Bronchoscopic assessment of the evolution of endobronchial tuberculosis

Comparative study of cryorecanalisation and cryoablation using flexible bronchoscopy for the treatment of endobronchial tuberculosis

To compare the efficacy and safety of cryorecanalisation and cryoablation using flexible bronchoscopy for the treatment of tumor-like endobronchial tuberculosis (EBTB). Patients with tumor-like EBTB (104) were randomly divided into a cryorecanalisation (54 patients) or cryoablation (50 patients) group to assess the differences in efficacy and complications between the treatments. The cryorecanalisation and cryoablation treatments' therapeutic efficacies were 81.5% and 48.0%, respectively (p = 0.000); in patients with less than moderate obstruction (≤ 50%), the therapeutic efficacies were 92.9% and 88.9%, respectively (p = 1.000). In patients with more than moderate obstruction (> 50%), cryorecanalisation and cryoablation's therapeutic efficacies were 77.5% and 25.0%, respectively (p = 0.000). The number of treatments in the cryorecanalisation and cryoablation groups were 2.46 ± 1.06 and 3.26 ± 0.75, respectively (p = 0.000). The main complication of the treatment protocol in both groups was bleeding, and the overall bleeding rate was 96.2% and 16.0% in the cryorecanalisation and cryoablation groups, respectively (p = 0.000). Cryorecanalisation via flexible bronchoscopy improved the outcome of patients with tumor-like EBTB and reduced the number of treatments required compared with cryoablation; however, it had a higher bleeding rate and the potential risk of severe bleeding.

Endobronchial tuberculosis mimicking malignancy: Lessons from a case report

Endobronchial tuberculosis is characterized by the presence of tuberculous lesions within the bronchi, irrespective of the formation of pulmonary lesions. When these lesions are visible, their morphology often raises the differential diagnosis of malignancy. Diagnostic challenges arise as sputum smear tests-crucial for mycobacterial identification-may yield negative results in up to half of the cases. Here, we present a 66-year-old male who exhibited clinical and radiological findings suggestive of malignancy but was ultimately diagnosed with endobronchial tuberculosis through a combination of bronchoscopy, histopathology, and polymerase chain reaction testing. The patient responded favorably to anti-tuberculosis therapy. This case underscores the importance of comprehensive diagnostic strategies for endobronchial tuberculosis, particularly in distinguishing it from tracheal malignancies.

Performance of Raman Spectroscopy in biopsy tissue for rapid diagnosis of Tracheobronchial Tuberculosis: A prospective study

Tracheobronchial tuberculosis (TBTB) is a specific form of pulmonary tuberculosis characterized by Mycobacterium tuberculosis involvement in the tracheobronchial tree. Rapid and accurate diagnostic tools for TBTB are crucial. Raman spectroscopy (RS) is a noninvasive tool that accesses molecular vibrations and sample characteristics, enabling the creation of a molecular fingerprint of biological samples, which has enormous potential on clinical diagnosis for TBTB. This study aimed to develop and validate a diagnostic model based on RS in bronchial biopsies for identifying TBTB. The training set included patients with TBTB (n = 18), airway malignant diseases (n = 20), and normal mucosal tissue biopsies as the healthy controls (n = 20). The spectral analysis results indicated that differential changes in tissue biomolecules, particularly certain amino acids, among the three groups. K-Nearest Neighbors (KNN), principal component analysis-linear discriminant analysis (PCA-LDA), principal component analysis-support vector machine (PCA-SVM) and decision tree methods were implemented to classify this same spectral data set. The PCA-SVM method exhibited highest classification accuracy, with a sensitivity of 88.89 % and an area under the receiver operating characteristic curve (AUROC) of 0.919. Subsequently, an independent validation set comprising 121 patients with suspected TBTB was enrolled to evaluate the performance of RS model using the PCA-SVM method. The sensitivity of RS model was 87.69 % (57/65) for diagnosing TBTB, higher than that of sputum smear, bronchial brush smear, the Bactec MGIT 960 Culture of bronchoalveolar lavage fluid, and comparable to GeneXpert sensitivity. In conclusion, the RS model using bronchial tissue provides a rapid and accurate method of identifying TBTB, showing potential as a powerful noninvasive tool for TBTB diagnosis under bronchoscopy.

Multidisciplinary care in nonmalignant central airway obstruction

PURPOSE OF REVIEW

The management of histologically benign central airway obstruction (CAO) is complex. Published studies have focused on the diagnostic approaches and therapeutic options provided by specific specialties, but there has been no focus on multidisciplinary management of this disease. Our objective is to review the current diagnostic and therapeutic modalities available for managing nonmalignant CAO from a multidisciplinary perspective involving otolaryngology, thoracic surgery and interventional bronchoscopists.

RECENT FINDINGS

For benign airway strictures, management is via medical and endoscopic therapy with surgical resection reserved for complex and recurrent stenoses. There is evidence and growing interest in intralesional corticosteroid injection in treating inflammation and potentially preventing recurrence. Airway specialists from distinct disciplines use different laser types, dilating balloons and anesthesia methods to manage benign CAO. Recent studies have demonstrated substantial improvements in patient breathlessness and quality of life following therapeutic airway interventions, highlighting the evolving landscape in this cross-disciplinary field.

SUMMARY

Nonmalignant CAO, arising from various mechanical, inflammatory, and infectious etiologies, poses significant morbidity and mortality risks. Current treatments include endoscopic resection, dilation, stent placement, and surgical resection which are selected based on lesion's complexity, extent, operability and patient's symptoms and goals. A multimodal and multidisciplinary approach to patient care could offer the best outcomes.

Imaging of acute dissemination of tuberculosis caused by alveolar lavage surgery in endobronchial tuberculosis characterized by caseous necrosis

Large amount of caseating overlying on bronchus were detected under bronchoscopy in our case. Bronchoalveolar lavage is a major method for diagnosing tuberculosis (TB). TB dissemination caused by bronchoalveolar lavage is very rare. In this case, the patient developed fever after bronchoalveolar lavage and CT confirmed acute dissemination. This might be related to caseating EBTB.

Clinical outcomes of multidrug-resistant tracheobronchial tuberculosis receiving anti-tuberculosis regimens containing bedaquiline or delamanid

The treatment of multidrug-resistant tracheobronchial tuberculosis poses challenges, and research investigating the efficacy of bedaquiline or delamanid as treatment for this condition is limited. This retrospective cohort study was conducted from 2017 to 2021. The study extracted data of patients with multidrug-resistant tracheobronchial tuberculosis from medical records and followed up on prognoses. Participants were divided into three groups: the bedaquiline, delamanid, and control group. Clinical outcomes and the risk factors associated with early culture conversion were analyzed. This study included 101 patients, with 32, 25, and 44 patients in the bedaquiline, delamanid, and control groups respectively. The differences in the treatment success rates among the three groups did not show statistical significance. Both the bedaquiline and delamanid groups had significantly higher culture conversion rates compared to the control after 2 or 6 months of treatment, with significantly shorter median times to culture conversion (bedaquiline group: 2 weeks, delamanid group: 2 weeks, control group: 12 weeks, P < 0.001). Treatment with bedaquiline or delamanid were identified as independent predictors of culture conversion at 2 months (bedaquiline group: aOR = 13.417, 95% CI 4.067-44.260, delamanid group: aOR = 9.333, 95% CI 2.498-34.878) or 6 months (bedaquiline group: aOR = 13.333, 95% CI 3.379-52.610, delamanid group: aOR = 5.000, 95% CI 1.357-18.426) of treatment through multivariable logistic regression analyses. The delamanid group showed better improvement in lumen stenosis compared to bedaquiline. Regimens containing bedaquiline or delamanid may accelerate the culture conversion during the early treatment phase in multidrug-resistant tracheobronchial tuberculosis, and delamanid appears to have the potential to effectively improve airway stenosis.

