Endobronchial tuberculosis

Long term management of people with post-tuberculosis lung disease

Post-tuberculosis lung disease (PTLD) is emerging as a significant area of global interest. As the number of patients surviving tuberculosis (TB) increases, the subsequent long-term repercussions have drawn increased attention due to their profound clinical and socioeconomic impacts. A primary obstacle to its comprehensive study has been its marked heterogeneity. The disease presents a spectrum of clinical manifestations which encompass tracheobronchial stenosis, bronchiectasis, granulomas with fibrosis, cavitation with associated aspergillosis, chronic pleural diseases, and small airway diseases-all persistent consequences of PTLD. The spectrum of symptoms a patient may experience varies based on the severity of the initial infection and the efficacy of the treatment received. As a result, the long-term management of PTLD necessitates a detailed and specific approach, addressing each manifestation individually-a tailored strategy. In the immediate aftermath (0-12 months after anti-TB chemotherapy), there should be an emphasis on monitoring for relapse, tracheobronchial stenosis, and smoking cessation. Subsequent management should focus on addressing hemoptysis, managing infection including aspergillosis, and TB-associated chronic obstructive pulmonary disease or restrictive lung function. There remains a vast expanse of knowledge to be discovered in PTLD. This review emphasizes the pressing need for comprehensive, consolidated guidelines for management of patients with PTLD.

A prediction model for risk of low oxygen saturation in patients with post-tuberculosis tracheobronchial stenosis during bronchoscopy

BACKGROUND

Low oxygen saturation (LOS) is a frequent occurrence for patients with post-tuberculosis tracheobronchial stenosis (PTTS) during bronchoscopic procedures. However, there are currently no systematic assessment tools to predict LOS risk in PTTS patients during bronchoscopy.

OBJECTIVES

This study aimed to develop an effective preoperative predictive model to guide clinical practice.

DESIGN

Retrospective cohort study.

METHODS

Data was retrospectively collected from PTTS patients who underwent bronchoscopic interventions between January 2017 and December 2022. Among all patients included in this study, patients between January 2017 and December 2021 were used as training cohort for the logistic regression model, and patients between January 2022 and December 2022 were utilized as validation cohort for internal validation. We used consistency index (C-index), goodness-of-fit test and calibration plot to evaluate the model performance.

RESULTS

A total of 465 patients who met the inclusion criteria were enrolled in the study. The overall incidence of LOS was 26.0% (121/465). Comorbidity, degree of stenosis, bronchoscopist level, thermal ablation therapy, balloon dilation, and airway stenting, as independent risk factors for the presence of LOS, were used to construct the nomogram prediction model. The C-index of training cohort was 0.827 (95% CI, 0.786-0.869), whereas that of validation cohort was 0.836 (95% CI, 0.757-0.916), combining with the results of the calibration plot and goodness-of-fit test, demonstrating that this model had good predictive ability.

CONCLUSION

The predictive model and derived nomogram with good predictive ability has been developed to preoperatively predict the risk of LOS in PTTS patients during bronchoscopy, allowing for individualized interventions for high-risk patients.

Sex-Specific Differences in the Clinical Profile Among Patients with Tracheobronchial Tuberculosis: A Hospital-Based Cross-Sectional Study in Shenzhen, China

Purpose

Tracheobronchial tuberculosis (TBTB) has been proposed to occur more commonly in female patients. However, to date, studies that systematically delineate differences between female and male patients with TB infection are lacking. We aimed to comprehensively assess the sex-specific differences in clinical manifestation, bronchoscopy performance, bacteriological examination, and imaging of TBTB in Shenzhen, China.

Methods

All patients with diagnosed TBTB from August 1, 2018 to July 31, 2021 at The Third People’s Hospital of Shenzhen were enrolled in the present study. Demographic information, clinical manifestations, blood tests, chest computed tomography, and bronchoscopic findings were collected, and assessed their sex-specific differences.

Results

Of these 331 patients, 238 patients (71.9%) were female, and 93 patients (28.1%) were male, with an overall average age of 37.3 years. The average age of male patients with TBTB was more than 5 years older than that of female patients. The prevalence of lymph fistula and diabetes mellitus was significantly higher in male patients than female patients (8.6% vs 1.7%, P = 0.005; 17.2% vs 2.1%, P < 0.001). The positive proportion of sputum smear was higher in male patients (27.9%) than in female patients (16.7%, P = 0.026). Moreover, the mean monocyte-to-lymphocyte ratio, serum CRP, and IL-6 levels were significantly higher in male patients than in female patients (P < 0.05).

