Endobronchial Tuberculosis

clinical investigations Endobronchial Tuberculosis· Clinical and Bronchoscopic Features in 121 Cases lung Hee Lee, M.D., F.C.C.P.;t Sung Soo lbrk, M.D., F.C.C.P.;:!: Dong Hoo Lee, M.D., F.C.C.P.;§ Dong Ho Shin, M.D., F.C.C.P.;II Suck Chul Yang, M.D.;~ and Byeong Moo Yoo, M.D.~ The clinical and bronchoscopic features of endobronchial tuberculosis in 121 patients were retrospectively investigated. The peale incidence occurred in the second decades, with 3.8 times higher incidence noted in female than in male subjects. A barking cough with sputum was the most common chief complaint in 61.1 percent. Parenchymal in&Itration anel/or consolidation was the most common roentgenographic Gnding of the chest in 58.6 percent. Hypertrophy with luminal narrowing was the most common bronchoscopic Goding in 43 percent. Bronchoscopically,

tuberculosis is a serious complication E ndobronchial of pulmonary tuberculosis. It is a major cause of morbidity, as it frequently heals with concentric scarring resulting in bronchostenosis, atelectasis, and secondary pneumonia. 1 Since bronchogenic cancer seems to be on the increase, some cases of atelectasis initially suspected as complications of bronchogenic malignancy have been subsequently diagnosed as endobronchial tuberculosis after examination with the Oexible bronchoSCOpe.2 Recently, diagnostic and therapeutic endoscopy has been applied widely for the bronchial lesions. However, there is sparse data on clinical manifestations of endobronchial tuberculosis and bronchoscopic features, apart from some isolated case reports. Zo7 This has prompted us to review our nine years of experience with endobronchial tuberculosis in Korea. We present the clinical and bronchoscopic findings in 121 patients with endobronchial tuberculosis.

right upper and right main bronchus were the most frequently involved in 30.5 percent. It was concluded from these data that using 6beroptic bronchoscopy allows not only substantial meaningful assessment of endobronchial tuberculosis but also relieves atelectasis eventually resulting in successful treatment with antituberculosis drugs. (Chest 1992; 102:99Q..94)

I

AFB = acid-fast bacilli

I

MATERIALS AND METHODS

A total of 121 patients with endobronchial tuberculosis (4.1 percent) out of 2,951 subjects who had a /lexible fiberoptic bronchoscopic examination at the Department of Internal Medicine of Hanyang University Hospital between the beginning of March 1982 and the end of December 1990 were included in this study. For diagnostic confirmation. positive stains of acid-fast bacilli (AFB) were identified on the tissue sections. sputum, and/or specimens -aspirated through endos<:opic biopsy and brushing or washing-out for cytology and culture. Reassessment was designed to detect bronchial stenosis with the fiberoptic bronchosmpe after antituberculosis chemotherapy (combination of isoniazid. rifampin. pyrazinamide, streptomycin or ethambutol or both) with adjuvant mrticosteroid, 30 mg prednisolone daily, for two to four weeks. Prior to the bronchoscopic examination. each patient received premedication with 0.25 mg atropine sulfate intramuscularly. After topical application of 4 percent lidocaine around the upper airways, a Fujinon DRO-l or Fujinon DRO-IL fiberoptic bronchoseope was inserted for endoscopic observation. Clinical information was retrospectively gathered from all available medical records. RESULTS

Clinical Features *From the De()lU'tment ofInternal Medicine of Hanyang University School of Medicine, Seoul, Korea. tProfessor of Medicine, Chairman of Internal Medicine and Director of Pulmonary Medicine. *Associate Professor of Pulmonary Medicine. §Professor of Medicine, Director of Gastroenterology. IlAssistant Professor of Pulmonary Medicine. ~ident ofInternaI Medicine. A summary of this study has been presented as poster at the 57th Annual Scientific Assembly, American College ofChest Physicians, San Francisco, November 8, 1991. Manuscript received November 11; revision accepted January 31. Reprint requelt,: Dr. Lee, Hanyang University Hospital, 17 Haeng Dong Dong, Sung Dong Ku, Seoul, Orea 133-792

Predominantly, the peak incidence occurred in the second decade, and the male to female ratio was 1:3.8. A barking cough with variable amounts of sputum was the most common chief complaint in 61.1 percent of the 121 patients. The barking cough was not responsive to antitussive medication, but it did respond well to steroids along with antituberculosis combination chemotherapy. Other complaints included chest pain, hemoptysis, generalized weakness, dyspnea, and fever. Decreased breath sounds, localized wheeze, and rhonEndobronchial Tuberculosis (1..8e 8t 81)

AFB Smear (.) in Bronchoscopic Washing and/or Brushing

/.