Risk Factors for Pulmonary Tuberculosis with Tracheobronchial Tuberculosis: Propensity Score Matching Analysis

Background

Pulmonary tuberculosis (PTB) with tracheobronchial tuberculosis (TBTB) can lead to tracheal stenosis and atelectasis, but the specific risk factors are currently unclear. Therefore, the goal of this retrospective study is to address this issue and help with the early diagnosis of TBTB.

Methods

Please include PTB hospitalized in our hospital from January 2021 to October 2023 in the study. After conducting bronchoscopy examinations, the patients were divided into two groups: the PTB group and the PTB&TBTB group. We used the propensity score matching (PSM) to align the baseline data of the two groups of patients, and then performed multiple logistic regression analysis to identify risk factors.

Results

643 patients with PTB were included in the study, 227 of whom (35.30%) were diagnosed with TBTB. A total of 204 pairs of patients were successfully matched using the PSM. After matching, there were no statistically significant differences in basic information between the two groups of patients (P>0.05). Multivariate logistic regression analysis revealed that disease course ≥ 1 month (OR=1.85, 95% CI: 1.21-2.83), complicated with diabetes (OR=3.00, 95% CI: 1.91-4.70), and concomitant pulmonary cavity (OR=3.46, 95% CI: 2.23-5.36) were risk factors for PTB accompanied by TBTB (all P<0.05).

Conclusion

After adjusting for various influencing factors using PSM, the analysis demonstrated that disease course ≥ 1 month, complicated with diabetes, and concomitant pulmonary cavity are risk factors for PTB combined with TBTB. This emphasizes the significance of improving screening and implementing early intervention measures.

Mimicking Metastasis: Endobronchial Tuberculosis Presenting as a Mass in a Pediatric Patient With Yolk Sac Tumor

Before the advent of an effective antitubercular treatment for tuberculosis and bronchoscopy, endobronchial tuberculosis (EBTB) often greatly contributed to airway stenosis and lung atelectasis in children. Even after the advent of efficacious therapy, EBTB poses major challenges for pediatric patients, manifesting as airway stenosis or obstruction. We report a case of a two-year-old male with a previous history of yolk sac testicular tumor whose follow-up PET-CT scan showed right middle lobe collapse. Flexible bronchoscopy demonstrated endobronchial mass, and biopsy revealed EBTB, excluding metastasis. This case illustrates varied presentations of tuberculosis and highlights the significance of early diagnosis with bronchoscopy in treating this condition before it can lead to severe complications. Antitubercular therapy must be initiated at the earliest when managing EBTB. The follow-up procedures must be diligent, and timely interventions should be made for optimal patient outcomes despite the availability of improved diagnostic techniques and treatment methods.

In vitro Antibacterial Effect Study of Plasma-Activated Saline on Mycobacterium Tuberculosis

Purpose

This study aimed to investigate the antibacterial effects of plasma-activated saline (PAS) on My-cobacterium tuberculosis (Mtb).

Methods

We conducted a growth assay on 3 strains of Mtb and an antibiotic sensitivity test on 4 strains of Mtb. Both tests included groups treated with normal saline (NS), PAS, and hydrochloric acid (HCl). The test of antibiotic sensitivity consisted of parallel tests with two concentrations of bacteria suspension: 10-2 and 10-4. The selected antibiotics were rifampicin (RIF), isoniazid (INH), ethambutol (EMB), and streptomycin (SM). The number of bacteria was determined after one month of culture under different conditions. The Kruskal-Wallis test was used to analyze the differences in grouping factors at representative time points.

Results

The growth assay indicated that PAS significantly inhibited the growth of 3 strains of Mtb compared with NS and HCl treatment groups. Furthermore, except for the initial observation time point, the remaining three observation time points consistently demonstrate no significant differences between the NS group and the HCl group. The antibiotic sensitivity test of INH, SM, and RIF indicated that PAS could inhibit the growth of antibiotic-resistant Mtb, and the antibiotic sensitivity test of INH and SM with bacterial suspension concentration of 10-2 and SM with bacterial suspension concentration of 10-4 showed statistically different results. The antibiotic sensitivity test of EMB indicated that the growth of Mtb in PAS was slower than that in NS and HCl in both antibiotic-resistant and sensitive Mtb, but there was no statistical difference.

Conclusion

The study indicates that PAS contains a significant amount of active substances and exhibits high oxidizability and an acidic pH state. The unique physicochemical properties of PAS significantly delayed the growth of Mtb, compared to the NS and the HCl. PAS not only inhibited the growth of drug-sensitive strains but also significantly enhanced the sensitivity of drug-resistant strains to anti-tuberculosis drugs, which may provide a new therapeutic strategy for the treatment of tuberculosis.

Successful Avoidance of Cicatricial Tracheobronchial Stenosis in a Patient With Endobronchial Tuberculosis by Early Administration of Systemic High-Dose Corticosteroids: A Case Report

A 63-year-old Japanese woman was referred to our hospital due to dry cough, fever, hoarseness, stridor, and difficulty breathing. Chest computed tomography showed circumferential wall thickening in the trachea, carina, right main bronchus, and right upper lobe bronchus, and granular and nodular shadows in right S2. Flexible laryngofiberscopy showed yellowish dry respiratory secretions adhering to the subglottis. Bronchoscopic findings showed that the tracheobronchial mucosa was swollen, hyperemic, and covered with yellowish-white, cheese-like materials, and ulcerative lesions with white coatings were observed from the subglottis to the trachea, carina, right main bronchus, and right upper lobe bronchus. A diagnosis of endobronchial tuberculosis (EBTB) was confirmed by polymerase chain reaction testing, and cultures were positive for Mycobacterium tuberculosis. In addition to anti-tuberculosis chemotherapy, intravenous high-dose methylprednisolone reduced her severe respiratory symptoms and prevented cicatricial tracheobronchial stenosis. Early administration of systemic high-dose corticosteroids may be effective for EBTB patients with severely active tracheobronchial mucosal and submucosal lesions.

Endobronchial growth: Tumor or tuberculosis

Endobronchial tuberculosis (EBTB) is characterized by tuberculosis infection of the tracheobronchial tree. It has variable presentation but tumorous growth-like presentation in bronchus is very rare. The clinical and radiological features are non-specific, which creates a diagnostic dilemma. Bronchoscopy and biopsy of the lesion are mandatory to confirm the diagnosis. In this case series, we are presenting three unique cases of endobronchial growth diagnosed as EBTB after biopsy and evaluation of bronchoalveolar lavage (BAL) with cartridge-based nucleic acid amplification test (CBNAAT) and other ancillary investigations for tuberculosis. Four patients presented to the outpatient department with non-specific symptoms of fever, cough, hoarseness of voice, and hemoptysis. They were evaluated with chest radiograph (CXR), contrast-enhanced computed tomography (CECT) thorax, and bronchoscopy. Bronchoscopy revealed growth in the bronchus in all three cases. A biopsy was taken and BAL was performed. All cases turned out to be EBTB in histopathological examination and BAL CBNAAT. They were treated with anti-tubercular drugs and all responded well to treatment. Endobronchial tuberculosis presenting as tumorous growth in the tracheobronchial tree is rare. There should be a high index of suspicion while dealing with patients with non-specific clinical and radiological features of tuberculosis. EBTB can be misdiagnosed as malignancy in most cases. Therefore, it should be kept as a differential diagnosis while encountering a mass lesion in the trachea or bronchus during bronchoscopy.