Conclusion

In summary, in patients with TBTB diagnosis, male sex was associated with a high prevalence of diabetes mellitus, lymph fistula, and smear-positive ratio, as well as high inflammation levels. The management of young female and male patients with diabetes mellitus and high inflammation levels should be strengthened. Furthermore, to reduce the burden of TBTB, we must pay attention to the risk of TBTB in past tuberculosis patients, especially male patients under 45 years old and female patients over 45 years old.

Endobronchial Lesions from Disseminated Mycobacterium avium Infection in a Patient with Anti-interferon-gamma Autoantibodies

A 78-year-old man was admitted to our hospital with a fever and left chest pain. Computed tomography showed multiple lung nodules, narrowing of the right bronchus intermedius with mediastinal lymphadenopathy, and an osteolytic lesion. Bronchoscopic findings showed rapid progression of multiple polypoid lesions and the bronchial stenosis. A biopsy of the endobronchial lesions revealed non-necrotizing granulomatous inflammation, and a tissue culture identified Mycobacterium avium. An anti-human immunodeficiency virus antibody was negative. Finally, anti-interferon-gamma (IFN-γ) autoantibodies were detected, and the patient was diagnosed with disseminated nontuberculous mycobacterium infection with anti-IFN-γ autoantibodies. Antimycobacterial therapy was effective, and radiographic findings, including the endobronchial lesions, were resolved.

Diagnostic Efficacy of Xpert MTB/RIF Assay in Bronchoalveolar Lavage Fluid for Tracheobronchial Tuberculosis: A Retrospective Analysis

Background: The Xpert Mycobacterium tuberculosis/rifampin (MTB/RIF) assay has shown good diagnostic efficacy in brushing and biopsy tissue samples from patients with tracheobronchial tuberculosis (TBTB). However, its diagnostic value in bronchoalveolar lavage fluid (BALF) is still unclear. Therefore, the present retrospective study aimed to evaluate the diagnostic value of the Xpert MTB/RIF assay in BALF.

Methods: The clinical data of 266 patients with suspected TBTB from January 2018 to October 2020 were pooled with complete details of bronchial brush and bronchoalveolar lavage samples. Smears of the bronchial brushings were stained with Auramine O stain to detect acid-fast bacilli (AFB), and BALF samples were used for culturing MTB with the BACTEC MGIT 960 system and the Xpert MTB/RIF assay. The diagnostic performance of these methods was assessed and compared.

Results: A total of 266 patients suspected to have TBTB were enrolled in the final analysis. Of these patients, 179 patients were confirmed to have TBTB and 87 patients were non-TBTB. The sensitivity of the Xpert MTB/RIF assay in BALF (87.2%) was significantly higher than that of the brush smear for AFB (35.2%, p < 0.001). No significant difference was observed between the sensitivities of the Xpert MTB/RIF assay in BALF and MTB culture in BALF (87.2 vs. 84.9%, p = 0.542). The specificities of the Xpert MTB/RIF assay in BALF, MTB culture in BALF, and the bronchial brush smear were 97.7, 97.7, and 98.9%, respectively. The positive predictive value (PPV) and negative predictive value (NPV) of the Xpert MTB/RIF assay in BALF, MTB culture in BALF, and the bronchial brush smear were 98.7 and 78.7%, 98.7 and 75.9%, and 98.4 and 42.6%, respectively. Among the MTB culture-positive patients with TBTB detected by the Xpert assay, 27.0% (20/74) were identified to be resistant to RIF.

Conclusions: The Xpert MTB/RIF assay in BALF enables a rapid and accurate diagnosis of TBTB and identification of RIF resistance, which is crucial for timely and proper treatment. Moreover, in patients with TBTB, BALF could be used as an alternative to bronchial brushing and biopsy tissues for the Xpert MTB/RIF assay.

Surgical intervention is safe, feasible, and effective in tubercular tracheobronchial stenosis

Objectives:

Posttubercular tracheobronchial stenosis is a troublesome sequela of tracheobronchial tuberculosis. Surgical resection is the treatment of choice when repeated bronchoscopic dilatations fail. Herein, we aim to present our surgical experience in the management of this problem and also to evaluate factors affecting the surgical outcomes.

