Successful Avoidance of Cicatricial Tracheobronchial Stenosis in a Patient With Endobronchial Tuberculosis by Early Administration of Systemic High-Dose Corticosteroids: A Case Report.

A 63-year-old Japanese woman was referred to our hospital due to dry cough, fever, hoarseness, stridor, and difficulty breathing. Chest computed tomography showed circumferential wall thickening in the trachea, carina, right main bronchus, and right upper lobe bronchus, and granular and nodular shadows in right S2. Flexible laryngofiberscopy showed yellowish dry respiratory secretions adhering to the subglottis. Bronchoscopic findings showed that the tracheobronchial mucosa was swollen, hyperemic, and covered with yellowish-white, cheese-like materials, and ulcerative lesions with white coatings were observed from the subglottis to the trachea, carina, right main bronchus, and right upper lobe bronchus. A diagnosis of endobronchial tuberculosis (EBTB) was confirmed by polymerase chain reaction testing, and cultures were positive for Mycobacterium tuberculosis. In addition to anti-tuberculosis chemotherapy, intravenous high-dose methylprednisolone reduced her severe respiratory symptoms and prevented cicatricial tracheobronchial stenosis. Early administration of systemic high-dose corticosteroids may be effective for EBTB patients with severely active tracheobronchial mucosal and submucosal lesions.

Endobronchial Tuberculosis in an HIV-positive Case.

INTRODUCTION: Tuberculosis is an opportunist infection that is fatal and most frequently seen in HIV-positive patients due to immunosuppression. Endobronchial lesions can portray symptoms in different ways. Endobronchial Tuberculosis is one of these lesions. CASE REPORT: An HIV-positive, untreated 26-year-old patient with fever, cough, and dyspnea consulted our clinic. In the chest X-ray taken, effusion on the right side and non-homogeneous density increase in the middle and upper lobes, bilaterally more prominent on the right side, were observed. Therefore, the patient underwent bronchoscopy because the CT (computerized tomography) showed mediastinal lymphadenopathy (LAP) and an endobronchial lesion in the left main bronchus. During bronchoscopy, a vegetative endobronchial lesion that causes obstruction in the left main bronchus was monitored. With the help of Pathology and PCR results, endobronchial tuberculosis was diagnosed. CONCLUSION: Even if Acid-alcohol-resistant Bacillus (ARB) is detected negative in patients who stop responding to antimicrobial treatment and are being monitored under radiological scanning, a distinctive diagnosis of endobronchial tuberculosis should be kept in mind while performing bronchoscopy.

Clinical characteristics and drug resistance profile of patients with endobronchial tuberculosis in South Korea: single-center experience.

BACKGROUND: Tuberculosis (TB) is a major infectious disease worldwide; there has been a significant increase in the number of elderly patients with TB, largely contributing to TB-related mortality. Although endobronchial tuberculosis (EBTB) is a unique form of pulmonary TB, available data on the clinical characteristics and drug susceptibility (DST) patterns of patients with EBTB are scarce. METHODS: We evaluated the clinical characteristics of patients with EBTB in South Korea and the culture-based DST patterns of EBTB. Further, the DST patterns were compared between elderly (≥65 years) and young (<65 years) patients. We retrospectively reviewed data of patients with EBTB who had the results of DST and were diagnosed between January 2013 and December 2019 at a tertiary referral hospital in South Korea. Phenotypic DST of 15 first-line and second-line anti-TB drugs was performed using Mycobacterium tuberculosis isolates prior to treatment. RESULTS: Of the 230 patients with EBTB, 69% were in elderly patients (≥65 years). Any-resistance occurred in 24 patients (10.4%), while multi-drug resistance (MDR) and extensive drug resistance (XDR) were observed in six patients (2.6%). Compared to that of the elderly treatment-naïve patients, previously treated elderly patients had a significantly higher proportion of resistance to rifampin (14.3% vs. 2.2%; P=0.031), ethambutol (9.5% vs. 0.7%; P=0.046), and pyrazinamide (9.5% vs. 0.7%; P=0.046). Further, MDR/XDR was observed more frequently in the previously treated elderly patients than that in the treatment-naïve elderly patients (14.3% vs. 1.4%; P=0.017). A relatively small number of drug-resistant cases (5.6%) were observed in young patients. CONCLUSIONS: Elderly EBTB patients with previous Anti-tuberculous medications had a significantly higher proportion of drug-resistant TB. These patients should be carefully assessed using DST analysis before treatment.

Transbronchial brushing cytology and paired biopsy in endobronchial tuberculosis: A report of 72 cases focusing on the morphological features.