Long term management of people with post-tuberculosis lung disease

Post-tuberculosis lung disease (PTLD) is emerging as a significant area of global interest. As the number of patients surviving tuberculosis (TB) increases, the subsequent long-term repercussions have drawn increased attention due to their profound clinical and socioeconomic impacts. A primary obstacle to its comprehensive study has been its marked heterogeneity. The disease presents a spectrum of clinical manifestations which encompass tracheobronchial stenosis, bronchiectasis, granulomas with fibrosis, cavitation with associated aspergillosis, chronic pleural diseases, and small airway diseases-all persistent consequences of PTLD. The spectrum of symptoms a patient may experience varies based on the severity of the initial infection and the efficacy of the treatment received. As a result, the long-term management of PTLD necessitates a detailed and specific approach, addressing each manifestation individually-a tailored strategy. In the immediate aftermath (0-12 months after anti-TB chemotherapy), there should be an emphasis on monitoring for relapse, tracheobronchial stenosis, and smoking cessation. Subsequent management should focus on addressing hemoptysis, managing infection including aspergillosis, and TB-associated chronic obstructive pulmonary disease or restrictive lung function. There remains a vast expanse of knowledge to be discovered in PTLD. This review emphasizes the pressing need for comprehensive, consolidated guidelines for management of patients with PTLD.

Post tuberculosis lung disease and tuberculosis sequelae: A narrative review

Post Tuberculosis lung disease (PTLD) and post tuberculosis sequelae is a global and poorly recognized problem, amplified by social factors and immunocompromising conditions, inadequate treatment, lack of effective prevention of tuberculosis (TB) infection and disease. As a disease, it remained until recently poorly defined, with studies heterogenous with regards to regions, population demographics, risk factors, cohort sizes, and methods. Pathophysiologically, even successfully treated pulmonary TB disease has sequelae i.e. involving central and peripheral airways, lung parenchyma and pleura, resulting in airway narrowing and dilatation, fibrocavitation and emphysema, pulmonary vascular changes as well as pleural fibrosis. Functionally patients have airflow limitation, restrictive disease or a mixture of both not rarely associated with respiratory, or even ventilatory failure. Quality of life is often impaired through disability, TB relapse, superinfections and through increased susceptibility to reinfection and persistent inflammation, leading to progressive lung function decline and an increased risk of cardiovascular disease and cancer. Premature mortality due to PTLD is very likely, but poorly described.

Development, assessment and validation of a novel prediction nomogram model for risk identification of tracheobronchial tuberculosis in patients with pulmonary tuberculosis

OBJECTIVE

Tracheobronchial tuberculosis (TBTB), a specific subtype of pulmonary tuberculosis (PTB), can lead to bronchial stenosis or bronchial occlusion if not identified early. However, there is currently no available means for predicting the risk of associated TBTB in PTB patients. The objective of this study was to establish a risk prediction nomogram model for estimating the associated TBTB risk in every PTB patient.

METHODS

A retrospective cohort study was conducted with 2153 PTB patients. Optimised characteristics were selected using least absolute shrinkage and selection operator regression. Multivariate logistic regression was applied to build a predictive nomogram model. Discrimination, calibration and clinical usefulness of the prediction model were assessed using C-statistics, receiver operator characteristic curves, calibration plots and decision analysis. The developed model was validated both internally and externally.

RESULTS

Among all PTB patients who underwent bronchoscopies (n=2153), 40.36% (n=869) were diagnosed with TBTB. A nomogram model incorporating 11 predictors was developed and displayed good discrimination with a C-statistics of 0.782, a sensitivity of 0.661 and a specificity of 0.762 and good calibration with a calibration-in-the-large of 0.052 and a calibration slope of 0.957. Model's discrimination was favourable in both internal (C-statistics, 0.782) and external (C-statistics, 0.806) validation. External validation showed satisfactory accuracy (sensitivity, 0.690; specificity, 0.804) in independent cohort. Decision curve analysis showed that the model was clinically useful when intervention was decided on at the exacerbation possibility threshold of 2.3%-99.2%. A clinical impact curve demonstrated that our model predicted high-risk estimates and true positives.

CONCLUSION

We developed a novel and convenient risk prediction nomogram model that enhances the risk assessment of associated TBTB in PTB patients. This nomogram can help identify high-risk PTB patients who may benefit from early bronchoscopy and aggressive treatment to prevent disease progression.

Clinical Factors for Successful Removal of Airway Silicone Stents in Patients With Post-Tuberculosis Tracheobronchial Stenosis

BACKGROUND

After relieving stenosis with an airway silicone stent in post-tuberculosis bronchial stenosis (PTTS), stent removal is attempted if it is determined that airway patency can be maintained even after stent removal. However, the factors affecting airway stent removal are not well known. We investigate the factors that enable the successful removal of airway silicone stents in patients with PTTS.

METHODS

We retrospectively analyzed PTTS patients who underwent bronchoscopic intervention from January 2004 to December 2019. Successful stent removal is defined as airway patency maintained when the stent is removed, so that reinsertion of the stent is not required. A multivariate logistic regression analysis was used to identify independent factors associated with successful stent removal at the first attempt.

RESULTS

Total 344 patients were analyzed. Patients were followed up for a median of 47.9 (26.9-85.2) months after airway stent insertion. Approximately 69% of PTTS patients finally maintained airway patency after the stent was removed. Factors related to successful stent removal at the first attempt were older age and male sex. Absence of parenchymal calcification, segmental consolidation & bronchiolitis, and no trachea involved lesion were relevant to the successful stent removal. Stent dwelling for 12-24 months was associated with successful stent removal compared to a duration of less than 12 months.

CONCLUSION

For patients whose airway patency is determined to be maintained even without a stent, it is necessary to attempt stent removal in consideration of factors related to successful stent removal.

Rigid Bronchoscopy for Post-tuberculosis Tracheobronchial Stenosis

The healing process of tracheobronchial tuberculosis (TB) results in tracheobronchial fibrosis causing airway stenosis in 11% to 42% of patients. In Korea, where pulmonary TB is still prevalent, post-TB tracheobronchial stenosis (PTTS) is one of the main causes of benign airway stenosis causing progressive dyspnea, hypoxemia, and often life-threatening respiratory insufficiency. The development of rigid bronchoscopy replaced surgical management 30 years ago, and nowadays PTTS is mainly managed by bronchoscopic intervention in Korea. Similar to pulmonary TB, tracheobronchial TB is treated with combination of anti-TB medications. The indication of rigid bronchoscopy is more than American Thoracic Society (ATS) grade 3 dyspnea in PTTS patients. First, the narrowed airway is dilated by multiple techniques including ballooning, laser resection, and bougienation under general anesthesia. Then, most of the patients need silicone stenting to maintain the patency of dilated airway; 1.5 to 2 years after indwelling, the stent could be removed, this has shown a 70% success rate. Acute complications without mortality develop in less than 10% of patients. Subgroup analysis showed successful removal of the stent was significantly associated with male sex, young age, good baseline lung function and absence of complete one lobe collapse. In conclusion, rigid bronchoscopy could be applied to PTTS patients with acceptable efficacy and tolerable safety.

Differences in epidemiological and clinical features between adult and pediatric tracheobronchial tuberculosis patients in Southwest China

Background

Tracheobronchial tuberculosis (TBTB) is a common form of extrapulmonary tuberculosis that affects the tracheobronchial tree. However, the mechanism has not been fully elucidated. Comparisons of clinical characteristics in various age groups can aid in the understanding of TBTB.

