Memon, A M

Shafi, A

Thawerani, H

English

eCommons@AKU

eCommons@AKUSection of Pulmonary & Critical Care Department of MedicineApril 1996Endobronchial tuberculosis--manifesting bycoughing up of bronchial cartilageA M. MemonAga Khan UniversityA ShafiH ThaweraniFollow this and additional works at: https://ecommons.aku.edu/pakistan_fhs_mc_med_pulm_critcarePart of the Critical Care Commons, and the Pulmonology CommonsRecommended CitationMemon, A. M., Shafi, A., Thawerani, H. (1996). Endobronchial tuberculosis--manifesting by coughing up of bronchial cartilage.Journal of Pakistan Medical Association, 46(4), 86-88.Available at: https://ecommons.aku.edu/pakistan_fhs_mc_med_pulm_critcare/93Endobronchial Tuberculosis Manifesting by Coughing Up ofBronchial CartilagePages with reference to book, From 86 To 88 Abdul Majeed Memon ( Department of Medicine, Aga Khan University Hospital, Karachi. ) Anwar Shafi ( Ziauddin Postgraduate Institute of Medical Sciences, Karachi. ) Hasina Thawerani ( National Institute of Cardiovascular Diseases, Karachi. ) Introduction As compared to the Tuberculosis involving the lung parenchyrna, endobronchial tuberculosis (EBTB)is less well known. The importance of endobronchial tuberculosis lies in the fact that it has variedclinical manifestations and the diagnosis can be missed at initial presentation. We describe a case whereendobronchial tubereulosis manifested by expectoration of bronchial cartilage.Case Report A 32 years old physician presented with a four months history of severe cough, initially dry but later onproductive with copious whitish sputum, dyspnea and wheezing. The cough and dyspnea wereaggravatedon lying down causing difficulty in sleeping at night. He gave no history of fever,haemoptysis or weight loss. The past medical history was insignificant and he denied any familyhistory of tuberculosis. He did not have any wheezing spells in the past.Physical examination revealed an apparently healthy young man with normal weight, temperature andblood pressure. There was no lymphadenopathy. Abdominal, cardiovascular and central nervous systemexamination were normal. The chest examination revealed moderate bilateral wheeze.His 1-lb was 13.9 g/dl, WBC 7.7x109/L with neutrophils 72% and lymphocytes 21% and ESR 40mmHg after the first hour. Chest X- ray, PA and lateral views did not show any infiltrative or cavitaiylesion.He was given bronchodilators and oral as well as inhalation steroid therapy with minimal relief ofsymptoms. Approximately a week later he coughed up a whitish meat like mass measuring l.5x1.0x0,6cm in volume after which his wheezing and dyspnea subsided and he had minimal residual cough.Microscopic examination of the expectorated material revealed a crescentic rim of focally necrotichyaline cartilage (Figure 1)around necrotic material with partially autolysed granulomas (Figure 2),composed of epithelioid cells admixed with few lymphocytes and occasional multinucleated giant cells(Figure 3).Periodic acid Schiff stain was negative for fungi and Ziehi-Neelsen stain was negative for acid fastbacilli. His symptoms returned after three weeks while on bronchodilators. He again expectorated asmall piece of similar material which revealed necmtic tissue on histopathologic examination.Computerized Axial Tomographic (CAT) scan of the chest was perfonned to look for any parenchymadamage but no lesion was seen.Fiberoptic bronchoscopv under L.A. showed partial obstruction of the left main stern bronchus andtotal obstructionof the left upper lobe bronchus by necrotic tissue. The wall of the left. upper bronchuswas completely collapsed. Bronchiallavage was done and biopsy obtained. A biopsy of the left upperlobe showed necrotic material and bronchial washing for AFB smear was negative. A post-bronchoscopic sputum sample smear was, however, loaded with AFB. This was later confirmed bymicrobial culture which yielded mycobacterium tuberculosis.The patient was started on INH, Rifampacin, Etbambutol and Pyrazinamide. He is asymptornatic onthese medications and has stopped coughing. No further expectoration of necrotic material has occurredsince six months.Discussion Endobronchial tuberculosis can be seen in both primary as well as post-primary tuberculosis1. Becauseof its location and the fact that it can present without any abnormality on chest x-ray, it constitutes adefinite diagnostic problem2. A shift in age distribution, from younger to older age group after theadvent of effective anti-tuberculosis chemotherapy3, in western countries adds another dimension ofdifficulty for the physicians in diagnosing this disease.Although, many cases of endobronchial tuberculosis have been reported over the years, coughing tip ofa piece of bronchial cartilage has not been reported. A medline search did not uncoverany reported casein the last 30 years. In adults bronchial lesions are most commonly secondaiy to repeated implantationof tubercle bacilli from an adjacent parenchymal source. On rare occasions small portions of bronchialwall may be sloughed off.Early diagnosis of endobronchial tuberculosis is of paramount importance keeping in mind the fact thatserious complications or even death may result due to missed or delayed