Objectives: The objectives of this study were to review the transbronchial brushing cytology and histological specimens of endobronchial tuberculosis (EBTB) and to explore the morphological features, diagnostic pitfalls, and dilemmas. Material and Methods: Transbronchial brushing cytology and concurrent biopsy specimens obtained between July 2017 and June 2020 were reviewed. EBTB was confirmed based on the clinical response to the anti-TB treatment in addition to the positive findings of at least one of the following methods: Acid-fast bacilli stain (AFB), auramine-rhodamine stain (A-R), detection of TB bacterial DNA (TB-DNA) by polymerase chain reaction, T-cell spot test (T-spot), and typical pathologic changes of TB on cytology or bronchoscopy biopsy. A total of 72 confirmed cases were studied. Results: Of the 72 patients, 42/72 (58.3%) and 30/72 (41.7%) were female and male patients, respectively. Bronchoscopic findings revealed five subtypes of EBTB, including inflammation infiltration, ulceration necrosis, granulation hyperplasia, cicatrices stricture, and tracheobronchial malacia. AFB, A-R, TB-DNA, and T-spot were positive in 39, 26, 33, and 46 cases, respectively. The detection rate of necrosis in the cytological specimens (90.3%) was significantly higher than that in the biopsy specimens (77.8%; P < 0.01). The percentage of Langhans giant cells detected by cytology (13.9%) was significantly lower than that detected by the pathological examinations of the tissues (38.9%) (P < 0.01). The detection rates of metaplastic squamous cells and epithelioid cells showed no significant difference with respect to the cytology and biopsy findings. In addition to the two patients who had concurrent carcinomas, atypical cells were reported in nine patients through cytopathological diagnosis, among them two were suspected to have carcinomas, two were with the impression that spindle cell neoplasms could not be excluded, and the other five were considered as reactive atypia. Moreover, one biopsy could not rule out the well-differentiated squamous cell carcinoma. Conclusion: Some morphological variations may cause challenges in cytological evaluation. Moreover, diagnostic dilemmas can occur even in the assessments of tissue pathology.

Pulmonary tuberculosis and COVID-19 coinfection: Hickam's Dictum revisited.

COVID-19 and pulmonary tuberculosis (PTB) coinfection is associated with increased mortality and presents a unique diagnostic challenge to the clinician. We describe three cases of newly diagnosed PTB in COVID-19 patients treated at our centre and their clinical and radiological features. The challenges associated with diagnosis and management are also explored. Patient 1 was a case of smear positive, endobronchial tuberculosis incidentally diagnosed due to CT changes, and eventually made good recovery. Patient 2 was a case of COVID-19 who succumbed but was diagnosed posthumously due to a positive sputum culture for tuberculosis. Patient 3 showed radiographic features of PTB and was treated empirically for TB. In conclusion, COVID-19 and PTB coinfection should be suspected in the presence of constitutional symptoms, prior immunocompromised states, prolonged respiratory symptoms or fever, or unresolved radiological abnormalities, more so in regions where TB is endemic.

Identification of potential genes in endobronchial tuberculosis after bronchoscopic cryotherapy by transcriptome sequencing.

BACKGROUND: Bronchoscopic cryotherapy facilitates the treatment of endobronchial tuberculosis (EBTB) and helps suppress progressive bronchial stenosis. However, the molecular mechanism of bronchoscopic cryotherapy in EBTB patients has not been reported. METHODS: Transcriptome sequencing was performed to explore differentially expressed mRNAs (DEGs) in EBTB patients before and after bronchoscopic cryotherapy. Gene Ontology (GO) and KEGG analyses were carried out. Five genes (MKLN1, HIGD1A, PTGES, SKIL, and MCEMP1) were selected and validated using real-time qPCR (RT- qPCR). RESULTS: In transcriptome analysis, 448 DEGs with p < 0.05 and|logFC| > 1 were identified; of these, 171 and 277 DEGs were significantly up- and down-regulated after bronchoscopic cryotherapy, respectively. Results displayed 337 biological process (GO-BP), 48 cellular component (GO-CC) and 62 molecular function (GO-MF) terms and 20 KEGG pathways. RT- qPCR results were consistent with the sequencing data. CONCLUSION: These data provide informative evidence and recommendations for further scientific research on bronchoscopic cryotherapy for EBTB.

Bronchoscopic Features and Morphology of Endobronchial Tuberculosis: A Malaysian Tertiary Hospital Experience.