Methods

This retrospective study was conducted at the Public Health Clinical Center of Chengdu between July 2017 and December 2021, including adults and children with TBTB. Clinical data were extracted from medical records. T/T' test, Mann-Whitney U test, Chi-square test, or Fisher's exact test were used in this study.

Results

This study enrolled 347 patients with TBTB (175 adults and 172 children). Adult females were more susceptible to TBTB, whereas gender-based differences were not observed in children. Children had a higher occurrence of irritant dry cough and fever, and acute hematogenous disseminated PTB, and specific types of EPTB, but a shorter interval before diagnosis, and lower diagnostic yields compared to adults (P < 0.05). Adults presented more extensive lung lesions and cavitations as compared to children. Granulation hyperplasia and lymph fistula were more frequently observed in children, as well as airway stenosis, but less severe.

Conclusions

The study revealed important variations exist in multiple respects between adults and children with TBTB.

Characteristics analysis of 157 cases of central airway stenosis due to tracheobronchial tuberculosis: A descriptive study

Background

Tracheobronchial stenosis, particularly central airway stenosis, which frequently results in severe complications such as lung damage, occurs in patients with tracheobronchial tuberculosis (TBTB).

Objectives

To analyze the clinical characteristics of patients with central airway stenosis due to tuberculosis (CASTB).

Methods

Retrospective analysis was performed on the clinical features, radiological features, bronchoscopic features and treatment of 157 patients who were diagnosed with CASTB in two tertiary hospitals in Chongqing, China, from May 2020 to May 2022.

Results

CASTB mostly occurs in young patients and females. Patients with CASTB exhibited different symptoms repeatedly during the disease, especially varying degrees of dyspnea, prompting many patients to undergo bronchoscopic intervention and even surgery. Patients with cicatricial strictures constituted the highest proportion of the TBTB subtype with CASTB and 35.7% of the patients with CASTB were found to have tracheobronchomalacia (TBM) under bronchoscopy. CASTB and TBM mainly involved the left main bronchus. Patients with lower levels of education had higher rates of TBM. Patients with TBM manifested shortness of breath more frequently than patients without TBM. Patients with TBTB who had undergone bronchoscopic interventions have a higher rate of TBM.

Conclusions

Despite mostly adequate anti-tuberculosis chemotherapy, patients with TBTB can present with CASTB involving severe scarring stenosis, bronchial occlusion, tracheobronchomalacia and even destroyed lung.

A prediction model for risk of low oxygen saturation in patients with post-tuberculosis tracheobronchial stenosis during bronchoscopy

BACKGROUND

Low oxygen saturation (LOS) is a frequent occurrence for patients with post-tuberculosis tracheobronchial stenosis (PTTS) during bronchoscopic procedures. However, there are currently no systematic assessment tools to predict LOS risk in PTTS patients during bronchoscopy.

OBJECTIVES

This study aimed to develop an effective preoperative predictive model to guide clinical practice.

DESIGN

Retrospective cohort study.

METHODS

Data was retrospectively collected from PTTS patients who underwent bronchoscopic interventions between January 2017 and December 2022. Among all patients included in this study, patients between January 2017 and December 2021 were used as training cohort for the logistic regression model, and patients between January 2022 and December 2022 were utilized as validation cohort for internal validation. We used consistency index (C-index), goodness-of-fit test and calibration plot to evaluate the model performance.

RESULTS

A total of 465 patients who met the inclusion criteria were enrolled in the study. The overall incidence of LOS was 26.0% (121/465). Comorbidity, degree of stenosis, bronchoscopist level, thermal ablation therapy, balloon dilation, and airway stenting, as independent risk factors for the presence of LOS, were used to construct the nomogram prediction model. The C-index of training cohort was 0.827 (95% CI, 0.786-0.869), whereas that of validation cohort was 0.836 (95% CI, 0.757-0.916), combining with the results of the calibration plot and goodness-of-fit test, demonstrating that this model had good predictive ability.

CONCLUSION

The predictive model and derived nomogram with good predictive ability has been developed to preoperatively predict the risk of LOS in PTTS patients during bronchoscopy, allowing for individualized interventions for high-risk patients.

The Usefulness of Bronchoscopy in the Diagnosis of Mycobacterium tuberculosis Complex Species Infection

BACKGROUND: Pulmonary tuberculosis is an active chronic infection of the lungs. It is still a public health problem globally caused by the Mycobacterium tuberculosis Complex (MTBC). These species are difficult to determine only by conventional tests. The clinical manifestations are almost similar between the strains and cause diagnosis delays. Prolonged and intolerable MTBC therapy inhibits infection control. AIM: This study aims to evaluate the usefulness of bronchoscopy in diagnosing the MTBC species infection. METHODS: This study recruited patients with difficulty expectorating sputum. Pulmonary tuberculosis was diagnosed with the Xpert MTB/RIF assay. This study assessed sputum Acid Fast Bacilli (AFB) staining, chest X-rays with active pulmonary tuberculosis, characteristics of Bronchoalveolar lavage (BAL), and bronchoscopic findings based on the Chung classification. The BAL of polymerase chain reaction analysis using RD9 and TbD1 primers to determine MTBC species. RESULTS: Out of the 30 cases, M. tuberculosis and Mycobacterium bovis 24 (80.0%) and 6 (20.0%) were identified in BAL fluid. There were 12 cases (40.0%) with AFB sputum test, and 25 (83.3%) of the Xpert MTB/RIF detected tuberculosis cases. All chest X-rays showed infiltrated and 22 (73.3%) pulmonary ectasis. There was a significant difference in MTBC species between sputum and BAL fluid (p < 0.05). The ulcerative type of bronchoscopy findings was significantly different in MTBC species (p < 0.05) and there was no macroscopic BAL fluid difference (p > 0.05). CONCLUSIONS: Bronchoscopy is a specimen collection technique that is beneficial in determining the diagnosis of MTBC. Analysis of BAL with molecular methods contributes to identifying MTBC species quickly and accurately.

Endobronchial tuberculosis in children: Defining the role of interventional bronchoscopy

INTRODUCTION

Endobronchial tuberculosis (EBTB) can lead to bronchopulmonary complications when diagnosis is delayed. Bronchoscopic treatment in children can be challenging due to small airway size. We report our experience treating children with EBTB.

METHODS

Retrospective study (2014-2020) of patients diagnosed with EBTB. Flexible bronchoscopy (FB) was performed in patients with previous diagnosis of pulmonary tuberculosis (PTB), after respiratory/radiological worsening was observed in spite of medical treatment. Treatment consisted in oral corticotherapy in all patients, and interventional bronchoscopy in selected cases. Our aim is to describe the endoscopic findings, interventional bronchoscopy alternatives, and outcome.

RESULTS

Of 45 patients with PTB, 13 (28.9%, 7 M/6 F) were diagnosed with EBTB, with a mean age of 3.9 years (0.4-12.8). Four bronchoscopic patterns were observed. Endobronchial granuloma (N:9; 69.2%): Excision with rigid bronchoscopy was achieved in five (1-5 procedures per patient), while corticotherapy alone was preferred in the remaining four due to small size/distal location of the granuloma. Caseum obstruction (2; 15.4%): dense mucous molds were removed with flexible/rigid bronchoscopy (6 and 8 procedures, respectively). Bronchial stenosis (1; 7.7%): two balloon dilatations with mitomycin-C application were performed. Extrinsic compression (1; 7.7%): oral corticotherapy alone was initiated. One patient developed bronchoscopy-related complications (pneumothorax requiring thoracic tube 48 h). With a medium follow-up of 4.6 years (1.8-7.6), three patients developed bronchiectasis while the remaining 10 improved clinically and radiologically.