Materials and Methods:

This is a retrospective analysis of a prospectively maintained database at a dedicated thoracic surgical unit in New Delhi, India, over 8 years. An analysis of demographic characteristics, perioperative variables including complications were carried out. The occurrence of postoperative complications, and/or hospital stay of >7 days was considered as “poor” surgical outcomes. Various parameters were analyzed to assess the factors predicting surgical outcomes.

Results:

A total of 20 patients were surgically managed in the study period. Two patients had tracheal stenosis. The left main bronchus was involved in 16 patients. In these 16 cases, 12 cases underwent lung preserving surgery (bronchial sleeve resection and sleeve lobectomy) and rest of 4 cases required pneumonectomy. All postoperative complications occurred in 5 (25%) patients. Prolonged air leak was the most common postoperative complication. On univariate analysis, surgical outcomes were poor in patients who had longer duration of symptoms (P = 0.03) and with >2 episodes of preoperative balloon dilatations (<0.001). On multivariate analysis, “total number of dilatations <4 times,” emerged as a significant predictive factor for lung preservation surgery.

Conclusions:

Surgical intervention is safe, feasible, and effective in tubercular tracheobronchial stenoses which fail to respond to bronchoscopic interventions. Early referral for surgery favors lung preservation.

Incidence, laboratory diagnosis and predictors of tracheobronchial tuberculosis in patients with pulmonary tuberculosis in Chongqing, China

Tracheobronchial tuberculosis (TBTB) is reported in 10-40% of patients with pulmonary tuberculosis (PTB). Due to its non-specific presentation, the diagnosis and management are frequently delayed. The aim of the present study was to investigate the incidence, predictors and laboratory diagnosis of concomitant TBTB and PTB in Chongqing, China. Bronchoscopy was performed in all patients with newly diagnosed or relapsed PTB in order to detect TBTB between January 2018 and April 2019 in a sub-tertiary hospital in Chongqing, China. The clinical characteristics and laboratory data were analyzed to identify predictors and determine the diagnostic yield of TBTB. A total of 341 (31.4%) of the 1,085 patients with PTB who underwent the bronchoscopic examination presented with concomitant TBTB. The parameters of female sex [odds ratio (OR)=2.57], clinical symptoms (OR=6.26) and atelectasis (OR=4.3) were independent predictors of TBTB. Cough (OR=32.48) and atelectasis (OR=3.14) were independent predictors of TBTB-associated tracheobronchial stenosis. The diagnostic yields of sputum smear, bronchial brush smear, sputum culture, GeneXpert Mycobacterium tuberculosis/rifampicin resistance (GX) using sputum, GX using brushings and in bronchial brush culture used for the diagnosis of TBTB were 44.2, 44.2, 63.5, 57.7, 71.2 and 75%, respectively. GX brushings had higher diagnostic yields compared with sputum or brush smears; however, there was no significant difference between sputum/brushings cultures and GX with sputum. The incidence of TBTB in PTB was 31.4% in Chongqing, China. The parameters of female sex, atelectasis and cough were the major predictors of concomitant TBTB and associated tracheobronchial stenosis. Although GX is an accurate and rapid test to detect TBTB, additional laboratory techniques should also be adopted to improve diagnostic yields in the detection of TBTB in patients with PTB.

Surgical repair for post-tuberculosis tracheobronchial stenosis

AIM

Post-tuberculosis tracheobronchial stenosis is rare but one of the most dangerous complications of tracheobronchial tuberculosis. Balloon dilatation, stent insertion, laser photoresection, argon plasma coagulation, and cryotherapy are some of the initial treatments recommended for mild to moderate cases. Here, we report a case series of patients who underwent segmental resection and end-to-end anastomosis for bronchial stenosis and a sliding technique for severe and long-segment tracheal stenosis.

METHODS

We retrospectively reviewed the medical records of patients with post-tuberculosis tracheobronchial stenosis operated on in our thoracic surgery department. Of the 7 cases that were treated, two had severe tracheal stenosis stretching over 50% of the tracheal length, one was operated on using resection and end-to-end anastomosis, and the other had sliding tracheoplasty. The other 5 cases of bronchial stem stenosis were treated with segmental resection and end-to-end anastomosis.

