An unusual endobronchial Tumour

S. A. SaleemiS. A. Saleemi

A 28 years old Sudanese office workerA 28 years old Sudanese office worker smoker, married with 2 childrensmoker, married with 2 children four weeks history of dry cough and four weeks history of dry cough and

occasional hemoptysis.occasional hemoptysis. Good appetite, no weight lossGood appetite, no weight loss No chest pain, no shortness of breathNo chest pain, no shortness of breath No history of recent travel No history of recent travel No past history of respiratory illnessNo past history of respiratory illness Not on any medicationsNot on any medications

CASE HISTORY

Past medical historyPast medical history Kaposi Sarcoma of both lower limbs treated Kaposi Sarcoma of both lower limbs treated

with chemotherapy and radiation therapy 3 with chemotherapy and radiation therapy 3 years ago. years ago.

His HIV screening was negative on several His HIV screening was negative on several occasions. occasions.

Clinical examination:

Afebrile, P80/min regular, BP 110/70, RR 20/minAfebrile, P80/min regular, BP 110/70, RR 20/min

SpO2 96% on RASpO2 96% on RA

No pallor, no jaundice, No cervical lymphadenopathy No pallor, no jaundice, No cervical lymphadenopathy

Trachea central, Chest clear , no added soundsTrachea central, Chest clear , no added sounds

CVS: unremarkableCVS: unremarkable

Abdomen: NADAbdomen: NAD

CNS: no abnormal signsCNS: no abnormal signs

Legs: No calf swelling. Residual changes on his lower Legs: No calf swelling. Residual changes on his lower limbs after phototherapy and radiotherapy.limbs after phototherapy and radiotherapy.

investigationsinvestigations FBC and differential - Normal valuesFBC and differential - Normal values ESR 35ESR 35 Renal profile- normalRenal profile- normal Liver profile- normalLiver profile- normal Bone profile – normalBone profile – normal Sputum culture - normalSputum culture - normal Sputum for Acid Fast stain (AFB)- negativeSputum for Acid Fast stain (AFB)- negative Recent spirometry- normalRecent spirometry- normal ECG - normalECG - normal

Chest X-ray

DR. Saleemi DR. Saleemi

Bronchoscopy Bronchoscopy

Bronchial washingBronchial washing

Biopsy of both lesionsBiopsy of both lesions

Bronchial washBronchial wash Negative for malignant cells, Negative for malignant cells, Culture Negative Culture Negative AFB stain NegativeAFB stain Negative

BiopsyBiopsy Caseating granulomaCaseating granuloma

The patient was started on anti tuberculosis The patient was started on anti tuberculosis treatment comprising of four drugs treatment comprising of four drugs Isoniazid, Rifampicin, pyrazinamide and Isoniazid, Rifampicin, pyrazinamide and Ethambutol. Ethambutol.

Later on Bactec AFB culture of bronchial Later on Bactec AFB culture of bronchial wash came back as positive for wash came back as positive for Mycobacterium tuberculosis, Mycobacterium tuberculosis,

Final sensitivity result showed pan-sensitive Final sensitivity result showed pan-sensitive mycobacterium tuberculsismycobacterium tuberculsis

Follow-up after six weeks showed resolution of Follow-up after six weeks showed resolution of cough symptom and significant clearing of lung cough symptom and significant clearing of lung infiltrates on repeat chest X-ray. infiltrates on repeat chest X-ray.

A repeat bronchoscopy was not offered in view of A repeat bronchoscopy was not offered in view of significant clinical and radiological improvementsignificant clinical and radiological improvement

Endobronchial tuberculosis

is usually a complication of primary is usually a complication of primary pulmonary tuberculosis mostly occurring pulmonary tuberculosis mostly occurring in children, but can occur in adults. The in children, but can occur in adults. The incidence of endobronchial TB is higher incidence of endobronchial TB is higher in females.in females.

1.Ip MS; So SY; Lam WK; Mok CK. Endobronchial tuberculosis revisited. Chest 1986 May; 89(5):72-30

Commonest form of endobronchial TBCommonest form of endobronchial TB

is mucosal erosions. is mucosal erosions.

Submucosal lymph node involvement Submucosal lymph node involvement

can lead to endobronchial ulceration, can lead to endobronchial ulceration, granulation tissue, polypoid or ulcerous granulation tissue, polypoid or ulcerous lesions and local infiltration causing lesions and local infiltration causing bronchial stenosis . bronchial stenosis .

- Matthews JI; Matarese SL; Carpenter JL. Endobronchial tuberculosis simulating lung cancer. Chest 1984 Oct; 86(4):642-4

- Altin S; Cikrikcioglu S; Morgul M; Kosaf F; Ozyurt H. 50 Endobronchial tuberculosis cases based on bronchoscopic diagnosis. Respiration 1997; 64(2): 162-4.

Erosion of mediastinal lymph nodes into Erosion of mediastinal lymph nodes into main bronchus has also been reported main bronchus has also been reported

Endobronchial Tb presenting as mass Endobronchial Tb presenting as mass lesion simulating lung cancer is rare and lesion simulating lung cancer is rare and only a few case reports are in the only a few case reports are in the literature.literature.

Guleria R, Gupta R, Panda JN. Endobronchial tuberculosis simulating lung cancer. Indian J Chest Dis Allied Sci 1997 Oct-Dec; 39(4): 251-4.

Cough is the most frequent symptom Cough is the most frequent symptom occurring in almost 97% of cases. occurring in almost 97% of cases.

The most serious complication of The most serious complication of endobronchial TB is bronchial stenosisendobronchial TB is bronchial stenosis

Early diagnosis and treatment is essential in Early diagnosis and treatment is essential in preventing the disabling complication of preventing the disabling complication of bronchial stenosis which can lead to bronchial stenosis which can lead to morbidity and even mortality due to morbidity and even mortality due to secondary complicationssecondary complications..

Lee JH, Chung HS. Bronchoscopic, radiologic and pulmonary function evaluation of endobronchial tuberculosis. Respirology Dec 2000,5(4) 411-7

Several treatment options have been tried to Several treatment options have been tried to prevent bronchial stenosis including prevent bronchial stenosis including Isoniazid inhalation and systemic steroids Isoniazid inhalation and systemic steroids but results are not promising. but results are not promising.

Role of corticosteroids therapy in preventing Role of corticosteroids therapy in preventing complications in endobronchial tuberculosis is complications in endobronchial tuberculosis is controversial. controversial.

Study from South Korea has shown no influence Study from South Korea has shown no influence on the outcome of endobronchial tuberculosis by on the outcome of endobronchial tuberculosis by addition of corticosteroids in a prospective trial . addition of corticosteroids in a prospective trial .

Park IW, Choi BW, Hue SH. Prospective study of corticosteroid as an adjunct in the treatment of Endobronchial tuberculosis in adults. Respirology 1997 Dec; 2(4) 275-81.

Most authors stress the need for early Most authors stress the need for early bornchoscopy to diagnose the condition so that bornchoscopy to diagnose the condition so that anti tuberculosis treatment is started on time to anti tuberculosis treatment is started on time to prevent serious complications of endobronchial prevent serious complications of endobronchial tuberculosis.tuberculosis.

- Cherian MJ, Dahniya MH, al-Marzouk N, Osmanagich E, Abul A, Haider A. Australias Radiol 1998 Primary pulmonary tuberculosis presenting as mass lesions and simulating tumours in children. Australas Radiol 1998 Nov; 42(4):309-12

- Chung HS; Lee JH. Bronchoscopic assessment of the evolution of Endobronchial tuberculosis. Chest.Feb2000, 117(2) 385-92

Thank youThank you