CONCLUSION

Bronchoscopic findings in EBTB include granuloma, stenosis, caseum obstruction and external compression. In selected cases, interventional bronchoscopy can minimize long-term bronchopulmonary complications.

Tuberculous bronchial stenosis: Diagnosis and role of interventional bronchoscopy

The reported prevalence of tuberculous bronchial stenosis in children is unknown and rarely reported in English-speaking literature. In adult patients with pulmonary tuberculosis, it varies from 40% in an autopsied series in the preantibiotic era to 10% in patients who have undergone routine bronchofibroscopy in modern times. We describe our experience of four cases of confirmed bronchial stenosis due to MTB collected between January 2000 and June 2021 in this case series descriptive study. The diagnosis of bronchial stenosis due to TB was made on flexible bronchoscopy. A TB diagnosis was made if MTB was cultured from respiratory secretions, when Ziehl-Neelsen smear or GeneXpert MTB/RIF test was positive, or if a chest radiograph revealed radiographic features typical of MTB. Bronchial stenosis due to TB is rare even if airway compression is frequently seen. Although an early diagnosis of bronchial stenosis due to TB is difficult on chest X-rays, all children in this series demonstrated parenchymal changes distal to the stenosis ranging from hyperinflation and lobar collaps to bronchiectasis. If bronchial stenosis resulting from TB disease is diagnosed early, balloon dilatation as described in this report, may be an effective and safe intervention, preventing long-term complications such as irreversible lung destruction, that may require pneumonectomy.

Post-tuberculosis tracheobronchial stenosis: long-term follow-up after self-expandable metallic stents placement and development of a prediction score-the Restenosis Score

Background

The insertion of self-expandable metallic stents (SEMS) for post-tuberculosis tracheobronchial stenosis (PTTS) was controversial. This study aimed to evaluate the efficacy and safety of SEMS for treating PTTS, and developed a scoring system for predicting the occurrence of restenosis after stenting in PTTS patients.

Methods

We conducted a retrospective review of 87 patients who were diagnosed with PTTS and experienced SEMS insertion between January 2000 and December 2017. All procedures were performed via flexible bronchoscopy under conscious sedation and local anesthesia.

Results

A total of 85 SEMS were successfully placed in 77 patients. Comparing with pre-stenting, there were significant improvements in the lumen diameters of the stenotic segment, mMRC scale and lung function after short-term SEMS placement. During the long-term (average 163.32 months) follow-up, 48 patients (62.3%) did not develop restenosis after stenting; the other 29 patients (37.7%) developed and eventually, 12 remained under interventional therapies and 11 had bronchial atresia. Multivariate Cox regression analysis revealed that the difference value between SEMS length and the stenosis-segment length, stenosis type, and the number of pre-stenting thermal ablation were independently related to restenosis occurrence and were subsequently used to establish the Restenosis Score. The model’s development group (0.83, 95% CI 0.74–0.92) and external validation set (0.94, 95% CI 0.77–1.00) showed excellent discrimination.

Conclusion

SEMS placement could serve as a safe and effective treatment option for most patients with PTTS. Further, we built a prediction model depending on the independent predictors of restenosis occurrence, the Restenosis Score. This validated tool might provide a decision support and a better management for PTTS patients who underwent SEMS implantation.

Identification of potential genes in endobronchial tuberculosis after bronchoscopic cryotherapy by transcriptome sequencing

BACKGROUND

Bronchoscopic cryotherapy facilitates the treatment of endobronchial tuberculosis (EBTB) and helps suppress progressive bronchial stenosis. However, the molecular mechanism of bronchoscopic cryotherapy in EBTB patients has not been reported.

METHODS

Transcriptome sequencing was performed to explore differentially expressed mRNAs (DEGs) in EBTB patients before and after bronchoscopic cryotherapy. Gene Ontology (GO) and KEGG analyses were carried out. Five genes (MKLN1, HIGD1A, PTGES, SKIL, and MCEMP1) were selected and validated using real-time qPCR (RT- qPCR).

RESULTS

In transcriptome analysis, 448 DEGs with p < 0.05 and|logFC| > 1 were identified; of these, 171 and 277 DEGs were significantly up- and down-regulated after bronchoscopic cryotherapy, respectively. Results displayed 337 biological process (GO-BP), 48 cellular component (GO-CC) and 62 molecular function (GO-MF) terms and 20 KEGG pathways. RT- qPCR results were consistent with the sequencing data.

CONCLUSION

These data provide informative evidence and recommendations for further scientific research on bronchoscopic cryotherapy for EBTB.

Early and Regular Bronchoscopy Examination on Effect of Diagnosis and Prognosis for Patients With Tracheobronchial Tuberculosis

BACKGROUND

Bronchoscopy is the main method for the diagnosis of tracheobronchial tuberculosis (TBTB). However, it is not well-used in patients with pulmonary tuberculosis (PTB), leading to misdiagnosis. The aim of this study is to verify the value and feasibility of bronchoscopy for an early diagnosis and treatment of TBTB.

MATERIALS AND METHODS

A prospective observational study was performed in patients with active PTB. The ratios of TBTB and tracheobronchial stenosis were analyzed with propensity score matching (PSM) for baseline characteristics, and a Cox regression model was further employed to adjust for residual confounding factors.

RESULTS

A total of 656 patients with active PTB were enrolled in the study that included 307 patients in the active group and 349 patients in the non-active group. The ratio of TBTB was significantly higher in the active group than that in the non-active group [hazard ratio (HR), 2.31; 95% CI, 1.70-3.14; p < 0.001]. With PSM, the proportion of tracheobronchial stenosis in the non-active group was significantly higher than that in the active group (HR, 1.84; 95% CI, 1.15-2.95; p = 0.011). Moreover, the number of patients with moderate to severe stenosis were significantly higher than that in the active group (HR, 4.13; 95% CI, 2.25-7.63; p < 0.001). Similar results were obtained with multivariate analysis. With 12 months of treatment, both therapeutic effective rate (84.7 vs. 68.2%; p = 0.009) and improvement rate of non-fibrotic tracheobronchial stenosis (79.1 vs. 47.4%; p = 0.022) were higher in the active group than that in the non-active group.

CONCLUSION

Active and regular bronchoscopy is conducive to early diagnosis of TBTB, combined with prompt anti-tuberculosis therapy, greatly reducing the occurrence of tracheobronchial stenosis and improving prognosis.

Bronchoscopic Features and Morphology of Endobronchial Tuberculosis: A Malaysian Tertiary Hospital Experience

The diagnosis of endobronchial tuberculosis (EBTB) is difficult as it is not well visualized radiologically, and bronchoscopy is not routinely performed for tuberculosis (TB) patients. Bronchoscopic characterization via endoscopic macroscopic features can speed up the diagnosis of EBTB and prompt immediate treatment. In this study, we identified the clinical and bronchoscopic morphology of 17 patients who were diagnosed with EBTB from 2018 to 2020. Demographics, radiological, microbiological and histopathological data were recorded. Endobronchial lesions were classified according to Chung classification. The diagnosis was made based on a histopathological examination (HPE) of endobronchial biopsy, and/or positive ‘Acid-fast bacilli’ (AFB) microscopy/Mycobacterium tuberculosis (MTB) culture on microbiological examination of bronchial alveolar lavage (BAL) and/or positive MTB culture on endobronchial biopsy specimens. Furthermore, EBTB was predominant in young women, age 20 to 49 years old, with a male to female ratio of 1 to 2. Underlying comorbidities were found in 53% of the patients. Cough, fever and weight loss were the main symptoms (23.5%). The indications for bronchoscopy are smear-negative TB and persistent consolidation on chest radiographs. Consolidation was the main radiological finding (53%). An active caseating lesion was the main EBTB endobronchial subtype (53%). The leading HPE finding was caseating granulomatous inflammation (47%). All patients showed good clinical response to TB treatment. Repeated bronchoscopy in six patients post TB treatment showed a complete resolution of the endobronchial lesion. EBTB bronchoscopic characterization is paramount to ensure correct diagnosis, immediate treatment and to prevent complication.