/~­ '

AFB Smear (.) Only in Sputum

/

Culture (.) in Sputum

and/or Bronchial Washing FIGURE 1. Diagnostic yield from 121 patients of endobronchial tuberculosis. AFB is acid-fast bacilli. Bronchial Biopsy Only

chi were heard over the chest in 57 percent of the 121 patients. Acid-Fast BaciUi Yield from Sputum and Bronchial Washing As shown in Figure 1, in our series, prebronchoscopic sputum sample was positive for AFB in 17 percent of the cases. Staining for AFB was positive in the sputum samples or bronchial washings or both in 79 percent ofthe patients. In the remaining 21 percent of patients, diagnoses were confirmed by culture of sputum sample or bronchial washing for AFB, or bronchoscopic biopsy specimens.

Bronchoscopic Findings

Hypertrophy with luminal narrowing is the most common finding in 43 percent of the patients. Other bronchoscopic findings included mucosal edema and redness, erosion and ulceration, and cicatricial stenosis with pseudomembrane in 20.6, 18.2, and 18.2 percent of the cases. The right upper (16.5 percent) and right main bronchus (14.0 percent) were the most frequently involved obstruction sites observed by means of bronchoscopy. Both lower bronchi were involved in 18.2 percent of the patients (Fig 2 and 3). After removal of the pseudomembrane by curettage with forceps during a bronchoscopy, tenaceous secretions which had been exposed around the opened site were visible. In our series, 44 out of 121 patients had received corticosteroids and curettage for pseudomembrane, but residual bronchostenosis was found in

23 patients after treatment (Fig 4). Pathologic findings were essentially chronic granulomatous inflammation showing caseation necrosis, or nonspecific chronic inflammation. Squamous metaplasia was observed frequently.

Roentgenographic Appearance Seventy one out of 121 patients (58.7 percent) had parenchymal infiltration, and 24.8 percent had loss of volume. Ten patients (8.3 percent) had a cavitating lesion. Interestingly, ten patients (8.3 percent) had clear lung fields. Both upper and lower lung fields were the most frequently involved in 52.1 percent of the patients (Fig 5). DISCUSSION

The incidence of endobronchial tuberculosis was reported to be from 10 to 38.8 percent in patients with pulmonary tuberculosis by bronchoscopic examination.3,8·" We found endobronchial tuberculosis in 4.1 percent of 2,951 subjects who had undergone a flexible bronchoscopic examination at our hospital. Endobronchial tuberculosis is thought to arise from direct implantation of tubercle bacilli in bronchi and infiltration by adjacent mediastinal lymph nodes, lymph node erosion, hematogenous spread, and extension into the peribronchial region by lymphatic drainage from parenchyma.8.12.13 Ip et a13 showed that male subjects were affected twice as often as female subjects. Our study showed a 3.8 times higher incidence in women than in men.

Cicatricial Stenoaia with

Hypertrophy with Luminal

Pseudomembrane

Narrowing

Mucosal Edema _~/

2. Bronchoscopic findings in 121 patients of endobronchial tuberculosis.

and Redneaa

FIGURE

Erosion and Ulceration CHEST I 102 I 4 I OCTOBER, 1992

991

(Site)

Right Lung

Left Lung

Trachea Main Bronchus Upper Middle Lower Upper & Middle Upper & Lower Middle & Lower Both Side 20

15

10

5

o

5

10

15

20

(%)

FIGURE 3. The involved site by bronchoscopy in 121 patients of endobronchial tuberculosis.

Also, increased incidence in the second decade may be related to high prevalence ofdisease in the country where the younger population is infected frequently. The barking cough with sputa was present in 61.1 percent of the patients. The characteristic localized wheeze was found in 19 percent of patients, and 24.0 percent were asymptomatic. Moreover, chest roentgenograms frequently showed atelectasis. This would make it difficult to differentiate endobronchial tuberculosis not only from bronchial asthma, but also from bronchogenic carcinoma in old age. 2.5.6 Even with normal chest films, endobronchial tuberculosis in patients has been reported. 13.14 Ten percent of the patients demonstrated no abnormality on chest

films in our study. Normal roentgenograms, therefore, do not exclude endobronchial involvement. One might expect to find sputum smears positive for AFB. Unexpectedly, negative staining for AFB was common. Diagnostic yield of sputum examination in our series was 79 percent. Before bronchoscopy, sputum smear for AFB was positive in only 21 cases (17 percent). Our study was in agreement with previous reports that tubercle bacilli might be difficult to demonstrate on smear or culture. 12.15.16 The reason, however, is not clear. Presumably, expectoration of sputum is difficult because of entrapment of mucus by proximal endobronchial granulation tissue. Also, ulceration of involved mucosa is necessary for a positive AFB smear

