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Right Middle Lobe Syndrome Due to Endobronchial Tuberculosis in Immunocompromised Young Female - An Interesting Case Report from Western India FREE TO VIEW

Ram K Chopra, MD; A. Sunayna, DTCD; Smita Agale, DTCD
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Ruby Hall, Pune, India

Chest. 2013;144(4_MeetingAbstracts):224A. doi:10.1378/chest.1679027
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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: Endobronchial tuberculosis (EBTB) presenting as right middle lobe syndrome ( RMLS ) is an uncommon clinical condition though reported frequently in India and other Asian countries , incidence varying from 9% to 26.1% in various case series(3). RMLS is a chronic and recurrent collapse of right middle lobe. Non tuberculous causes of right middle lobe collapse are malignancy, compression by enlarged post infectious lymph nodes, asthma etc. We report an interesting case of RMLS with odematous and stenosed right middle lobe opening with positive BAL AFB in a 12 years old immunocompromised female .

CASE PRESENTATION: 12 year old female child with immunocompromised status due to HIV presented with history of cough with expectoration, low grade evening rise of temperature, weight loss and loss of apetite.On examination she had decreased air entry near the mammary area with coarse crepitations. Lab investigations: Total leucocyte count was 5900,. ESR was raised, Absolute CD4 count was 75, Mantoux test was negative, Sputum was negative for acid fast bacilli (AFB). Xray chest PA view : Irregular linear opacity in lower zone abutting the cardiac sillhoutte, suggestive of RML opacity and Lateral radiograph showed : Wedge shaped opacity between the major and minor fissure with apex at hilum and base anteriorly near the sternum, confirming right middle lobe atelectasis. CT chest further confirmed Right middle lobe collapse and in addition showed bronchiectasis. No other parenchymal lesions were noted. Subsequently Bronchoscopy was done and it revealed edematous stenosed right middle lobe opening with intense mucosal hyperemia. Bronchial washings showed AFB and brush biopsy from RML revealed lymphocytes and epetheloid cells. Thus diagnosis of endobronchial tuberculosis with RMLS was confirmed. Patient was put on 4 drugs - isoniazid, rifampacin, pyrazinamide and ethambutol as per the dosage and duration protocol with satisfactory clinical improvement and 50% regression of RML opacity after 6 months. Interesting radiological and bronchoscopic images will be displayed on the poster presentation.

DISCUSSION: Right middle lobe syndrome is defined as chronic or recurrent collapse of the middle lobe of the right lung(1). It is of two types (a) Obstructive, with a demonstrable airway occlusion,as in our case and (b) Non obstructive type patent right middle lobe bronchus apperent on bronchoscopy. Reported etiologies of right middle lobe syndrome include inflammation (47%), malignant tumors(22%), bronchiectasis(15%), tuberculosis(9%), benign tumors(2%), aspiration(2%), and the rest miscellaneous ones(2). EBTB presenting as RMLS is an uncommon clinical condition in children. Some authors have reported this syndrome mainly in elderly patients. It occurs more commonly in females than males. Out of different types of endobronchial tuberculosis edematous type of EBTB is most common cause of middle lobe syndrome. Our patient had oedematous and stenosed right middle lobe bronchus as reported in other case series. Treatment with anti tubercular drugs for 6 to 9 months generally suffices but surgery ( right middle lobe lobectomy ) is indicated in chronic collapse with bronchiectasis and with recurrent symptoms.

CONCLUSIONS: Our patient presented with features suggestive of right middle lobe collapse and this was confirmed by lateral radiograph, CT thorax and bronchoscopically by stenosed opening of right middle lobe bronchus and the etiology proved to be M. tuberculosis.

Reference #1: Gudmundsson G, Gross TJ. Middle lobe syndrome.Am Fam Physician 1996 ; 53(8) 2547-2550.

Reference #2: Wagner RB, Jhonston MR.Middle lobe syndrome: collective review. Annals of thoracic surg 1983; 35: 679- 686.

Reference #3: Young S. Hawang et al., The causes of right middle lobe syndrome: recent experiences for last 2 years in Korea. Chest 2008, vol 134, no 4 _ meeting abstracts.

DISCLOSURE: The following authors have nothing to disclose: Ram K Chopra, A. Sunayna, Smita Agale

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