Efficacy and safety of CO2 cryotherapy in the treatment of infants with tracheobronchial tuberculosis

OBJECTIVE

This study aimed to investigate the efficacy and safety of CO₂ cryotherapy for lymph node fistula tracheobronchial tuberculosis (TBTB) in infants.

PATIENTS AND METHODS

A retrospective analysis was undertaken on seven patients with lymph node fistula tracheobronchial tuberculosis who underwent fiberoptic bronchoscopy (FB) interventional therapy in the respiratory department of Tianjin Children's Hospital from July 2012 to July 2020. The efficacy, safety, and prognosis of CO₂ cryotherapy intervention for the treatment of lymph node fistula TBTB in infants were summarized and analyzed.

RESULTS

Seven patients with lymph node fistula TBTB were included in this study. Their ages ranged from 6-13 months. The course of the disease from onset to TBTB ranged from 20 to 70 days. The pathological diagnoses of seven cases by FB combined with tissue biopsy were lymph node fistula TBTB, of which 28.57% (two cases) were in the early stage of rupture and 71.43% (five cases) were in the rupture stage. All patients were treated with CO₂ cryotherapy combined with foreign body forceps and local injection drugs based on systemic antituberculosis chemotherapy. Two patients were treated once with CO₂ cryotherapy, and five were treated three times. According to the comparison of the clinical symptoms, imaging results, and endoscopic presentations before and after the intervention, six patients achieved clinical cure, and one achieved clinical improvement. No severe intraoperative or postoperative complications were observed. The clinical symptoms, endoscopic findings, radiological manifestations, and quality of life of all patients showed marked improvement. No recurrence occurred after 3-6 months of follow-up with FB.

CONCLUSION

CO₂ cryotherapy can improve the treatment effect of lymph node fistula in infants with TBTB and reduce the incidence of complications. This treatment is safe and reliable in infants.

Endobronchial Lesions from Disseminated Mycobacterium avium Infection in a Patient with Anti-interferon-gamma Autoantibodies

A 78-year-old man was admitted to our hospital with a fever and left chest pain. Computed tomography showed multiple lung nodules, narrowing of the right bronchus intermedius with mediastinal lymphadenopathy, and an osteolytic lesion. Bronchoscopic findings showed rapid progression of multiple polypoid lesions and the bronchial stenosis. A biopsy of the endobronchial lesions revealed non-necrotizing granulomatous inflammation, and a tissue culture identified Mycobacterium avium. An anti-human immunodeficiency virus antibody was negative. Finally, anti-interferon-gamma (IFN-γ) autoantibodies were detected, and the patient was diagnosed with disseminated nontuberculous mycobacterium infection with anti-IFN-γ autoantibodies. Antimycobacterial therapy was effective, and radiographic findings, including the endobronchial lesions, were resolved.

Left Main Bronchus Stenosis Lesion, Neutrophil Count, and Platelet Count Are Predictors of Post-Tuberculosis Bronchomalacia

Background

Post-tuberculosis bronchomalacia (PTBM) is one of the main conditions occurring in patients after tracheobronchial tuberculosis (TBTB), and is also associated with the recurrence of symptoms. The present study aimed to investigate the predictors of PTBM in patients who had been undergoing appropriate TB treatment.

Material/Methods

Clinical data of 104 patients with symptomatic airway stenosis after TBTB between January 01, 2019 and June 31, 2020 were recorded and analyzed. The association between baseline clinical characteristics, laboratory results, and PTBM was calculated with logistical regression. The time from onset of bronchoscopic intervention was examined by Kaplan-Meier estimates; differences between the 2 groups were tested by the log-rank test.

Results

Fifty-seven patients (54.81%) had PTBM. In the multivariate logistical analysis, the left main bronchus stenosis lesion (odds ratio [OR]=3.763), neutrophil (NEUT) count (OR=1.527), and platelet (PLT) (OR=1.010) count were predictors of PTBM. During follow-up, patients with BM had a significantly longer duration from onset of bronchoscopic intervention than patients without BM (hazard ratio=2.412, P<0.0001). Further, all patients needing long-term bronchoscopic intervention therapy were subsequently identified as having PTBM. Additionally, blood PLT counts were significantly decreased to normal levels in the non-BM group (P<0.05), but not in the BM group (P>0.05).

Conclusions

PTBM is most likely to occur in the left main bronchus. The inflammatory and immune responses associated with NEUT and PLT may represent therapeutic targets of PTBM. Our study is the first to report that decreased blood PLT count has the potential to monitor the treatment response.

Pseudomembranous Tracheobronchitis due to Mycobacterium tuberculosis

Although the incidence is declining in the western world, Mycobacterium tuberculosis remains one of the most common infectious organisms responsible for significant morbidity and mortality worldwide. Pulmonary tuberculosis (TB) is the most commonly seen presentation; however, TB can affect nearly any of the body's organ systems. Endobronchial TB (EBTB) can complicate pulmonary TB or more rarely present as an isolated finding. It is essential to recognize and treat this condition promptly, as it can develop into tracheobronchial stenosis and chronic respiratory failure.

Here we discuss the case of a 43-year-old female with a left upper lobe cavitary lesion who presented with weight loss, dyspnea, and hoarseness. After failing multiple courses of antibiotics, the patient underwent bronchoscopy, and pseudomembranous tracheobronchitis (PMTB) was diagnosed. Cultures of endobronchial samples grew Mycobacterium tuberculosis. Standard anti-TB quadruple therapy was initiated, and the patient clinically improved.

Several subtypes of EBTB have been identified earlier. However, to the best of our knowledge, tuberculous PMTB has not previously been reported. This case allows us to consider the diagnostic and therapeutic implications of this condition.

Diagnostic Efficacy of Xpert MTB/RIF Assay in Bronchoalveolar Lavage Fluid for Tracheobronchial Tuberculosis: A Retrospective Analysis

Background: The Xpert Mycobacterium tuberculosis/rifampin (MTB/RIF) assay has shown good diagnostic efficacy in brushing and biopsy tissue samples from patients with tracheobronchial tuberculosis (TBTB). However, its diagnostic value in bronchoalveolar lavage fluid (BALF) is still unclear. Therefore, the present retrospective study aimed to evaluate the diagnostic value of the Xpert MTB/RIF assay in BALF.

Methods: The clinical data of 266 patients with suspected TBTB from January 2018 to October 2020 were pooled with complete details of bronchial brush and bronchoalveolar lavage samples. Smears of the bronchial brushings were stained with Auramine O stain to detect acid-fast bacilli (AFB), and BALF samples were used for culturing MTB with the BACTEC MGIT 960 system and the Xpert MTB/RIF assay. The diagnostic performance of these methods was assessed and compared.