The diagnosis of endobronchial tuberculosis (EBTB) is difficult as it is not well visualized radiologically, and bronchoscopy is not routinely performed for tuberculosis (TB) patients. Bronchoscopic characterization via endoscopic macroscopic features can speed up the diagnosis of EBTB and prompt immediate treatment. In this study, we identified the clinical and bronchoscopic morphology of 17 patients who were diagnosed with EBTB from 2018 to 2020. Demographics, radiological, microbiological and histopathological data were recorded. Endobronchial lesions were classified according to Chung classification. The diagnosis was made based on a histopathological examination (HPE) of endobronchial biopsy, and/or positive 'Acid-fast bacilli' (AFB) microscopy/Mycobacterium tuberculosis (MTB) culture on microbiological examination of bronchial alveolar lavage (BAL) and/or positive MTB culture on endobronchial biopsy specimens. Furthermore, EBTB was predominant in young women, age 20 to 49 years old, with a male to female ratio of 1 to 2. Underlying comorbidities were found in 53% of the patients. Cough, fever and weight loss were the main symptoms (23.5%). The indications for bronchoscopy are smear-negative TB and persistent consolidation on chest radiographs. Consolidation was the main radiological finding (53%). An active caseating lesion was the main EBTB endobronchial subtype (53%). The leading HPE finding was caseating granulomatous inflammation (47%). All patients showed good clinical response to TB treatment. Repeated bronchoscopy in six patients post TB treatment showed a complete resolution of the endobronchial lesion. EBTB bronchoscopic characterization is paramount to ensure correct diagnosis, immediate treatment and to prevent complication.

Endobronchial Tuberculosis Simulating Acute Foreign Body Inhalation: A Case Report.

Endobronchial tuberculosis is a rare form of pulmonary tuberculosis, that can be due to the rupture of an infected lymph node through bronchial wall or lymphatic spread to the lining of the bronchial tree. Clinical presentation is non-specific, and can simulate inhalation of a foreign body. Otolaryngologists should be aware of its presentation often atypical. The following case is an unusual presentation of endobronchial tuberculosis in a 23-month-old patient initially diagnosed as a foreign body in the respiratory tract with acute dyspnea with unilateral wheezing and suspected foreign body on chest computed tomography. Bronchoscopy revealed a granulomatous mass in carina and both primary bronchi. Granuloma ablation improved patient's respiratory status. The pathology revealed an epithelioid and gigantic cellular with caseous necrosis compatible with tuberculosis. This unusual presentation of tuberculosis should be known to otolaryngologists and pediatricians in view of the frequency of tuberculosis in our context as well as increase in its incidence.

Impact of the bronchopulmonary sequestration on endobronchial tuberculosis: the case report and the review of literature.

INTRODUCTION: We describe the rare case of endobronchial tuberculosis (EBTB) and chronic pulmonary atelectasis with mediastinal distortion. Finding of the concomitant venous anomaly of inferior vena cava revealed the diagnosis of bronchopulmonary sequestration. CASE REPORT: A 22-year-old Caucasian woman presented with a history of chronic cough, initially treated as bronchial asthma for a year. Chest X-ray showed fibrocaseous cavernous tuberculosis on the right lung. Acid Fast Bacilli (AFB) were found in sputum samples. Patient was treated for 6 months with usual antituberculous regiment. Control chest X-ray showed subatelectasis of the upper right lobe. Six months later the first thorax computed tomography (CT) showed complete atelectasis of the right lung. Patient was admitted to the hospital again after 6 years due to the persistent fever and cough. Endoscopic finding and histopathological analysis confirmed EBTB. Thoracic CT scan revealed duplication of inferior vena cava which led to profound vascular analysis and aberrant arterial vascularization of aortic origin that contributed to the diagnosis of bronchopulmonary sequestrations. Antituberculous treatment was initiated (streptomycin, isoniazid, rifampicin, ethambutol and pyrazinamide) and lasted for 8 months. After 8 months a follow-up fiberoptic bronchoscopy showed the progression of endoscopic finding with 60-70% tracheal stenosis. Histopathological finding of the mid-trachea showed non-specific granulations. During 7 years of follow-up repeated bronchoscopy and thoracic CT scans were unchanged and patient was well-shaped. CONCLUSIONS: The clinician should consider bronchopulmonary sequestration in the cases of recurrent EBTB.

Coexistence of tuberculosis and squamous cell carcinoma in the right main bronchus: A case report.