RESULTS

All five patients with bronchial stenosis had a good outcome; the ipsilateral lung was well ventilated and respiratory function was good. One patient with tracheal stenosis, treated with segmental resection and end-to-end anastomosis, died after the surgery, and the other patient, treated with slide tracheoplasty, had a good recovery.

CONCLUSION

The treatment plan for patients with post-tuberculosis tracheobronchial stenosis should be on a patient-by-patient basis. Sliding tracheoplasty can be a treatment option in patients with long-segment tracheal stenosis.

A variety of bacterial aetiologies in the lower respiratory tract at patients with endobronchial tuberculosis

Recently, our understanding of the elusive bacterial communities in the lower respiratory tract and their role in chronic lung disease has increased significantly. However, little is known about the respiratory microorganisms in patients with endobronchial tuberculosis (EBTB), which is a chronic inflammatory disease characterized by destruction of the tracheobronchial tree due to Mycobacterium tuberculosis (MTB) infection. We retrospectively reviewed data for histopathologically and microbiologically confirmed EBTB patients diagnosed at a tertiary referral hospital in South Korea between January 2013 and January 2019. Bacterial cultures were performed on bronchial washing from these patients at the time of EBTB diagnosis. A total of 216 patients with EBTB were included in the study. The median age was 73 years and 142 (65.7%) patients were female. Bacteria were detected in 42 (19.4%) patients. Additionally, bacterial co-infection was present in 6 (2.8%) patients. Apart from MTB, the most common microorganisms identified were Staphylococcus aureus (n = 14, 33.3%) followed by Klebsiella species (n = 12, 28.6%; 10 Klebsiella pneumoniae, 2 Klebsiella oxytoca), Streptococcus species (n = 5, 11.9%), Enterobacter species (n = 4, 9.5%), and Pseudomonas aeruginosa (n = 3, 7.1%). A variety of microorganisms were isolated from the bronchial washing indicating that changes in microorganism composition occur in the airways of patients with EBTB. Further studies are needed to investigate the clinical significance of this finding.

Endobronchial tuberculosis polyps

Endobronchial tuberculosis (TB) is an uncommon manifestation of Mycobacterium tuberculosis. We report a case of endobronchial TB polyps in a patient from India presenting with cough, loss of weight and night sweats. Computed tomography chest revealed enlarged mediastinal lymph nodes, endobronchial invasion, and nodular infiltrates in the right lower lobe. Flexible bronchoscopy revealed two endobronchial polyps at the carina and left main bronchus which were biopsied. Histopathology showed non‐caseating granulomas. Both the biopsy and bronchial washings did not identify acid‐fast bacilli on Ziehl‐Neelsen stain and had negative TB complex DNA polymerase chain reaction. One month after bronchoscopy, M. tuberculosis was cultured from the bronchial washings. Following six months of TB treatment, there was full resolution of symptoms and significant radiological improvement. We highlight the diagnostic challenges in endobronchial TB which may impact on the timely institution of treatment.

Scarring Airway Stenosis in Chinese Adults: Characteristics and Interventional Bronchoscopy Treatment

Background:

Scarring airway stenosis is commonly seen in China as compared to other developed countries, due to the high prevalence of tuberculosis. Nowadays, interventional bronchoscopy treatment has been widely used to treat this disease in China. This study demonstrated the characteristics of scarring airway stenosis in Chinese adults and retrospectively evaluated the efficacy of interventional bronchoscopy treatment of this disease.

Methods:

Patients with scarring airway stenosis from 18 tertiary hospitals were enrolled between January 2013 and June 2016. The causes, site, and length of scarring airway stenosis were analyzed, and the efficacy of the interventional bronchoscopy treatment was evaluated.

Results:

The final study cohort consisted of 392 patients. Endotracheobronchial tuberculosis (EBTB) was the most common cause of scarring airway stenosis (305/392, 77.8%) in Chinese adults with a high rate of incidence in young women. The left main bronchus was most susceptible to EBTB, and most posttuberculosis airway scarring stenosis length was 1.1–2.0 cm. The average clinical success rate of interventional bronchoscopy treatment for scarring airway stenosis in Chinese patients is 60.5%. The stent was inserted in 8.7% scarring airway stenosis in China.