Results: A total of 266 patients suspected to have TBTB were enrolled in the final analysis. Of these patients, 179 patients were confirmed to have TBTB and 87 patients were non-TBTB. The sensitivity of the Xpert MTB/RIF assay in BALF (87.2%) was significantly higher than that of the brush smear for AFB (35.2%, p < 0.001). No significant difference was observed between the sensitivities of the Xpert MTB/RIF assay in BALF and MTB culture in BALF (87.2 vs. 84.9%, p = 0.542). The specificities of the Xpert MTB/RIF assay in BALF, MTB culture in BALF, and the bronchial brush smear were 97.7, 97.7, and 98.9%, respectively. The positive predictive value (PPV) and negative predictive value (NPV) of the Xpert MTB/RIF assay in BALF, MTB culture in BALF, and the bronchial brush smear were 98.7 and 78.7%, 98.7 and 75.9%, and 98.4 and 42.6%, respectively. Among the MTB culture-positive patients with TBTB detected by the Xpert assay, 27.0% (20/74) were identified to be resistant to RIF.

Conclusions: The Xpert MTB/RIF assay in BALF enables a rapid and accurate diagnosis of TBTB and identification of RIF resistance, which is crucial for timely and proper treatment. Moreover, in patients with TBTB, BALF could be used as an alternative to bronchial brushing and biopsy tissues for the Xpert MTB/RIF assay.

Multi-disciplinary management of patients with benign airway strictures: A review

Histologically benign airway strictures are frequently misdiagnosed as asthma or COPD and may present with severe symptoms including respiratory failure. A clear understanding of pathophysiology and existing classification systems is needed to determine the appropriate treatment options and predict clinical course. Clinically significant airway strictures can involve the upper and central airways extending from the subglottis to the lobar airways. Optimal evaluation includes a proper history and physical examination, neck and chest computed tomography, pulmonary function testing, endoscopy and serology. Available treatments include medical therapy, endoscopic procedures and open surgery which are based on the stricture's extent, location, etiology, morphology, severity of airway narrowing and patient's functional status. The acuity of the process, patient's co-morbidities and operability at the time of evaluation determine the need for open surgical or endoscopic interventions. The optimal management of patients with benign airway strictures requires the availability, expertise and collaboration of otolaryngologists, thoracic surgeons and interventional pulmonologists. Multidisciplinary airway teams can facilitate accurate diagnosis, guide management and avoid unnecessary procedures that could potentially worsen the extent of the disease or clinical course. Implementation of a complex airway program including multidisciplinary clinics and conferences ensures that such collaboration leads to timely, patient-centered and evidence-based interventions. In this article we outline algorithms of care and illustrate therapeutic techniques based on published evidence.

Self-expanding covered metallic stents as a transition to silicone stent implantation in management of severe post-tuberculosis bronchial stenosis

BACKGROUND AND AIMS

Post-tuberculosis bronchial stenosis (PTBS) is one of the most common complications of tracheobronchial tuberculosis. Silicone stent serves as a major treatment for maintaining airway patency. However, silicone stent placement remains a large challenge in patients with severe cicatricial PTBS. Our objective was to evaluate the efficacy and safety of covered, self-expanding, metallic stents (SEMSs) as a transition to silicone stent implantation for treating severe PTBS.

METHODS

We retrospectively reviewed the data of patients with severe PTBS who received airway stenting in the First Affiliated Hospital of Guangdong Medical University between September 2015 and May 2019. The types of the stent, intervention procedures, bronchoscopic findings, clinical outcomes and related complications were collected and analyzed.

RESULTS

Fifty-eight cases with severe PTBS were included in this study. Thirteen (22.4%) of the patients received bronchial silicone stent implantation immediately after dilations. For the remaining 45 (77.6%) patients, silicone stents could not be deployed after dilations and SEMSs implantation was implemented as a bridge to silicone stenting. The SEMSs were placed for an interval of 28.4 ± 11.1 days. All of the silicone stents were inserted successfully following the removal of SEMSs. No SEMS-related complication occurred. The subgroup analysis showed that patients who received transitional SEMSs had less luminal caliber but fewer transbronchial dilations before silicone stent implantation (p < 0.05).

CONCLUSION

Covered SEMS placement as a transition to silicone stenting could serve as a feasible procedure to reduce complications and improve the success rate of silicone stent implantation in patients with severe PTBS.The reviews of this paper are available via the supplemental material section.

Topical mitomycin-C as an adjuvant to multimodal endoscopic treatment for tracheobronchial stenosis secondary to endobronchial tuberculosis

Tracheobronchial stenosis secondary to endobronchial tuberculosis (TSTB) is a rare but debilitating complication of endobronchial tuberculosis (EBTB). Topical mitomycin-C (TMC) has been successfully utilized to restore airway patency and to prevent recurrence of TSTB, although little is known about its exact efficacy. Here, we report the biggest case series to date involving seven patients who received TMC as part of multimodality endoscopic treatment for TSTB with varying levels of success. All patients presented with dyspnoea during or after treatment completion for pulmonary tuberculosis (PTB). Four patients had short-segment concentric membranous TSTB while two patients had concurrent bronchomalacia. Another one patient had a thick fibrotic band adjacent to luminal opening. We hypothesize that TMC is more efficacious in short membranous stenosis without concurrent bronchomalacia and/or thick fibrotic bands. More studies are needed to bridge the current gaps in knowledge regarding the optimal role and benefits of TMC for TSTB patients.

Endobronchial Tuberculosis and Bronchostenosis: A Rare Case of Bronchial Occlusion in a Patient With History of Tuberculosis

Pulmonary tuberculosis is common worldwide, and many of these patients develop endobronchial tuberculosis (EBTB). Bronchostenosis is a known complication of EBTB though most patients with endobronchial stenosis do not develop severe bronchostenosis or occlusion. We present a rare case of a patient with a right upper lobe bronchus occlusion and a history of tuberculosis.

Inflammatory Lesions Mimicking Chest Malignancy: CT, Bronchoscopy, EBUS, and PET Evaluation From an Oncology Referral Center

Infective and inflammatory diseases can mimic malignancy of the lung. Granulomatous inflammations are common causes of pulmonary nodule, mass, or nodal disease. Systemic infection or inflammation also commonly involves the lung that may raise suspicion of a malignant process. Even in patients with a known malignancy, inflammatory diseases can simulate new metastasis or disease progression. Knowledge of the imaging features of these diseases is essential to prevent missed or overdiagnosis of malignancy. Radiologists also need to be familiar with the scope and limitations of bronchoscopy, endobronchial ultrasound, PET-CT, and biopsy to guide clinical management. In this review, we discuss the imaging features and diagnostic approach of common mimickers of chest malignancy that involve the chest wall, pleura, lung parenchyma, and mediastinal nodes.

Surgical intervention is safe, feasible, and effective in tubercular tracheobronchial stenosis

Objectives:

Posttubercular tracheobronchial stenosis is a troublesome sequela of tracheobronchial tuberculosis. Surgical resection is the treatment of choice when repeated bronchoscopic dilatations fail. Herein, we aim to present our surgical experience in the management of this problem and also to evaluate factors affecting the surgical outcomes.

Materials and Methods:

This is a retrospective analysis of a prospectively maintained database at a dedicated thoracic surgical unit in New Delhi, India, over 8 years. An analysis of demographic characteristics, perioperative variables including complications were carried out. The occurrence of postoperative complications, and/or hospital stay of >7 days was considered as “poor” surgical outcomes. Various parameters were analyzed to assess the factors predicting surgical outcomes.

Results:

A total of 20 patients were surgically managed in the study period. Two patients had tracheal stenosis. The left main bronchus was involved in 16 patients. In these 16 cases, 12 cases underwent lung preserving surgery (bronchial sleeve resection and sleeve lobectomy) and rest of 4 cases required pneumonectomy. All postoperative complications occurred in 5 (25%) patients. Prolonged air leak was the most common postoperative complication. On univariate analysis, surgical outcomes were poor in patients who had longer duration of symptoms (P = 0.03) and with >2 episodes of preoperative balloon dilatations (<0.001). On multivariate analysis, “total number of dilatations <4 times,” emerged as a significant predictive factor for lung preservation surgery.

