic. However, information for establishing a definite microbiological diagnosis in each of these categories is lacking.We aimed to present bronchoscopic appearances and percentages for the EBTB subtypes and to compare bronchoscopic appearances with microbiological positivity in bronchial lavage fluid.

METHODS

From 2003 to 2009, 23 biopsy-proven EBTB patients were enrolled in the study. Diagnosis of EBTB was histopathologically confirmed in all patients.

RESULTS

The commonest subtype was the edematous-hyperemic type (34.7%); other subtypes in order of occurrence were: tumorous (21.7%), granular (17.3%), actively caseating (17.3%), fibrostenotic (4.3%), and nonspecific bronchitic (4.3%). Although all patients were sputum-smear-negative for acid-fast bacilli (AFB), 26% of patients were smear-positive for AFB in the bronchial lavage fluid. The bronchial lavage fluid grew Mycobacterium tuberculosis in 39.1% of all patients.The bronchial lavage smear positivity for AFB in the bronchial lavage fluid was 75%, 25%, 20%, 12.5%, 0%, and 0% for the granular, actively caseating, tumorous, edematous-hyperemic, fibrostenotic, and nonspecific bronchitic subtypes of EBTB, respectively. Culture positivity for Mycobacterium tuberculosis in bronchial lavage fluid was 75%, 50%, 40%, 25%, 0%, and 0%, respectively.

CONCLUSION

The commonest subtype of EBTB was the edematous-hyperemic subtype. The granular type had the highest smear positivity and culture positivity for Mycobacterium tuberculosis in bronchial lavage fluid. Bronchoscopy should be performed in all patients suspected to have EBTB.

Tuberculous otitis media with endobronchial tuberculosis

Although tuberculosis can affect various organs and tissues, the lung is the site most commonly involved. Extrapulmonary tuberculosis (EPTB) involves relatively inaccessible and variable sites and is consequently often overlooked by clinicians. The ear is a notably very rare site of EPTB, and the diagnosis is difficult because of the variable and confusing signs and symptoms. To our knowledge, this is the first case in which tuberculous otitis media and endobronchial tuberculosis coexisted.

[Diagnostic difficulty in bronchopulmonary tuberculous pseudotumor]

Pseudotumour is a rare presentation of bronchopulmonary tuberculosis, occurring in immunocompetent patients, which simulates lung cancer and may thus cause diagnostic difficulty. To assess the frequency and clinical features of tuberculous pseudotumour in immunocompetent patients, we analyzed all cases of pulmonary tuberculosis hospitalized in our department. Tuberculous pseudotumour was defined by the presence of a bronchial or pulmonary lesion suggestive of lung cancer. Over a period of 11 years, 12 cases of tuberculous pseudotumour were collected among 341 cases of pulmonary tuberculosis (3.5%). Mean age was 45 years. All patients were smokers. Symptoms were not specific and were dominated by cough and chest pain. Radiological investigations showed consolidation in five cases and a mass lesion in five cases. Fibreoptic bronchoscopy visualized a tumour in four cases and stenosing bronchial wall infiltration in one case. Mean delay to diagnosis was 47 days. The confirmation of tuberculosis was bacteriologic in only three cases but histological in the others (four bronchial biopsies, two transbronchial biopsies, one pleural biopsy, four surgical specimen). The positive diagnosis of tuberculous pseudotumour is difficult because the clinical and radiological presentation may closely mimic lung cancer, especially as the cases are usually smear negative, leading to a very late diagnosis.

[Clinical perspective as seen in Archivos de Bronconeumología]

This article discusses the current main clinical problems of thoracic surgery and pneumology by means of the articles published in 2008 in the "clinical notes" section of the journal Archivos de Bronconeumología. The 18 cases published -which deal with topics ranging from pharmacologic toxicity to lung function- will enable us to discuss the main novelties in each one of the various fields and highlight future areas for research.

[Endobronchial tuberculosis -- clinical and bronchoscopic features]

Endobronchial tuberculosis (ET) is a serious complication of pulmonary tuberculosis and is a major cause of morbidity. The aim of our retrospective study was to characterize the clinical, radiological, microbiological and bronchoscopic features of ET. Between January 1999 and June 2002 a total of 14 patients were diagnosed as having ET in our hospital. There were 8 (57%) men and 6 women with a median age of 39.6 +/- 18.1 years (range from 20 to 78 years). Cough was the most common complain and it was present in 71.4% of patients. Only 5 patients were sputum smear positive. Five patients (35.7%) had parenchymal infiltration and this was the most common roentgenographic appearance. Forms of ET were classified into subtypes: actively caseating (n=4), granular (n=3), tumorous (n=3), edematous-hyperemic (n=2) and ulcerative (n=2). The upper lobes were affected in 9 (64.3%) patients. Nine patients had involvement of the left bronchial tree, 3 of the right and in 2 there were bilateral lesions. The diagnosis could be established in 11 (78.6%) cases by bronchial biopsy. All patients had positive bronchial lavage cultures for acid-fast bacilli. Clinical manifestations and roentgenographic appearance of ET are not specific and so bronchoscopy is mandatory for the prompt diagnosis and follow-up of its evolution.