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An Endobronchial Tuberculosis as a Pulmonary Mass With Metastasis-like Lesion of Spine FREE TO VIEW

Chhar Bun Paul, MD
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Calmette Hospital, Phnom Penh, Cambodia

Chest. 2014;145(3_MeetingAbstracts):92A. doi:10.1378/chest.1732731
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SESSION TITLE: Tuberculosis Case Report Posters

SESSION TYPE: Case Report Poster

PRESENTED ON: Sunday, March 23, 2014 at 01:15 PM - 02:15 PM

INTRODUCTION: Endobronchial tuberculosis (EBTB) is defined as tuberculosis infection of tracheobronchial tree with microbial and histopathological evidence. It is present in 10-40% of patients with active pulmonary tuberculosis, and it is often misdiagnosed as bronchial asthma or lung cancer. We report a patient with endobronchial tuberculosis with a metastasis-like lesion of thoracic vertebra (T11).

CASE PRESENTATION: A 26-year-old woman presented to our hospital with chief complaints of chest pain and dyspnea. She presented with three-moth history of dry cough, shortness of breath, anorexia, weight loss, and a progressive back pain. She lived with her mother who has been treated for pulmonary tuberculosis 3 years ago. On physical examination she was thinly built and her vital signs were stable. The examination of respiratory system revealed diminished vesicular breath sound and vocal resonance in the left lower lung. Other examinations were unremarkable. She could not obtain available sputum sample for the examination of acid-fast bacilli. Complete blood count was normal (WBC: 7.04 giga/L, RBC: 5.85 tera/L, Hb: 133 g/L, Platelete: 380 giga/L), CRP: 0,29 mg/L, renal function test and liver function test were normal and HIV serology was negarive. The chest radiography showed an atelectasis of a lower lobe of left lung (Figure 1) The chest computed tomography demonstrated a mass of left lower lobe, (Figure 2), with destruction of vertebral body of T11 (Figure 3). Flexible bronchoscopy showed a mass of carina where the biopsy was performed. (Figure 4). The result of anapathology showed an inflammatory reaction of granuloma tissue suggestive of tuberculous infection. The patient was put on a classic antituberculosis treatment (Category I: 2HRZE/4HR). After one month of treatment, she reported a remarkable improvement of her symptoms with an increased appetite.

DISCUSSION: Endobronchial tuberculosis is known as a very infectious form of tuberculosis that remains a diagnostic challenge. It is usually seen at the younger population, and female predominance. Clinical manifestation of endobronchial tuberculosis are non-specific and include chronic productive cough, barking cough, chest pain, haemoptysis, generalized weakness, dyspnea and fever. In recent studies, sputum positivity in EBTB has been demonstrated from 16 to 53,3%. 10 to 20% of patients with endobronchial tuberculosis may have normal chest radiographs. Computed tomography is very useful in evaluating endobronchial lesions such as obstruction and stenosis. The bronchoscopic approach is mandatory to prompt diagnosis of EBTB. In strict sense of a correct classification of TB, EBTB might be allocated among the extrapulmonary forms. For its treatement, Partha et al. used Category I ATD (2HRZE/4HR) for all this 3 cases along with oral prednisolone at a dose of 1.5 mg/kg body weight, gradually tapered over 8 weeks. The role of steroids is quite controversial, however, and when orally administered they could reduce the inflammatory reaction with positive reflexes both on the early and late bronchial stenosis. In our case, bronchoscopic and computed tomography imaged of the lesions were simulating malignancy. However tuberculosis was proven by bronchoscopic biopsy of these lesions.

CONCLUSIONS: In conclusion, this case report is a reminder that endobronchial tuberculosis must take into consideration in defferential diagnosis of endobronchial lesions. A bronchoscopy with biopsy is useful in confirming the diagnosis and differenciating from others causes, especially cancer.

Reference #1: Hoheisel G, Chan BK, Chan CH, Chan KS, Teschler H, Costabel U. Endobronchial tuberculosis: diagnostic features and therapeutic outcome. Respir Med. 1994 Sep;88(8):593-7.

Reference #2: Han JK, Im JG, Park JH, Han MC, Kim YW, Shim YS. Bronchial stenosis due to endobronchial tuberculosis: successful treatment with self-expanding metallic stent. AJR Am J Roentgenol. 1992 Nov;159(5):971-2.

Reference #3: Casali L, Crapa ME. Endobronchial Tubercolosis: a peculiar feature of TB often underdiagnosed. Multidiscip Respir Med. 2012 Oct 22;7(1):35.

DISCLOSURE: The following authors have nothing to disclose: Chhar Bun Paul

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