Laryngeal tuberculosis (TB) is an uncommon and a highly virulent form of tuberculosis. We present a case of a patient with dyspnea, weight loss, and a newly diagnosed supraglottic mass.
A 39 year old male with no significant past medical history presented with dysphonia and dyspnea. A direct laryngoscopy one month prior to admission demonstrated a supraglottic mass involving the pre-epiglottic space, epiglottis and piriform sinus (Figure 1). Biopsy of the mass revealed granulomatous inflammation with necrosis and ulceration. Tissue stains for fungus and acid fast bacilli (AFB) were negative. The patient’s symptoms continued to worsen. He was subsequently admitted with complaints of progressive dyspnea, fatigue and a 20 pound weight loss. There is no history of hemoptysis or night sweats. Social history revealed that he has no known exposures to asbestos or tuberculosis, however, he did spend 90 days in jail over 12 months ago. A PPD placed two months prior at his primary care physician’s office was negative. The patient is employed as an insulator, working with fiberglass and using a mask approximately 50% of the time. Initial work up revealed significant arterial hypoxemia and a chest X-Ray demonstrated signs of apical bullous emphysema and bilateral micronodular infiltrates. A chest CT was performed which showed severe interstitial lung disease with a fine reticulonodular pattern in the upper lobes, bullous emphysematous changes, nodular calcifications and cavitary lesions. The largest cavitary lesion was located in the left upper lobe (Figure 2). No lymphadenopathy was noted. Initially the patient did not have any sputum production and was subsequently referred for bronchoscopy for diagnostic evaluation. A bronchoalveloar lavage (BAL) of the left upper lobe was performed. A protected brush specimen and forceps biopsies were obtained from the same area. The BAL gram smear was positive for AFB. A PPD placed in the hospital became positive.
Upper airway structures can be infected with Mycobacterium tuberculosis. Structures such as the trachea, larynx, epiglottis and nasopharynx are exposed to organisms in the expectorated sputum of patients with active pulmonary cavitary lesions. Laryngeal TB is uncommon with relatively few cases reported in the literature. Occasionally this disease may be associated with pulmonary cavities. Hoarseness, cough and sore throat represent the most common symptoms of laryngeal TB. Pathology may reveal ulceration or necrotizing granuloma. This patient was started on quadruple therapy (rifampin, isoniazid, pyrazinamide, and ethambutol) and felt significant improvement within 48 hours.
Laryngeal tuberculosis is a highly infectious yet treatable disease that responds well to therapy. The right clinical scenario and high index of suspicion allow for earlier diagnosis and subsequent treatment.
J.C. Reap, None.