Conclusions:

Surgical intervention is safe, feasible, and effective in tubercular tracheobronchial stenoses which fail to respond to bronchoscopic interventions. Early referral for surgery favors lung preservation.

Conservative management of airway tear as a complication of silicone endobronchial stenting in bronchomalacia secondary to endobronchial tuberculosis

Tracheobronchial stenosis due to tuberculosis (TSTB) is a potentially debilitating complication of endobronchial tuberculosis (EBTB). Endobronchial interventions including silicone stent insertion is an acceptable approach to improve quality of life among patients with TSTB. However, little is known about the optimal management strategy for patients with bronchomalacia secondary to EBTB (B-EBTB) and whether stent-related complication rates are higher among this group of patients. Herein, we report two patients with B-EBTB who unfortunately developed bronchial tear related to silicone endobronchial stenting. Both patients were successfully managed conservatively without the need for emergency open surgery. We hypothesize that endobronchial intervention might be more beneficial for patients with pure TSTB and might be riskier in cases of bronchomalacia with reduced airway thickness and loss of airway cartilaginous support. More future studies are needed to bridge the current gap in knowledge regarding the optimal management and role of endobronchial interventions among patients with B-EBTB.

A Case of Laryngeal Tuberculosis, Endobronchial Tuberculosis and Pulmonary Tuberculosis Coexistent in an Immunocompetent Host

Historically associated with poor prognosis seen in advanced disease, laryngeal tuberculosis (LTB) now represents only 1% of all cases of tuberculosis (TB). The incidence of LTB has decreased drastically with the introduction of anti-tubercular drugs. LTB can be primary or secondary to pulmonary tuberculosis. LTB can mimic laryngeal cancer. We present a case of primary laryngeal TB with descending tracheobronchial spread in an immunocompetent 71-year-old female who developed progressive dysphonia over several months with unintentional weight loss and non-productive cough. Non-contrast enhanced computed tomography (CT) revealed clustering of subcentimeter stellate nodules in the right upper lung field with an enlarging ground-glass opacity in the right lower lung but did not show structural abnormalities within the neck. Positron emission tomography (PET) showed pathologic fluorodeoxyglucose (FDG) uptake within the larynx and trachea with extension into the left mainstream bronchus as well as the proximal left upper and lower lobe bronchi. Diffuse standardized uptake value (SUV) was greatest in the larynx (20.5). Polymerase chain reaction (PCR) on bronchoscope sputum specimen confirmed Mycobacterium tuberculosis. Findings were consistent with primary laryngeal TB with endobronchial extension. She was started on a four-drug regimen comprising of isoniazid, rifampin, ethambutol, and pyrazinamide with a good response. Her close contacts were treated as well. This case highlights the unusual spread of primary laryngeal TB in an immunocompetent host. Early diagnosis can limit adverse complications and unnecessary exposure to healthcare workers. To our knowledge, this is the first case of primary LTB with proximal spread to the tracheobronchial and pulmonary tuberculosis.

Long-term outcomes of tracheobronchial stenosis due to tuberculosis (TSTB) in symptomatic patients: airway intervention vs. conservative management

Background

Patients with tracheobronchial stenosis due to tuberculosis (TSTB) have a variable clinical course and response to treatment including airway intervention. There are no clear guidelines on the best approach to manage such patients. This study examines long-term outcomes of patients with TSTB and factors associated with recurrent symptoms or need for repeat airway intervention following initial bronchoscopic intervention.

Methods

This is a retrospective analysis of patients with TSTB over an 18-year period. Symptoms, radiological, bronchoscopic findings, airway interventions and complications were obtained. Multivariate logistic regression analysis was performed to identify factors predictive of recurrence of symptoms or need for repeat airway intervention.

Results

A total of 131 patients with mean age 50±18 years and median follow-up 5 (interquartile range, 2–10) years were included. Nineteen (29.7%) patients underwent balloon dilatation alone, 22 (34.4%) had additional resection or stenting, and 19 (29.7%) underwent all 3 procedures. Among patients conservatively managed, a larger proportion (55.6%) of patients with no recurrence of symptoms had active TB. Patients who developed recurrent symptoms had longer symptom duration (12 vs. 3 months, P=0.025), and more had recurrent lower respiratory tract infections (50% vs. 5.6%, P=0.003), lung collapse (90.0% vs. 41.7%, P=0.011) or linear fibrosis (70.0% vs. 30.6%, P=0.033) compared to those without recurrent symptoms. Bronchomalacia (OR =17.18; 95% CI, 3.43–86.18) and prior bronchoscopic airway resection (OR =4.97; 95% CI, 1.20–20.60) were strongly associated with the recurrence of symptoms or need for repeat airway intervention on multivariate logistic regression analysis.

Conclusions

Bronchomalacia and prior bronchoscopic airway resection are associated with the recurrence of symptoms despite airway intervention. Patients who are diagnosed with TSTB early in the course of active TB may be conservatively managed.

A variety of bacterial aetiologies in the lower respiratory tract at patients with endobronchial tuberculosis

Recently, our understanding of the elusive bacterial communities in the lower respiratory tract and their role in chronic lung disease has increased significantly. However, little is known about the respiratory microorganisms in patients with endobronchial tuberculosis (EBTB), which is a chronic inflammatory disease characterized by destruction of the tracheobronchial tree due to Mycobacterium tuberculosis (MTB) infection. We retrospectively reviewed data for histopathologically and microbiologically confirmed EBTB patients diagnosed at a tertiary referral hospital in South Korea between January 2013 and January 2019. Bacterial cultures were performed on bronchial washing from these patients at the time of EBTB diagnosis. A total of 216 patients with EBTB were included in the study. The median age was 73 years and 142 (65.7%) patients were female. Bacteria were detected in 42 (19.4%) patients. Additionally, bacterial co-infection was present in 6 (2.8%) patients. Apart from MTB, the most common microorganisms identified were Staphylococcus aureus (n = 14, 33.3%) followed by Klebsiella species (n = 12, 28.6%; 10 Klebsiella pneumoniae, 2 Klebsiella oxytoca), Streptococcus species (n = 5, 11.9%), Enterobacter species (n = 4, 9.5%), and Pseudomonas aeruginosa (n = 3, 7.1%). A variety of microorganisms were isolated from the bronchial washing indicating that changes in microorganism composition occur in the airways of patients with EBTB. Further studies are needed to investigate the clinical significance of this finding.

Endobronchial tuberculosis polyps

Endobronchial tuberculosis (TB) is an uncommon manifestation of Mycobacterium tuberculosis. We report a case of endobronchial TB polyps in a patient from India presenting with cough, loss of weight and night sweats. Computed tomography chest revealed enlarged mediastinal lymph nodes, endobronchial invasion, and nodular infiltrates in the right lower lobe. Flexible bronchoscopy revealed two endobronchial polyps at the carina and left main bronchus which were biopsied. Histopathology showed non‐caseating granulomas. Both the biopsy and bronchial washings did not identify acid‐fast bacilli on Ziehl‐Neelsen stain and had negative TB complex DNA polymerase chain reaction. One month after bronchoscopy, M. tuberculosis was cultured from the bronchial washings. Following six months of TB treatment, there was full resolution of symptoms and significant radiological improvement. We highlight the diagnostic challenges in endobronchial TB which may impact on the timely institution of treatment.

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.