Conclusions:

Scarring airway stenosis exhibits specific characteristics in Chinese patients. Interventional bronchoscopy is a useful and safe treatment method for the disease.

Characteristics and clinical role of bronchoscopy in diagnosis of childhood endobronchial tuberculosis

BACKGROUND

Endobronchial tuberculosis (EBTB) is the most frequent complication of primary pulmonary tuberculosis (PTB) in children. The aim of the study was to analyze characteristics and clinical role of bronchoscopy in diagnosis of childhood EBTB.

METHODS

A retrospective, descriptive study was undertaken in 157 children with EBTB undergone flexible bronchoscopy (FB) between January 2006 and June 2014.

RESULTS

The median age of the enrolled patients was 3.4 years, with 73.2% of patients under five years old. The most common subtype was tumorous type (145/157, 92.4%). If only involved bronchus were considered, the common affected sites were right middle lobe bronchus (49/228, 21.5%), left upper lobe bronchus (41/228, 18.0%), right upper lobe bronchus (41/228, 18.0%), right main bronchus (35/228, 15.4%), respectively. Children younger than five years old were at higher risk to have multiple endobronchial lesions (P=0.044), with an odds ratio of 2.313 (95% confidence interval: 1.009-5.299). Before the bronchoscopy, only 16 (10.2%) patients were highly suspected of EBTB, while the others were diagnosed as PTB without EBTB (69.4%), or misdiagnosed as pneumonia or foreign body aspiration (20.4%) on admission.

CONCLUSIONS

The patients under five years old are at high risk to progress to EBTB and have multiple endobronchial lesions. The most frequent subtype of EBTB in children is tumorous type. The lesions are seen in the right bronchial system more frequently. FB should be performed to detect the endobronchial lesions in suspected patients as soon as possible.

Bronchoscopic techniques in the management of patients with tuberculosis

Tuberculosis (TB) is one of the leading causes of morbidity and mortality worldwide. Early diagnosis and treatment are key to prevent Mycobacterium tuberculosis transmission. Bronchoscopy can play a primary role in pulmonary TB diagnosis, particularly for suspected patients with scarce sputum or sputum smear negativity, and with endobronchial disease. Bronchoscopic needle aspiration techniques are accurate and safe means adopted to investigate hilar and mediastinal lymph nodes in cases of suspected TB lymphadenopathy. Tracheobronchial stenosis represents the worst complication of endobronchial tuberculosis. Bronchoscopic procedures are less invasive therapeutic strategies than conventional surgery to be adopted in the management of TB-related stenosis. We conducted a non-systematic review aimed at describing the scientific literature on the role of bronchoscopic techniques in the diagnosis and therapy of patients with TB. We focused on three main areas of interventions: bronchoscopic diagnosis of smear negative/sputum scarce TB patients, endobronchial TB diagnosis and treatment and needle aspiration techniques for intrathoracic TB lymphadenopathy. We described experiences on bronchoalveolar lavage, bronchial washing, and biopsy techniques for the diagnosis of patients with tracheobronchial and pulmonary TB; furthermore, we described the role played by conventional and ultrasound-guided transbronchial needle aspiration in the diagnosis of suspected hilar and mediastinal TB adenopathy. Finally, we assessed the role of the bronchoscopic therapy in the treatment of endobronchial TB and its complications, focusing on dilation techniques (such as balloon dilation and airway stenting) and ablative procedures (both heat and cold therapies).

Tracheobronchial tuberculosis: a clinical review

Endobronchial tuberculosis (EBTB) is defined as tuberculous infection of the tracheobronchial tree. The exact pathogenesis is unclear, and it has a heterogenous clinical course. Its diagnosis requires the clinician to have a high index of suspicion based on clinical symptoms and radiological features. Computed tomography and bronchoscopy are useful tools in its evaluation. The goal of treatment is in the eradication of tuberculous bacilli with appropriate anti-tuberculous therapy. Use of corticosteroids is controversial for the prevention of tracheobronchial stenosis. Interventional bronchoscopy or surgical intervention is employed to restore airway patency once significant stenosis occurs.