FIGURE 4. Sequential bronchoscopic chan~es of a characteristic endobronchial tuberculosis. There was whitish pseudomembrane causin~ a remarkable stenosis around the openin~ site of left lower bronchus (left). After removal of pseudomembrane by primary curetta~e. tenaceous secretions around the opened site were demonstrated (center). Four weeks later with se(.1mdary curettage and antituberculosis chemotherapy, there was discernible improvement (right).

992

Endobronchial Tuberculosis (Lse fit 8/)

(Site)

l_~-~-_-~_---

Upper Middle

I------~~

Lower

II

Upper & Middle

[----Jlf.~

Upper & Lower

~] g~. ~~

Middle & Lower Both Lung Normal

20 FIGURE

15

10

5

o

5

10

15

5. Roent~eno~raphic site in 121 patients of endobronchial tuberculosis.

result. 3 ,12 Therefore, it is clear that the bronchoscopic approach is mandatory for the prompt diagnosis of endobronchial tuberculosis by increasing the positive rate in patients with negative AFB smear. The most common initial lesion was infiltration of lymphocytes into the bronchial mucosa, and the next was partial stenosis by considerable congestion and edema of the mucosa.1 7 Development of caseous necrosis with formation of tuberculous granuloma can be found at the mucosal surface. Fibrotic change of the lamina propia, as well as healing of mucosal ulcerations or erosions with or without squamous metaplasia, \\rould eventually progress to cicatricial stenosis.13 .1H,19 Bronchoscopically, a whitish pseudomembrane resulting in stenosis or obstruction of bronchi was a characteristic finding in the patients with atelectasis caused by endobronchial tuberculosis. The most common sites of involvement were the right upper lobe and right main bronchus. Roentgenographic appearance of the chest in endobronchial tuberculosis usually shows consolidation or loss of volume. Consolidation or loss of volume was found in 83.4 percent of our patients. It should be noted that ten patients (8.3 percent) had clear chest roentgenograms. A clear roentgenogram of the chest, therefore, does not exclude endobronchial pathologic condition, especially in young female patients, whose cough is barking in nature and resistant to general antitussive agents. Both upper and lo\\rer lung fields were the most frequently involved, noted in 52.1 percent of the patients. This is supported by the frequency of tuberculosis in stem bronchus opposite the opening of the airway draining the tuberculous

cavity or focus in the upper lung field 20 and the direct implantation theory of etiology of endobronchial tuberculosis by virtue of gravity in the lower lung field. The indications for corticosteroid therapy in tuberculosis are not completely defined. In our experience, the majority of patients suffering from a barking cough were responsive to corticosteroids in combination with antituberculosis drugs if not rapidly responsive to only conventional antituberculosis therapy. The mechanisms are not clear. Corticosteroid treatment has been advocated by some authors as in our study, but others have claimed no benefit. 3 ,5,22 Corticosteroids are likely to be beneficial in earlier stages when hypersensitivity is the predominant mechanism, but are unlikely to be helpful in more advanced cases when extensive fibrosis is present. Close follow-up is advisable as stenosis may develop later despite antituberculosis chemotherapy \vith or \vithout corticosteroids.1 9 Pseudomembrane causing cicatricial stenosis could be removed by curettage \vith forceps during bronchoscopy, where tenaceous secretions \\rere visible around the opened site. Bronchoscopy is a very useful tool in relieving atelectasis caused by cicatricial obstruction and in the assessment of bronchostenosis. In view of the fact that tuberculosis is one of the COmlTIOn endemic diseases in developing countries, young female patients, whose cough is barking in nature and resistant to general antitussive agents, should be evaluated for endobronchial tuberculosis, even \\rith clear chest roentgenogram and negative sample. Furthermore, we would like to emphasize that the bronchoscopic approach is a substantially CHEST I 102 I 4 I OCTOBER, 1992

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useful means of making a differential diagnosis of atelectasis in older patients of cancer-risk age. REFERENCES

2 3 4 5 6 7 8 9 10 11

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Plan to Attend ACCP's

58th Annual SCientific Assembly Chicago ~---~ -- ~ OCtober 25-29, 1992

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Endobronchial Tuberculosis (Lee et al)