BACKGROUND: Lung cancer with pulmonary tuberculosis (TB) refers to the occurrence of lesions simultaneously or sequentially in the lung(s) of the same patient, and the pathological examination and sputum TB examination diagnose them as lung cancer and TB, respectively. The occurrence of endobronchial TB (EBTB) with endobronchial tumor sequentially in the same bronchus lesion of the same patient is relatively rare. CASE SUMMARY: A 62-year-old female patient was admitted to a local hospital on June 18, 2019 after a 3-mo history of dyspnea. She was a farmer and had no history of smoking and alcohol misuse. The patient had neither family nor work contact indicating exposure to TB. Emergency chest computed tomography (CT) examination showed that the right main bronchus was occupied and malignant tumor was possible. Histopathologic examination of a bronchial biopsy showed granulomatous inflammation with caseification and the presence of acid fast bacilli (AFB). However, after 6 mo of antitubercular treatment, repeat bronchoscopy and biopsy histological examination showed squamous cell carcinoma. The patient has started on systemic chemotherapy with carboplatin. After another two cycles of therapy, chest CT showed complete resolution of the lesions. Bronchoalveolar lavage and bronchial aspirate were negative for AFB and cancer cells. CONCLUSION: It is not only more likely that a patient presenting with what appears to be TB will concurrently have a pulmonary malignancy than someone who does not have a TB infection, but also that it is of greater urgency to make an expedited diagnosis of the malignancy.

Asymptomatic endobronchial tuberculosis represented as a solitary airway stenosis without tree-in-bud appearance on computed tomography.

Bronchoscopy is a crucial tool for diagnosing endobronchial tuberculosis in patients with airway stenosis. Early diagnosis and treatment may reduce airway sequelae and prevent the spread of infection.

Pseudomembranous Tracheobronchitis due to Mycobacterium tuberculosis.

Although the incidence is declining in the western world, Mycobacterium tuberculosis remains one of the most common infectious organisms responsible for significant morbidity and mortality worldwide. Pulmonary tuberculosis (TB) is the most commonly seen presentation; however, TB can affect nearly any of the body's organ systems. Endobronchial TB (EBTB) can complicate pulmonary TB or more rarely present as an isolated finding. It is essential to recognize and treat this condition promptly, as it can develop into tracheobronchial stenosis and chronic respiratory failure. Here we discuss the case of a 43-year-old female with a left upper lobe cavitary lesion who presented with weight loss, dyspnea, and hoarseness. After failing multiple courses of antibiotics, the patient underwent bronchoscopy, and pseudomembranous tracheobronchitis (PMTB) was diagnosed. Cultures of endobronchial samples grew Mycobacterium tuberculosis. Standard anti-TB quadruple therapy was initiated, and the patient clinically improved. Several subtypes of EBTB have been identified earlier. However, to the best of our knowledge, tuberculous PMTB has not previously been reported. This case allows us to consider the diagnostic and therapeutic implications of this condition.

Asthma and pulmonary tuberculosis: misdiagnosis or coexistence.

Asthma and pulmonary tuberculosis (PTB) are disease entities with different pathogenesis. However, endobronchial tuberculosis (EBTB), a peculiar form of PTB, can mimic the symptoms of asthma. Although uncommon, the coexistence of asthma and PTB can appear. We report three cases of PTB. The first two cases with EBTB were misdiagnosed as asthma and the third case with asthma developed PTB four months after high-dose inhaled corticosteroid (ICS) therapy. The first two cases presented with chronic cough up mucopurulent/purulent sputum and localized wheezing which revealed diagnostic clues. The third case presented with dry cough and showed a positive bronchodilator response and the right pulmonary apical fibrosis which could be associated with quiescent tuberculous infection. EBTB should be included in the differential diagnosis of asthma. Although rare, physicians should be aware that PTB can also be developed during the treatment course of asthma.

Central versus peripheral lesion on chest X-Ray: A case series of 31 endobronchial tuberculosis patients with negative sputum smears.

Background: Clinical characteristics of endobronchial tuberculosis (EBTB) patients whose sputum smears were negative have not been elucidated yet. Method: EBTB patients with negative sputum smears were documented retrospectively at the outpatient pulmonary clinic from late 2015 to early 2019. Results: We described the characteristics of 31 EBTB patients with negative sputum smears. The median age was 36 years (range 18-81 years). The male-to-female ratio is 1:1.58. The "peripheral" lesion group included 16 cases with opacity/consolidation, 2 cases with atelectasis, 1 case with cavitary lesion, and 1 case with pleural effusion. The "central" lesion group included four cases with normal chest X-ray and seven cases with only unilateral hilar enlargement. EBTB patients with "central" lesion were more common the presence of cough, the positive rate of bronchial lavage acid-fast bacilli smear, and the rate of misdiagnosis as pharyngitis, bronchitis, or asthma than that with "peripheral" lesion. Conclusions: EBTB with negative sputum smears was found in adult patients at any age and predominant in females. The diagnosis of EBTB with "central" lesion was more difficult than that with "peripheral" lesion. The location of the lesion could play a role in inducing cough among EBTB patients.