diagnosis4. Diagnosis isusually delayed because endobronchial tuberculosis can masquarade as different disease. It can presentas obstructive airway disease2,5. In elderly patients, it can simulate lung cancer especially on visualappearance at bronchoscopy6. A chest X-ray showing unilateral obstructive emphysema may also be apresenting feature7.Traditional methods like chest X-ray and sputum tests for acid fast bacilli employed in the diagnosis ofpulmonaiy tuberculosis may not be very helpful as endobronchial tuberculosis may be present in theabsence of chest X-ray abnormality and a negative AFB smear8. It has been shown that sputum AFBsmear may be negative in 85% of cases of endobronchial tubervculosis3. Although in our case thesimple sputum test clinched the diagnosis.Fiberoptic bronchoscopy has proved to be a very useful procedure not only from the diagnostic point ofview but also by virtue of its value in disease management and follow-up5. However, in our case, thehistopathologic studies of bronchoscopic biopsy did not reveal any acid fast bacilli and bronchialwashing was also negative for acid fast bacilli. Bronchoscopy has been shown to relieve atelectasiswith improved success of treatment with anti- tuberculosis drugs9. It can also be used to evaluate theresponse of endobronchial tuberculosis to medications10. CT scan can also be employed to assess thedegree of endobronchial invèlvernent2. In our case CT scan was, however, normal.Treatment consists of the standard anti-tuberculosis drugs, which generally give good results10,11,13,There is no documented role of corticosteroids in the treatment of endobronchial tuberculosis12.The most common complication of endobronchial tuberculosis is residual bronchostenosis which canoccur despite properanti- tuberculosis chemotherapy4,11. It has been reported that some degree ofbronchial stenosis is present in greater than 90% of patients with endobronchial tuberculosis14. In somecases stenosis can be severe and may require surgical treatment11. Surgical treatment consists of sleeveresectionofthebronchus and lobectomies11,15. Otherforms of treatment for bronchial stenosis secondaryto endobronchial tuberculosis include balloon dilatation and laser photoresection2. A case has beenreported which was successfully treated with self expanding metallic stent14.The value of careful sputum study for acid fast bacilli is probably under stress. In a country like ours,with non-availability of bronchoscopic facility at most institutions, the need for cost effective testscannot be over emphasized. Pulmonary tuberculosis is very common in our daily practice, all we needto do is look for more patients with endobronchial tuberculosis and help prevent major complications.References 1. Smith, L,S. and Schillaci, R.F. Endobronchial tuberculosis - serial fiberoptic bronàhoscopy andnatural histoiy. Chest, 1987;91:644-7.2. Khan. J.A., Islam, N., Akhter, J. et a!. Endobronchial tuberculosis simulating bronchial asthma. J.Pak. Med. Assoc., 1994;44:49-50.3. Mary, S.M, Lam, W.K. and Mok, C.K. Endobronchial tuberculosis revisited. Cheat, 1986;89:727-30.4. Chang, S.C., Lee, P.Y., Perng, R.P. The value of roentgenographic and fiberobronchoscopic findingsin predicting out come of adults with lower lung fie!d,T.B.Arch.Intem. Med., 1991;151:1581-83.5. Abdulla, F and Dietrich, K.A. Endobronchial tuberculosis manifested as obstructive airway diseasein a 4 months old infant. South Med. J., 1990;83: 715-17.6. Van-Den, B.P., Lamberechts, M., Tack. J. et al. Endobronchial tuberculosis mimicking lung cancer inelderly patients. Respir. Med.. 1991 ;85:107-9.7. Wood, G.S., Gonzalez, C., Done, S. eta!, Endobronchial tuberculosis in children. A case report andreview, lnt. J Pediatr Otorhinolyringol., 1990:20:241-45.8. Teo, S.K. Endobronchial tuberculosis. A case report of 5 cases. Singapore Med. J., 199031:447-50.9. Lee, J.H., Park, S.S.,Lee, D.H. et a!. Endobronchial tuberculosis - Clinical and bronchoscopicfeatures in 121 cases Chest, 1992;102:990-4.10. Kim, Y.fl., Kim, H.T., Lee, KS. et al. Serial fiberoptic observations of endobronchial tuberculosisbefore and early after anti-tuberculosis chemotherapy. Chest, 1993;103:673-7.11. Tse, C.Y. and Natkunam, R. Serious sequelae of delayed diagnosis of endobronchial tuberculosis.Tubercle, 1988,69 213-16.12. Chan, H.S., Sun. A. and Hoheiscl, GB. Endobronchial tuberculosis - Is corticosteroid treatmentuseful? A report of 8 cases and review of literature. Postgrad. Med. 3., 1990;66:822-6.13. Van, D., Brande, P.M., Van-De, M.F. et al. Clinical spectrum of endobronchial tuberculosis inelderly patients. Arch. Intern Med., 1990;150:2105-8.14. Han, J.K., Im. JO,, Park, J.H. et al. Bronchial stenosis due to endobronchial tuberculosis. Successfultreatment with self expanding metallic stent (AiR) Am. J. Roentgenol.. 1992;159:971-2.15. Watanabe, Y., Murakami, S. and Iwa, T Bronchial stricture ducto endobronchial tuberculosis.Thorac. Cardiovaac Surg., 1988:36:27-32.

Endobronchial tuberculosis--manifesting by coughing up of bronchial cartilage

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Endobronchial tuberculosis--manifesting by coughing up of bronchial cartilage

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