Tracheobronchial tuberculosis

Tracheobronchial tuberculosis (TBTB) is reported in approximately 10% to 39% of the patients with pulmonary tuberculosis. It is defined as the tubercle infection of the trachea and or bronchi. Due to its non-specific presentation, insidious onset and normal chest radiography in about 10-20% of the patients, the diagnosis is delayed. Bronchoscopy is the most definite method of diagnosis which provides adequate specimens for microbiological and histopathological diagnosis. Tracheobronchial stenosis is one of the most common long term complications of TBTB resulting in significant morbidity. It is estimated that 90% of patients with TBTB have some degree of tracheal and or bronchial stenosis. In this review article, we will discuss the pathogenesis, symptoms, imaging, bronchoscopic findings, and treatment of TBTB and management of tracheobronchial stenosis.

Tuberculous Tracheobronchial Strictures Treated with Balloon Dilation: A Single-Center Experience in 113 Patients during a 17-year Period

PURPOSE

To evaluate the safety and effectiveness of balloon dilation in the treatment of tuberculous tracheobronchial strictures (TTBSs) in a series of 113 patients at a single institution.

MATERIALS AND METHODS

The institutional review board approved the study and waived the requirement to obtain informed consent. Between 1997 and 2014, under bronchoscopic and fluoroscopic guidance, a total of 167 balloon dilation sessions were performed in 113 consecutive patients (14 male and 99 female patients; mean age, 37 years [age range, 17-73 years]), with a range of one to eight sessions per patient (mean, 1.5 sessions). Outcomes were number and/or frequency of balloon dilations, technical success, primary and secondary clinical success, improvement in respiratory status, airway patency rate, and alternative treatment after balloon dilation. A two-tailed paired t test and the Kaplan-Meier method were used to evaluate the improvement in respiratory status and airway patency rate after balloon dilation, respectively.

RESULTS

Dilation was successful in 82 patients (73%) after single (n = 67) or multiple (n = 15) balloon dilations, with a mean follow-up of 30.3 months. Clinical failure occurred in 31 patients (27%). In these 31 patients, symptoms recurred 1 day to 113 months (mean, 13 months) after repeat balloon dilations. These 31 patients required alternative treatment, including temporary stent placement (n = 12), cutting balloon dilation (n = 12), radiation-eluting balloon dilation (n = 3), and surgery (n = 4). Before, immediately after, and 1 month after the procedure, pulmonary function test results showed significant improvements in mean forced vital capacity (P < .001), forced expiratory volume in 1 second (P = .001), forced expiratory flow in the midexpiratory phase (P = .020), and peak expiratory flow (P = .005).

CONCLUSION

Balloon dilation of TTBSs is a safe, minimally invasive primary treatment that relieved symptoms in a large percentage of patients (73%). In patients with TTBSs refractory to balloon dilation, temporary stent placement, cutting balloon dilation, or radiation-eluting balloon dilation can be an alternative treatment.

Incidence and clinical predictors of endobronchial tuberculosis in patients with pulmonary tuberculosis

BACKGROUND AND OBJECTIVE

Incidence and predictors of endobronchial tuberculosis (EBTB) remain unknown because of the lack of prospective studies. Our objective was to assess the incidence and predictors of concomitant EBTB in patients with active pulmonary tuberculosis (PTB).

METHODS

We prospectively performed routine bronchoscopic examination in all patients with PTB to detect EBTB. Clinical and bronchoscopic findings were analyzed to elucidate predictors of EBTB.

RESULTS

Bronchoscopies of 429 PTB patients were performed at a tertiary referral hospital in Korea. Among those, 233 patients (54.3%) had EBTB. Female gender (odds ratio (OR) 4.35, 95% confidence interval (CI) 1.78-10.63), longer symptom duration (>4 weeks; OR 1.86, 95% CI 1.05-5.46), and no previous history of tuberculosis (OR 4.16, 95% CI 1.22-14.18) were found to be the independent predictors of concomitant EBTB in patients with active PTB. Most of the EBTB/PTB patients had mild stenosis, and more than 20% of them had severe stenosis at the time of diagnosis. Patients with EBTB had follow-up bronchoscopy to evaluate persistent airway stenosis. Persistent bronchostenosis with the lumen narrowed by more than one third occurred in 20.7% (30/145) of patients. The involvement length and decreased forced expiratory volume in 1 s were the risk factors for persistent bronchostenosis.