Topical mitomycin-C as an adjuvant to multimodal endoscopic treatment for tracheobronchial stenosis secondary to endobronchial tuberculosis.

Tracheobronchial stenosis secondary to endobronchial tuberculosis (TSTB) is a rare but debilitating complication of endobronchial tuberculosis (EBTB). Topical mitomycin-C (TMC) has been successfully utilized to restore airway patency and to prevent recurrence of TSTB, although little is known about its exact efficacy. Here, we report the biggest case series to date involving seven patients who received TMC as part of multimodality endoscopic treatment for TSTB with varying levels of success. All patients presented with dyspnoea during or after treatment completion for pulmonary tuberculosis (PTB). Four patients had short-segment concentric membranous TSTB while two patients had concurrent bronchomalacia. Another one patient had a thick fibrotic band adjacent to luminal opening. We hypothesize that TMC is more efficacious in short membranous stenosis without concurrent bronchomalacia and/or thick fibrotic bands. More studies are needed to bridge the current gaps in knowledge regarding the optimal role and benefits of TMC for TSTB patients.

Endobronchial Tuberculosis and Bronchostenosis: A Rare Case of Bronchial Occlusion in a Patient With History of Tuberculosis.

Pulmonary tuberculosis is common worldwide, and many of these patients develop endobronchial tuberculosis (EBTB). Bronchostenosis is a known complication of EBTB though most patients with endobronchial stenosis do not develop severe bronchostenosis or occlusion. We present a rare case of a patient with a right upper lobe bronchus occlusion and a history of tuberculosis.

A Case of Laryngeal Tuberculosis, Endobronchial Tuberculosis and Pulmonary Tuberculosis Coexistent in an Immunocompetent Host.

Historically associated with poor prognosis seen in advanced disease, laryngeal tuberculosis (LTB) now represents only 1% of all cases of tuberculosis (TB). The incidence of LTB has decreased drastically with the introduction of anti-tubercular drugs. LTB can be primary or secondary to pulmonary tuberculosis. LTB can mimic laryngeal cancer. We present a case of primary laryngeal TB with descending tracheobronchial spread in an immunocompetent 71-year-old female who developed progressive dysphonia over several months with unintentional weight loss and non-productive cough. Non-contrast enhanced computed tomography (CT) revealed clustering of subcentimeter stellate nodules in the right upper lung field with an enlarging ground-glass opacity in the right lower lung but did not show structural abnormalities within the neck. Positron emission tomography (PET) showed pathologic fluorodeoxyglucose (FDG) uptake within the larynx and trachea with extension into the left mainstream bronchus as well as the proximal left upper and lower lobe bronchi. Diffuse standardized uptake value (SUV) was greatest in the larynx (20.5). Polymerase chain reaction (PCR) on bronchoscope sputum specimen confirmed Mycobacterium tuberculosis. Findings were consistent with primary laryngeal TB with endobronchial extension. She was started on a four-drug regimen comprising of isoniazid, rifampin, ethambutol, and pyrazinamide with a good response. Her close contacts were treated as well. This case highlights the unusual spread of primary laryngeal TB in an immunocompetent host. Early diagnosis can limit adverse complications and unnecessary exposure to healthcare workers. To our knowledge, this is the first case of primary LTB with proximal spread to the tracheobronchial and pulmonary tuberculosis.

Endobronchial tuberculosis polyps.

Endobronchial tuberculosis (TB) is an uncommon manifestation of Mycobacterium tuberculosis. We report a case of endobronchial TB polyps in a patient from India presenting with cough, loss of weight and night sweats. Computed tomography chest revealed enlarged mediastinal lymph nodes, endobronchial invasion, and nodular infiltrates in the right lower lobe. Flexible bronchoscopy revealed two endobronchial polyps at the carina and left main bronchus which were biopsied. Histopathology showed non-caseating granulomas. Both the biopsy and bronchial washings did not identify acid-fast bacilli on Ziehl-Neelsen stain and had negative TB complex DNA polymerase chain reaction. One month after bronchoscopy, M. tuberculosis was cultured from the bronchial washings. Following six months of TB treatment, there was full resolution of symptoms and significant radiological improvement. We highlight the diagnostic challenges in endobronchial TB which may impact on the timely institution of treatment.