SESSION TITLE: Infectious Disease Student/Resident Case Report Posters II
SESSION TYPE: Medical Student/Resident Case Report
PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM
INTRODUCTION: In right middle lobe syndrome (RMLS), the right middle lobe (RML) is chronically or recurrently collapsed secondary to a pathological condition, such as endobronchial tuberculosis (EBTB). Patients with EBTB are at an increased risk of RMLS due to the anatomically narrow RML bronchus. We present a case of a young female patient with recurrent chest infections who was found to have EBTB-related RMLS.
CASE PRESENTATION: The patient is a 40 year-old female non-smoker who presented with dry cough, dyspnea on exertion, and right middle lobe pneumonia. Her past history included two episodes of pneumonia in 2010, complicated by left pleural effusion (Fig 1A), which was drained with labs suggesting no infection or malignancy. Her white cell count was elevated (4,500 cells/microliter) with a positive quantiferon test. Chest X-ray revealed a right perihilar opacity (Fig 1B). Computed tomography (CT) revealed a right middle lobe consolidation and several pulmonary nodules suggestive of prior granulomatous disease (Fig 1C). Flexible bronchoscopy revealed near-complete obstruction of the right middle lobe orifice, with edema and inflammation of the airway mucosa in this region (Fig 2) but not in the adjacent bronchus intermedius. Culture was positive for mycobacterium tuberculosis complex and further testing suggested pan-sensitivity. The patient was subsequently initiated on rifampicin, isonaizid, pyrazidamide, and ethambutol therapy with vitamin B6 supplementation.
DISCUSSION: The diagnosis of EBTB-related RMLS requires thorough clinical assessment substantiated by a combination of chest X-ray, CT, bronchoscopy, bronchoalveolar lavage, culture, and/or lung biopsy. Our patient’s chest x-ray suggested right middle lobe pneumonia. Furthermore, bronchoscopy revealed edematous and fibrotic bronchial mucosa in the RML causing its obstruction. These findings, which differ from more common presentations of RMLS due to extrinsic compression from hilar adenopathy, were consistent with previous reports of EBTB-related RMLS. Medical management for tuberculosis with the standard agents (and vitamin B6 supplementation to prevent neuropathy) is mandatory. Surgical resection of the middle lobe, with bronchoplasty or tracheobronchoplasty if central airways are involved, may be indicated. Other management options for bronchial stenosis include laser ablation, balloon dilation, and stent placement.
CONCLUSIONS: We presented a 40 year-year old woman with EBTB-related RMLS that was managed subsequently with anti-tuberculous antibiotics.
Reference #1: Kim HC, Kim HS, Lee SJ, et al. Endobronchial tuberculosis presenting as right middle lobe syndrome: clinical characteristics and bronchoscopic findings in 22 cases. Yonsei Med J 2008; 49:615-619
Reference #2: Gupta PP, Gupta KB, Agarwal D. Middle Lobe Syndrome due to Tuberculous Etiology: A Series of 12 Cases. Indian Journal of Tuberculosis 2006; 53:104-108
Reference #3: Chung HS. Endobronchial Tuberculosis. Journal of the Korean Medical Association 2006; 49:799-805
DISCLOSURE: The following authors have nothing to disclose: Sean Goh, Martin Feuer, Raja Flores, Andrea Wolf
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