Endobronchial lesions are usually due to malignancies either primary lung or due to metastatic breast, colorectal, genitourinary tract, thyroid, adrenal carcinomas, sarcomas, melanomas or plasmacytomas. Rarely infectious process can produce them.
A 36 years old male, non-smoker with PMH of Schistosomiasis presented with two-weeks of nonproductive cough and 15 pounds weight-loss, anorexia, generalized weakness and shortness of breath over a two-month period. Prior ER visit for atypical chest pain two months prior to this hospitalization revealed a normal examination and CXR. The patient emigrated from Sierra Leone two years-ago and works as a home health aid. He had a positive tuberculin skin test with a normal CXR one year ago; he did not receive prophylaxis. The patient appeared cachexic and uncomfortable. He was febrile, tachypneic and complaining of left side pleuritic pain radiated to the scapular area and left shoulder. He had decreased air entry at the left base on auscultation. A palpable, tender mass of a 5x4 cm over the right anterolateral 7thrib and tenderness to palpation over the sacral area was noticed. No clubbing was noted. Abdominal examination revealed no hepato-splenomegaly. There were no palpable lymph nodes. The rest of the physical exam was unremarkable. Laboratory showed a WBC of 10.6, Hct of 31% and platelets of 355. Electrolytes, hepatic and renal profiles were normal. HIV test was negative. ESR was 3mmHg. A CXR showed a new left lower lobe (LLL) infiltrate and sub-pleural density compared to a two-month-old CXR. Chest CT demonstrated a left infra-hilar mass, a hypodense lesion in the liver and bony destruction of right sacrum, left first and right seven ribs (figure 1). Induced sputum for AFBx3 was negative. Flexible bronchoscopy (FFB) revealed an endobronchial tumorous lesion completely occluding the LLL bronchus (figure 2). Initial differentials for a post-obstructive consolidation with hepatic, rib and sacral lesions included malignancy; sarcoidosis; infections like actinomycosis, tuberculosis or rarely aspergillosis. TBBx revealed non-necrotizing granulomas with positive AFB (Figure 2). Biopsy of 7th rib revealed lympho-histiocitic collections with positive AFB. Tissue cultures grew mycobacterium TB.
Incidence of tuberculosis in USA is 3.8/100,000; it is 10 times more common in foreign-born patients. Endobronchial tuberculosis (EBTB) is caused by MTB in the bronchial wall and has been reported in 20–30%; is uncommon in developed countries and diagnosis is usually delayed. EBTB lesions are classified into seven subtypes based in FFB: actively caseating, edematous-hyperemic, fibrostenotic, tumorous, granular, ulcerative and nonspecific bronchitic. Tissue diagnosis is conclusive. Endobronchial lesions are uncommon and usually due to malignancies and they can mimic other etiologies. FFB characteristics of the lesion can be suggestive; the most common type is the caseating variety (43%) and the tumorous type is the least common (10.5%). Monthly bronchoscopic evaluation for the first 3 months is recommended to monitor for the development of strictures in all types of EBTB. In patients with tumorous EBTB a closer and longer follow up is advised. Extra-pulmonary TB accounts for 20% of all cases with most common sites being lymph nodes, pleura, kidneys, meninges, and bone or joints.Bone and joint tuberculosis accounts for a third of these cases. Skeletal tuberculosis often involves the spine, weight-bearing joints and extraspinal tuberculous osteomyelitis.Disseminated TB is rare and exact incidence is unknown. Sacro iliac joint involvement is seen in 10% of all cases of skeletal TB.Our patient had rare manifestations of a common disease mimiking malignancy. He was started on anti tubercular medications and is doing well clinically.
EBTB is a rare in developed countries but should be considered in the differential of endo bronchial lesions.In patients with multi-systemic involvement, disseminated tuberculosis remains a diagnostic possibility.
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