CONCLUSIONS

In patients with active PTB, 50% or more have EBTB. Female gender and longer duration of symptoms are the main predictors of concomitant EBTB. Immediate diagnostic bronchoscopy in patients with active PTB should be considered in selected patients for detection of brocnhostenosis.

Endobronchial tuberculosis

Endobronchial tuberculosis refers to tuberculous infection of the tracheobronchial tree. Diagnosis requires a high index of suspicion since symptoms are attributed to co-existing pulmonary tuberculosis and airway lesions are not detectable on chest radiograph. While computed tomography and bronchoscopy are useful for the evaluation of tracheobronchial stenosis or obstruction, goals of treatment remain in the eradication of tubercle bacilli and prevention of airway stenosis. Corticosteroids may halt progression of active disease to fibro-stenotic stage, however if tracheobronchial stenosis causing post-obstructive pneumonia, atelectasis and dyspnea has occurred, airway patency must be restored mechanically by surgery or bronchoscopic techniques.

Balloon Dilatation of a Case of Tuberculous Tracheobronchial Stenoses during the Course of Antituberculous Treatment

We report a case of posttuberculosis (TB) tracheobronchial stenoses presented with progressive exertional dyspnea during the course of anti-TB treatment. An 83-year-old Japanese man was admitted for progressive dyspnea; chest X-ray and CT showed stenosis of distal trachea and left main bronchus. Pulmonary function test revealed reduction of FEV1. Balloon dilatation without stent insertion was the choice for this patient for multiple reasons with marked improvement of symptoms.

Challenges in endobronchial tuberculosis: from diagnosis to management

Despite the rapid advancement in diagnostic and therapeutic modalities, endobronchial tuberculosis (EBTB), defined as tuberculous infection of the tracheobronchial tree, continues to remain challenging for clinicians. Nonspecific respiratory symptoms along with normal chest radiograph in 10–20% of cases may be alleged for the diagnostic delay. Variable diagnostic yield with sputum microscopy might further compound the problem. In such cases, high resolution computed tomography (HRCT) works as a more sensitive tool and demonstrates involvement of tracheobronchial tree described classically as “tree-in-bud” appearance. Bronchoscopic biopsy is considered the most reliable method for confirmation of the diagnosis with 30% to 84% positivity in different series. Evolution of the disease is also unpredictable with frequent progression to bronchostenosis, therefore requiring regular follow-up and early intervention to halt the natural course. This review article elaborates various aspects of the disease with specific focus on diagnostic dilemma and recent advances in interventional bronchoscopy. In addition, this discussion evokes optimism for further research and introduction of innovative therapeutic modalities.

Use of lung-preserving surgery in left inflammatory bronchial occlusion and distal atelectasis: preliminary results

OBJECTIVES

Lung-preserving surgery was proved to be effective and safe to treat patients with benign bronchial strictures. However, this surgical treatment has been rarely reported in patients with complete occlusion in the left main bronchus. The aim of this study was to assess the value of this procedure and report our experience in the treatment of these patients with left atelectasis caused by inflammatory bronchial occlusion.

METHODS

We reviewed and analysed the medical records of 8 patients who had undergone left main bronchus sleeve resection for symptomatic left atelectasis caused by inflammatory bronchial occlusion from May 2007 to April 2011.

RESULTS

Eight patients (3 men and 5 women) with a medical history of active pulmonary tuberculosis were involved in this study. The median age was 23 years. Parenchyma-sparing left main bronchus resection was performed in 4 patients, 1 of whom received partial wedge resection in the lingual lobe. Left main bronchus sleeve resection plus superior lobectomy was performed in 2 patients and left main bronchus sleeve resection plus left inferior lobectomy in 2 patients, 1 of whom received additional partial wedge resection of the lingual lobe. The procedure was completed successfully in all 8 patients without postoperative deaths. The mean follow-up time was 49.3 months, ranging from 23 to 69 months. No major complications, including stenosis and atelectasis, were observed during the follow-up period. The symptoms of pulmonary atelectasis disappeared and pulmonary ventilation function improved significantly.

CONCLUSIONS

In symptomatic patients with left atelectasis caused by inflammatory bronchial occlusion, lung-preserving surgery is an effective and safe surgical treatment.

