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The Great Mimicker - Endobronchial Tuberculosis (EBTB) FREE TO VIEW

Chuen Peng Lee, MMed; Ser Hon Puah, MBBS; Mark Tien, MBChB; Christopher Seet, MBBS; Cheila May Dizon Coliat, MD; Albert Lim, MD; Wee See Yap, MMed
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Tan Tock Seng Hospital, Singapore, Singapore

Chest. 2013;144(4_MeetingAbstracts):225A. doi:10.1378/chest.1673455
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SESSION TITLE: Infectious Disease Global Case Reports

SESSION TYPE: Global Case Report

PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM

INTRODUCTION: Tuberculosis(TB) is a re-emerging disease, EBTB is a rare form of TB and its true incidence is likely underestimated. Chung et al (1) classified the bronchoscopic features of EBTB into 7 categories: actively caseating, edematous-hyperemic, fibrostenotic, tumourous, granular, ulcerative and non specific bronchitic. We present a case of tumourous EBTB masquerading as lung cancer in a young Kenyan. Bronchoscopic images before and after treatment will be presented.

CASE PRESENTATION: A 25 year old Kenyan man presented to our instituition in December 2012 for a 2 week history of fever associated with productive cough, 2 month history of blood streaked sputum, night sweats and a loss of weight. There was no frank hemoptysis. He had a positive TB contact history. Biochemical investigations revaled a raised C-reactive protein but normal pro-calcitonin levels and total white cell count. A chest X-Ray revealed airspace shadowing in the right mid-zone and suggestive of a round opacity in the right hilar region. A contrasted CT thorax showed a heterogenously enhancing right hilar mass (6.8 x 4.5x 3.7 cm) in the right upper lobe with invasion of the posterior mediastinum and numerous satellite nodules. Multiple mediastinal, paratracheal, para-aortic and subcarinal lymph nodes were involved as well. The patient underwent bronchoscopy in view of the high suspicion of a primary lung malignancy. Bronchoscopy showed submucosal tumor infiltration along the right upper lobe and middle lobe with tumor occluding the right upper lobe anterior segment orifice. A polypoid tumor was noted along the bronchus intermedius. Sputum cytology, bronchial washings, endobronchial tumor biopsy revealed no malignant cells. However it was noted that there were 2 small non-necrotising granulomas, with Langerhan's type giant cells seen in the subepithelial stroma. Special stains for Acid-Fast bacilli (Ziehl-Neelsen stain) and fungi were negative. Nuclei acid amplification test(NAAT) performed on his bronchial washings was positive. Culture from both sputum and bronchial washings were subsequently positive for Mycobacterium Tuberculosis Complex (MTC) sensitive to Rifampicin, Ethambutol, Isoniazid and Streptomycin. The patient was started on anti-tuberculous medications for a duration of 2 months before continuing on with dual anti-TB medications for another 4 months. Patient's symptoms ameliorated upon intiation of treatment. Repeat bronchoscopy within a month of intitation of therapy showed resolution of tumourous lesions.

DISCUSSION: EBTB predominently affects the young, mimicking malignancy, pneumonia and asthma. Burden of this disease is high in view of delayed diagnosis, high infectivity rates and catastrophic complication of bronchostenosis. Microbiology yield from sputum smears, bronchoalveolar lavage are relatively poor in EBTB. Bronchial biopsies and brushings had been shown to the more reliable methods of diagnosing EBTB(2). Our patient was started on anti-tuberculous treatment based on the NAAT from bronchial washings. Treament of EBTB does not differ from its parenchymal counterpart. Empirical steroids has not been shown to be beneficial.

CONCLUSIONS: Early microbial identification through NAAT could expedite treatment of EBTB and thus potentially reduce the likelihood of bronchostenosis.

Reference #1: Chung HS, Lee JH, Han SK, et al. Classification of endobronchial tuberculosis by the bronchoscopic features. Tuberc Respir Dis 1991; 38:108-115

Reference #2: Yu W, Rong Z. Clinical analysis of 90 cases with endobronchial tuberculosis. Zhonghua Jie He He Hu Xi Za Zhi. 1999 Jul;22(7):396-8.

DISCLOSURE: The following authors have nothing to disclose: Chuen Peng Lee, Ser Hon Puah, Mark Tien, Christopher Seet, Cheila May Dizon Coliat, Albert Lim, Wee See Yap

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