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J Thorac Cardiovasc Surg 2007;133:582-584
© 2007 The American Association for Thoracic Surgery

Brief Communication

Tuberculosis presenting as an endobronchial mass

^a Department of Surgery, Washington University in St Louis, St Louis, Mo
^b Department of Cardiothoracic Surgery, Weill Medical College of Cornell University, New York, NY
^c Department of Medicine, Weill Medical College of Cornell University, New York, NY
^d Department of Pathology, Weill Medical College of Cornell University, New York, NY
^e Department of Medicine, New York Hospital Queens, New York, NY.

Received for publication April 25, 2006; accepted for publication September 28, 2006.

^_* Address for reprints: Daniel Kreisel, MD, PhD, Department of Surgery, Washington University, Campus Box 8234, 600 S Euclid Ave, St Louis, MO 63110. (Email: kreiseld{at}wudosis.wustl.edu).

Endobronchial tuberculosis has become a rare condition in developed countries. Furthermore, tuberculosis is often not considered in the differential diagnosis of endobronchial masses. Thus diagnosis is often delayed because of the rarity of this condition and the nonspecific nature of the symptoms. This case report describes endobronchial tuberculosis in a young previously healthy woman.

Clinical Summary

A 25-year-old woman with a past history of asthma presented with new onset of a dry cough. This was associated with symptoms of fatigue and anorexia. The patient had emigrated from the Philippines to the United States several years ago and had been employed as an office manager in a garment store for the last 18 months. A PPD tuberculin skin test result was negative when she started that employment. A few weeks after the onset of her cough, she had right-sided pleuritic chest pain and worsening shortness of breath. A chest radiograph showed an opacity in her right lower lung field. She was thought to have pneumonia and was started on oral antibiotics. Because her symptoms failed to improve, a chest computed tomographic scan was obtained that demonstrated dense consolidation of her right middle and right lower lobes. It also showed an endobronchial lesion in her right mainstem bronchus at the level of the takeoff of her right upper lobe bronchus (Figure 1). Of note, bronchoalveolar lavage smears obtained at this initial flexible bronchoscopy were negative for acid-fast bacilli, and she was referred to the thoracic surgery service. Flexible bronchoscopy at our institution showed an endobronchial mass in her right mainstem bronchus opposite the orifice of her right upper lobe bronchus. This mass was nearly totally obstructing the airway and was covered with caseous material. The mass was cored out with a rigid bronchoscope. Histologic examination revealed necrotizing granulomatous inflammation, and rare mycobacterial organisms were demonstrated with acid-fast stain (Figure 2). A PPD tuberculin skin test result was positive, with an induration of 20 mm at 48 hours. Of note, she had negative test results for HIV. The patient was treated with isoniazid, rifampin (INN: rifampicin), ethambutol, and pyrazinamide. Cultures at 4 weeks grew Mycobacterium tuberculosis. The patient remains asymptomatic at 6-month follow-up, with a chest radiograph demonstrating clear lung fields.

View larger version (70K): [in this window] [in a new window]   Figure 1. Chest computed tomography demonstrates an endobronchial mass on the posterior wall of the right mainstem bronchus at the level of the takeoff of the right upper lobe bronchus.

View larger version (69K): [in this window] [in a new window]   Figure 2. A, Histopathologic examination of the endobronchial mass demonstrates a granuloma with multinucleated giant cells and central caseous necrosis. (Hematoxylin and eosin, original magnification 10x.) The inset shows higher magnification of multinucleated giant cell. (Hematoxylin and eosin, original magnification 60x.) B, Acid-fast stain demonstrates thin rod-like mycobacterium (Original magnification 60x.)

Endobronchial tuberculosis is thought to be secondary to implantation from an adjacent parenchymal focus, to result from rupture of a lymph node, or to be secondary to extension to the peribronchial region by lymphatic drainage. Although the precise incidence of endobronchial lesions in patients with tuberculosis might be underestimated because of the infrequent use of bronchoscopy, endobronchial tuberculosis has become a rare clinical entity in developed countries as effective chemotherapeutic agents have been introduced. Therefore tuberculosis is often not taken into consideration in the differential diagnosis of endobronchial lesions. In addition, the diagnosis is often delayed because findings on chest radiographs are nonspecific, and the diagnostic rate of smears from sputum or bronchoalveolar fluid can be low. Computed tomography can demonstrate the presence of endobronchial lesions, as was the case in our patient. It is important to note that patients with endobronchial tuberculosis have a high incidence of positive sputum samples, which represents a public health concern. Endobronchial tuberculosis has been classified bronchoscopically into 7 subtypes: actively caseating, edematous-hyperemic, fibrostenotic, tumorous, granular, ulcerative, and nonspecific bronchitic.¹ The actively caseating form can progress to the fibrostenotic subtype and result in airway stenosis, the most critical complication of this entity.

The timely diagnosis of endobronchial tuberculosis and expeditious initiation of treatment is of critical importance. During the active stage of the disease, chemotherapeutic agents have been shown to be efficient at eradicating tubercle bacilli. Moreover, if endobronchial tuberculosis is suspected, debridement of the lesion before initiation of antituberculosis treatment is not advisable because it can lead to dissemination of the infection and might predispose to formation of fistulas. Although a prospective study failed to show a benefit with the use of systemic corticosteroids, one report suggested that aerosol therapy with streptomycin and corticosteroids during the early stages of endobronchial tuberculosis might be beneficial in preventing progression to fibrostenosis.^2,3 Corticosteroids or other medical regimens cannot reverse airway fibrosis, and airway stenosis is inevitable if the disease is allowed to progress to the fibrostenotic subtype. Endobronchial ultrasonography has been used to guide the treatment of airway stenosis caused by endobronchial tuberculosis. Various interventional endobronchial techniques, such as laser ablation, balloon dilatation, or stent placement, have been used in its treatment.⁴ In more advanced cases, bronchoplastic procedures have been reported.⁵

In conclusion, this case highlights an unusual presentation of tuberculosis. A high index of suspicion is warranted to make a timely diagnosis of endobronchial tuberculosis and initiate early treatment. Serial bronchoscopies will be required in this patient to assess the degree of airway stenosis.

References

1. Chung HS, Lee JH. Bronchoscopic assessment of the evolution of endobronchial tuberculosis. Chest 2000;117:385-392.
   
2. Park IW, Choi BW, Hue SH. Prospective study of corticosteroids as an adjunct in the treatment of endobronchial tuberculosis in adults. Respirology 1997;2:275-281.[Medline]
   
3. Rikimaru T, Koga T, Sueyasu Y, Ide S, Kinosita M, Sugihara E, et al. Treatment of ulcerative endobronchial tuberculosis and bronchial stenosis with aerosolized streptomycin and steroids. Int J Tuberc Lung Dis 2001;5:769-774.[Medline]
   
4. Iwamoto Y, Miyazawa T, Kurimoto N, Miyazu y, Ishida A, Matsuo K, et al. Interventional bronchoscopy in the management of airway stenosis due to tracheobronchial tuberculosis. Chest 2004;126:1344-1352.
   
5. Kato R, Kakizaki T, Hangai N, Sawafuji M, Yamamoto T, Kobayashi T, et al. Bronchoplastic Procedures for tuberculous bronchial stenosis. J Thorac Cardiovasc Surg 1993;106:1118-1121.[Abstract]
   

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