Recurrent Tuberculous Fistular Granuloma During Antituberculous Drug Therapy, Managed With Repeated Bronchoscopy

Abstract

SESSION TITLE: Tuberculosis Global Case Reports SESSION TYPE: Global Case Report Poster PRESENTED ON: Tuesday, October 27, 2015 at 01:30 PM - 02:30 PM INTRODUCTION: In tuberculous (TB) lymphadenitis, caseous nodes attach to the bronchial wall and erode through it, leading to a fistulous tract and endobronchial granuloma. Drug therapy often has little impact on its progression. From 2007 to 2013, we experienced the cases of recurrent endobronchial TB granulomas associated with bronchial invasion of lymphadenitis. CASE PRESENTATION: Case 1. A 26-year-old woman was diagnosed with TB lymphadenitis via mediastinoscopic biopsy. No parenchymal lesions were observed. After 2 months of medication, cough worsened and two endobronchial granulomas of the proximal right intermediate bronchus were found on flexible bronchoscopy (FOB). One month later, wheezing developed and repeated FOB revealed a granuloma obstructing the proximal right main bronchus. Two months later, cough worsened again and granulomas were observed in the proximal left and right main bronchi. Four months later, tubular breathing sounds were noted; a granuloma also recurred in the proximal right main bronchus. AntiTB medication was administered for 18 months. Chest CT demonstrated improved lymphadenitis with no abnormal findings in the tracheobronchial tree. The patient refused follow-up bronchoscopy. Spirometric findings were normal. When she visited again because of throat trouble 38 months later, she had no respiratory symptoms and breath sounds were clear. Chest X-ray revealed no remarkable findings. Case 2. A 16-year-old boy was diagnosed with TB lymphadenitis via bronchoscopic biopsy of an endobronchial granuloma obstructing the apicoposterior segment of the left upper lobe, which developed from intraluminal invasion of mediastinal lymphadenitis. No parenchymal lesions were observed. After 1 month of medication, hemoptysis recurred and FOB revealed a granuloma in the distal left main bronchus. Follow-up FOB after 3 months confirmed the absence of residual lesions. AntiTB medication was administered for 18 months. Follow-up chest CT and spirometric findings were unremarkable. Case 3. A 31-year-old man was diagnosed with miliary TB, with lymphadenitis and bilateral pleural effusion. After 3 months of medication, dyspnea worsened and chest CT showed progression of lymphadenitis. FOB revealed several granulomas with obstruction or stenosis at all segments of the left upper lobe. Seven months later, chest CT scan demonstrated aggravated paraaortic lymphadenitis and FOB revealed a granuloma in the left main bronchus. After 2, 4, and 6 months, this granuloma developed repeatedly at the same site in the left main bronchus. Two months after that, the granuloma recurred at the lingular division of the left upper lobe. AntiTB medication was administered for 24 months. Follow-up chest CT scan showed well-healed lymphadenitis. FOB revealed residual obstruction and stenosis at 3 segments of the left upper lobe. FEV1 improved from 46 to 66% of the predicted normal, and FVC improved from 49 to 83%. DISCUSSION: The total number of recurrences was 10 in 3 cases. Six granulomas recurred at the same site and four recurred at a different site. Once an endobronchial granuloma was found, we removed as much as possible, via bronchoscopic procedures, to relieve bronchial stenosis. Follow-up FOB was performed in cases 1 and 2 if there were any findings suggestive of recurrence, and was performed after 2 months in case 3 because the risk of recurrence was high. Ultimately, significant stenosis remained in case 3, but this patient exhibited improved spirometric findings. Prolonging antiTB medication until lymphadenitis improves sufficiently is important even though drug therapy may not be entirely effective against progression of fistulous granulomas. CONCLUSIONS: In the case of TB lymphadenitis, particularly in cases of bronchus invasion, endobronchial granuloma can develop, and can recur even after almost complete removal because a fistulous tract has already formed. Aggressive bronchoscopic procedures should be considered to relieve significant bronchial stenosis. Therefore, if TB lymphadenitis is observed adjacent to the bronchus, close follow-up is advised even when drug therapy is administered. Reference #1: Polesky A, Grove W, Bhatia G. Peripheral Tuberculous Lymphadenitis; Epidemiology, Diagnosis, Treatment, and Outcome. Medicine 2005 ; 84 : 350-362 Reference #2: Gupta PR. Difficulties in managing lymph node tuberculosis. Lung India 2004; 21 : 50-53. Reference #3: Lincoln EM, Harris LC, Bovornkitti S, et al. Endobronchial tuberculosis in children. Am Rev Tuberc Pulm Dis 1958 ; 77 : 39-61 DISCLOSURE: The following authors have nothing to disclose: Hong Lyeol Lee, Jung Soo Kim No Product/Research Disclosure Information