imaging: endobronchial tb

PROF.DR.G.SUNDARAMURTHY’S UNIT M7DR.BHARGAVI.K

HISTORY IN BRIEF

48 yr old male was admitted With c/o hemoptysis for 1 day-10 episodes c/o giddiness k/c/o HT on Rx not a k/c/o PT On examination:Gen exmn- was normal Cvs-NAD Rs-fine crepts + right interscapular and

subscapular areas.

INVESTIGATIONS Rbs,Rft- within normal limits Hb-9.2 gms, complete profile- normal Sputum AFB- negative Further imaging ensued…….

Lung parenchyma shows TREE IN BUD OPACITY S/O ENDOBRONCHIAL SPREAD OF INFECTION, noted in R UPPER LOBE INVOLVING AZYGOUS LOBE ,LIMITED BY AZYGOUS fissure, apical anterior segment.

Tiny nodular opacities noted in throughout lung tissues on both sides.

?TB etiology.

.

Figure 1.  High-resolution CT scan (far left) and drawings of the lung (middle left), a budding tree (middle right), and tree buds (far right) show the tree-in-bud pattern.

Rossi S E et al. Radiographics 2005;25:789-801

©2005 by Radiological Society of North America

THE TERMINAL TUFTS -inflammation with caseous material in the respiratory bronchioles and alveolar ducts

STALKS -caseous material within the terminal bronchiole

Secondary PULMONARY lobule is supplied by a lobular bronchiole and a lobular artery that are located in the center of the lobule.

Under normal circumstances, the intralobular bronchiole is less than 1 mm in diameter and is not normally visible on CT scans

However, diseased bronchioles with mucous plugging with pus,fluid, wall thickening, or dilatation and peribronchiolar inflammation can be visualized on thin-section CT scans, often displaying the tree-in-bud phenomenon

Abnormal – tree in bud Normal ct section

TREE IN BUD PATTERN

Infection Bacterial

Tuberculosis(72%) Non-tuberculosis-MAC,staph aureus,H.influenzae.

Fungal Aspergillus

Viral Cytomegalovirus Respiratory syncytial virus

Idiopathic disorders Obliterative bronchiolitis Diffuse panbronchiolitis

CONGENITAL DISORDERS Cystic fibrosisKartagener’s syndrome

IMMUNOLOGICAL DISORDERS Allergic bronchopulmonary aspergillosis

CONNECTIVE TISSUE DISORDER Rheumatoid arthritisSjogren’s syndrome

MISCELLANEOUS AspirationInhalation of toxic fumes of gasesLangerhans cell histocytosisSarcoidosis

TUMOURSPERIPHERAL PULMONARY VASCULAR DISEASEThrombotic micro-angiography

ENDOBRONCHIAL TB

-TUBERCULOUS INFECTION OF THE TRACHEOBRONCHIALTREE WITH MICROBIAL AND HISTOPATHOLOGICAL EVIDENCE-10-40% OF PATIENTS WITH ACTIVEPULMONARY TUBERCULOSIS.

ENDOBRONCHIAL TBPATHOGENESIS

direct implantation of tubercle bacilliinto the bronchus from an adjacent pulmonary parenchymal lesiondirect airway infiltration from anadjacent tuberculous mediastinal lymph nodeErosion and protrusion of an intrathoracic tuberculous lymphnode into the bronchushematogenous spreadextension to the peribronchial region by lymphaticdrainage.

CLASSIFICATION OF ENDOBRONCHIAL TB (chung n lee)

ACTIVELY CASEATING(43%) EDEMATOUS-HYPEREMIC, FIBROSTENOTIC TUMOROUS GRANULAR ULCERATIVE NONSPECIFIC

CLINICAL SYMPTOMS

COUGH DYSPNEA LOCAL WHEEZE HEMOPTYSIS HOARSENESS ANOREXIA

SEQUELAE….

BRONCHOSTENOSIS BRONCHOSTRICTURES bronchiolitis obliterans bronchocentric granulomatosis BRONCHIECTASIS

DIAGNOSIS

SPUTUM EXAMINATION is the essential and first step .

C X-RAY: NORMAL IN 10-20%

BRONCHOSCOPY(BRONCHIAL BIOPSY/BRUSHING/ WASHINGS) AND CTare the methods of choice for accurate diagnosis of Bronchial involvement . Typical bronchoscopic finding is the presence of white gelatinous granulation tissue. The mucosa is nodular, red, vascular and some times ulcerated. It may simulate a bronchogenic Carcinoma

Nucleic acid amplification tests, such as PCRand other methods for amplifying DNA

TREATMENT

ATT-conventional chemotherapy containing INH, rifampicin, pyrazinamide and ethambutol.

CORTICOSTERIODS

balloon dilatation, self expanding metallic stent(FOR BRONCHIAL STENOSIS)

laser, curettage, resection and anastomosis