UNUSUAL PRESENTATION OF TB IN AN ENDEMIC COUNTRY

Abstract

SESSION TITLE: Pulmonary SESSION TYPE: Global Case Reports PRESENTED ON: 10/10/2018 01:00 PM - 02:00 PM INTRODUCTION: Endobronchial tuberculosis is the tuberculous infection of tracheobronchial tree with histological and microbiological evidence1. Diagnosis of endobronchial tuberculosis remains a challenge, in cases with normal chest radiograph. Endobronchial tuberculosis is highly contagious and delayed diagnosis leads to sequelae of broncho-stenosis. We report three cases of endobronchial tuberculosis diagnosed by bronchoscopy from a tertiary care hospital in Chennai, India. CASE PRESENTATION: Case-1: 48 year old male, with no known comorbidities, presented with hoarseness of voice, dry cough and breathlessness for 6 months. Chest radiograph was normal. Computed tomography showed nodularity of inner surface of trachea. Bronchoscopy revealed pseudomembranous form, corresponding to actively caseating variety of endobronchial TB( figure-1). Bronchial wash and brush showed many acid fast bacilli and bronchial biopsy showed granulomatous inflammation. Bronchoscopy repeated after a course of anti tuberculous treatment showed normal mucosa.Case-2: 31 year old female, presented with dry cough and fever since 6 weeks. Chest x-ray showed right perihilar opacity. CT chest showed few irregular, fluffy opacities in the right upper lobe and right hilar adenopathy. Bronchoscopy revealed tumorous variety with exophytic growth from RUL bronchus( figure-2). Bronchial wash and brush showed many acid fast bacilli and bronchial biopsy showed granulomatous inflammation.Case-3: 66 year old lady, a case of right renal cell carcinoma, with history of pulmonary tuberculosis 15 years back, presented with persistant fever and dry cough for 1 month and was evaluated to have right upper lobe fibrosis and nodular opacities in right upper lobe and left lower lobe on CT Chest. Bronchoscopy revealed ulcerative lesions in right tracheobronchial angle and right lower lobe apical segment(figure-3). Bronchial wash showed many acid fast bacilli and bronchial biopsy showed granulomatous inflammation. DISCUSSION: Endobronchial TB usually occurs in young patients2. Diagnosis is often challenging due to its wide range of presentations, clinically resembling bronchial asthma, foreign body, recurrent non resolving pneumonia, bronchogenic carcinoma. Seven types of endobronchial presentations based on bronchoscopic appearance include actively caseating, edematous hyperaemic, fibrostenotic, tumorous, granular, ulcerative, nonspecific bronchitis3. We hereby report actively caseating, tumurous and ulcerative varieties. Delayed diagnosis leads to multiple, irreversable complications like bronchial stenosis and strictures, airway obstruction, para cicatrical bronchiectasis, hemoptysis and atelectasis. CONCLUSIONS: Bronchoscopy remains investigation of choice for early diagnosis and followup, in cases of high clinical suspicion for tuberculosis with dry cough or sputum negative. Timely diagnosis prevents various complications and infection control. Reference #1: Hoheisel G, Chan BK, Chan CH, et al. Endobronchial tuberculosis : Diagnostic features and therapeutic outcome. Respir Med 1994; 88 : 593-97. Reference #2: M. S. Ip, W. K. Lam, S. Y. So, and C. K. Mok, “Endobronchial tuberculosis revisited,”Chest,vol.89,no.5,pp.727–730,1986 Reference #3: Winner-Muram HT, Rubin SA. Thoracic complications of tuberculosis. J Thoracic Imag 1990; 5 : 46-63 DISCLOSURES: No relevant relationships by ANILKUMAR GANDHAM, source=Web Response No relevant relationships by A. Gayathri, source=Admin input