Endobronchial tuberculosis presenting as right middle lobe syndrome: clinical characteristics and bronchoscopic findings in 22 cases

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.

A 76-Year-Old Woman With Incidental Right Middle Lobe Atelectasis

CASE PRESENTATION

A 76-year-old nonsmoking woman visiting from Honduras for the last 6 months with no known medical history originally presented to the ED complaining of abdominal pain. While in the ED, an incidental right middle lobe collapse was found on CT abdomen scan. Review of systems was positive for a chronic productive cough with white sputum for 3 years. She denied association with fevers, chills, night sweats, hemoptysis, appetite changes, or weight loss.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

A rare case of fibrostenotic endobronchial tuberculosis of trachea

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

Challenges in endobronchial tuberculosis: from diagnosis to management

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

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Investigation of endobronchial tuberculosis diagnoses in 22 cases

BACKGROUND

Endobronchial tuberculosis (EBTB) is a special form of pulmonary tuberculosis. In spite of much progress in the diagnosis of this disease in past years, delayed or mistaken diagnosis is still commonly seen.

OBJECTIVE

The aim of this study is to try to find out some useful clues for the diagnosis of EBTB, especially the early diagnosis.

METHODS

The medical records of patients with EBTB were analyzed retrospectively.

RESULTS

The male-to-female ratio was 1:2.2 out of 22 patients. Patients aged below 60-years-old constituted 72.7% of the cases. 22.7% of these patients were smokers. The male-to-female ratio of smokers was 4:1. 68.2% of these patients tested all showed negative result for the HIV test. The frequent complaints were cough, sputum, shortness of breath and fever, and antibiotic treatments were usually inefficacious. Multiple lobes lesion, exudative shadow and atelectasis were the frequent radiological findings. Acid-fast bacilli staining for sputum smear was positive in only 13.6% of these patients. Tuberculin skin test was positive in 59.1% of these patients. Granular lesion was the most common bronchoscopic appearance in these patients. Histological changes showed distinctive tuberculose lesion in 72.2% of 18 patients undergoing bronchoscopic biopsy.

CONCLUSION

The diagnosis of EBTB is easily delayed or mistaken because of nonspecific clinical manifestations and the low incidence of positive acid-fast bacilli staining. A high index of awareness of this disease is required for diagnosis. Bronchoscopy should be performed as soon as possible in suspected patients, especially when patients present positive tuberculin skin test or no response to antibiotic treatments.

Middle lobe syndrome: a review of clinicopathological features, diagnosis and treatment

Middle lobe syndrome (MLS) is a rare but important clinical entity that has been poorly defined in the literature. It is characterized by recurrent or chronic collapse of the middle lobe of the right lung but can also involve the lingula of the left lung. Pathophysiologically, there are two forms of MLS, namely obstructive and nonobstructive. Obstructive MLS is usually caused by endobronchial lesions or extrinsic compression of the middle lobe bronchus such as from hilar lymphadenopathy or tumors of neoplastic origin, resulting in postobstructive atelectasis and pneumonitis. In the nonobstructive type, no obstruction of the middle lobe bronchus is evident during bronchoscopy or with computerized tomography of the chest. The etiology of the nonobstructive form is not completely understood. Inefficient collateral ventilation, infection and inflammation in the middle lobe or lingula are thought to play a role, and bronchiectasis is the most common histological finding. Patients with proven endobronchial lesions or malignancy are usually offered surgical resection directly. This contrasts with nonobstructive MLS, where most patients respond to medical treatment consisting of bronchodilators, mucolytics and broad-spectrum antibiotics. However, some patients do not respond to conservative treatment and may suffer irreversible damage of the middle lobe or lingula, in addition to having recurrent symptoms of infection or inflammation. These selected patients can be offered surgical resection of the middle lobe or lingula, which is associated with a low mortality rate and favorable outcome.

Endobronchial tuberculosis: an overview

Endobronchial tuberculosis (EBTB), of which the incidence has been increasing in recent years, is a special type of pulmonary tuberculosis. The endobronchial tuberculose focuses often injure the tracheobronchial wall and lead to tracheobronchial stenosis. The tracheobronchial stenosis may cause intractable tuberculosis and make patients become chronic infection sources of tuberculosis, or may even cause pulmonary complications and result in death. The etiological confirmation of Mycobacterium tuberculosis is most substantial for diagnosis. However, because the positive rate of acid-fast bacillus staining for sputum smears is low and the clinical and radiological findings are usually nondistinctive, the diagnosis of EBTB is often mistaken and delayed. For early diagnosis, a high index of awareness of this disease is required and the bronchoscopy should be performed as soon as possible in suspected patients. The eradication of Mycobacterium tuberculosis and the prevention of tracheobronchial stenosis are two most substantial treatment goals. To get treatment goals, the diagnosis must be established early and aggressive treatments must be performed before the disease progresses too far.