Endobronchial tuberculosis (EBTB), defined as tuberculous infection of the tracheobronchial tree, is a rare manifestation of a common disease. As a complication of pulmonary tuberculosis, EBTB can result in endobronchial stenosis, atelectasis, bronchiectasis and obstructive pneumonia. The treatment of EBTB beyond antituberculous therapy remains uncertain.
We report a case of a 39 year old Chinese female with recurrent endobronchial tuberculosis who presented with worsening dyspnea, wheezing and developed complete obstruction of the left mainstem bronchus 3 months after initiating antituberculous therapy. Admission chest X-ray (figure 1) showed significant air-space disease and volume loss in the left lung, mediastinal shift to the left and over expansion of the right lung. CT scan of the chest demonstrated a 1 cm endobronchial occlusion of the left mainstem bronchus (figure 2). Bronchoscopically, the left mainstem bronchus was occluded by a fibrotic web (figure 3). After excluding active tuberculosis, she underwent flexible bronchoscopy with endobronchial steroid injection of 3cc of 40mg/ml triamcinolone acetonide at the site of obstruction (figure 4). She was also given 60mg of oral prednisone daily. Two weeks later, repeat bronchoscopy demonstrated a small opening at the site of the left mainstem bronchus obstruction (figure 5). Successful balloon dilatation (figures 6 and 7) and endobronchial stent placement (figure 8) were then performed with marked improvement in left lung volume (figure 9).DISCUSSION: The pathogenesis of EBTB is thought to be initiated when Mycobacteria bacilli directly implant from the lung parenchyma, infiltrate the airway from mediastinal lymph nodes or spread hematogenously. The incidence ranges from 10 to 39% and is higher in females in most series. The clinical features of EBTB are variable. Cough and fever are the most common symptoms and are often associated on physical exam with decreased breath sounds, localized wheeze and rhonchi. Chest X-rays show consolidation or volume loss. The main differential diagnoses include asthma, foreign body aspiration, bronchial carcinoma, inflammation, bacterial and fungal infections and sarcoidosis. The optimal treatment other than antituberculous therapy remains controversial. Systemic steroids have shown inconsistent responses. One previous report by Verhaege et al. showed resolution of EBTB with submucosal injection of methylprednisolone. As in our patient, endobronchial steroid injection offers an alternative to surgical resection which had been established as the treatment for strictures secondary to EBTB.
For stenotic EBTB, balloon dilatation with endobronchial stent placement may be feasible if local steroid injection therapy is able to open an area of complete stenosis.
C.A. Reichner, None.