Analysis of the surgical treatment of endobronchial tuberculosis (EBTB)

PURPOSE

Endobronchial tuberculosis (EBTB) is defined as tuberculosis infection of the tracheobronchial tree. EBTB may require aggressive treatment, including lung resection, because of severe bronchostenosis and its complications, despite formal anti-TB chemotherapy. We present our experience of treating 25 patients with EBTB.

METHODS

We reviewed retrospectively the medical records of 25 patients with EBTB treated between 2002 and 2012 at the Department of Thoracic Surgery in Beijing Chest Hospital.

RESULTS

All 25 patients (5 male, 20 female) underwent surgery for fibrostenotic type EBTB. Bronchoscopy showed fibrostenotic change in all patients and a cough was the most common symptom. Postoperatively, all patients were given anti-TB therapy to take for 6-9 months.

CONCLUSIONS

EBTB tends to occur at a higher incidence in young women. Surgery may be required for severe bronchostenosis and its complications and should be performed for symptomatic fibrostenotic type EBTB. During the operation, attention should be paid to prevent severe complications and postoperative anti-TB therapy is mandatory.

Tracheal wall thickening is associated with the granulation tissue formation around silicone stents in patients with post-tuberculosis tracheal stenosis

PURPOSE

Tracheal restenosis due to excessive granulation tissue around a silicone stent requires repeated bronchoscopic interventions in patients with post-tuberculosis tracheal stenosis (PTTS). The current study was conducted to identify the risk factors for granulation tissue formation after silicone stenting in PTTS patients.

MATERIALS AND METHODS

A retrospective study was conducted between January 1998 and December 2010. Forty-two PTTS patients with silicone stenting were selected. Clinical and radiological variables were retrospectively collected and analyzed.

RESULTS

Tracheal restenosis due to granulation tissue formation were found in 20 patients (47.6%), and repeated bronchoscopic interventions were conducted. In multivariate analysis, tracheal wall thickness, measured on axial computed tomography scan, was independently associated with granulation tissue formation after silicone stenting. Furthermore, the degree of tracheal wall thickness was well correlated with the degree of granulation tissue formation.

CONCLUSION

Tracheal wall thickening was associated with granulation tissue formation around silicone stents in patients with post-tuberculosis tracheal stenosis.

Long-term tolerance of airway silicone stent in patients with post-tuberculosis tracheobronchial stenosis

Surgery is a well-recognized modality of treatment for benign tracheobronchial stenosis. However, in some benign disease groups, such as tuberculosis, sarcoidosis, war gas exposure, and inhalation burns, multiplicity of involvement or long length of stenosed segment heightens surgical challenge. We investigated the outcomes and long-term tolerability of the Natural stent (N-stent) in such patients with post-tuberculosis tracheobronchial stenosis. A retrospective review was done for 17 patients who underwent silicone stenting (N-stent) for post-tuberculosis tracheobronchial stenosis during January 2000-December 2003 but needed persistent stent placement and still require the stent. Significant increase in the ratio of forced expiratory volume in 1 second (FEV1) to forced vital capacity (FVC), expressed as FEV1%, as well as in forced percentual vital capacity (FVC%) (Δ24% and Δ11%, respectively) in the short term and sustained increase in the FEV1% and FVC% (Δ26.5% and Δ16.5%, respectively) in the long term were noted at a median (range) interval of 1 (0.5-72) month and 72 (12-114) months, respectively, along with symptomatic relief. No procedure-related death occurred. Stent-related late complications included granulation tissue formation (76%), migration (70%), and mucostasis (17%). The median duration for which N-stents were tolerated was 7.9 (range, 3-11) years. N-stents are well-tolerated for a prolonged period. Stent-related complications occur, but are easily managed. These results might carry medical implications for those who have airway lesions difficult to correct surgically.

Posttuberculosis tracheobronchial stenosis: use of CT to optimize the time of silicone stent removal

PURPOSE

To evaluate whether air pockets (tracheobronchial air columns in the space between the outer surface of the stent and the adjacent airway wall) discernible at computed tomography (CT) can help optimize the time of stent removal in patients with posttuberculosis tracheobronchial stenosis (PTTS).

MATERIALS AND METHODS

The study was approved by the institutional review board, and informed consent was obtained from all patients. Data from 41 patients (five men, 36 women) with a median age of 39 years (range, 21-64 years) who underwent silicone stent placement owing to PTTS, followed by CT and stent removal 6-12 months after clinical stabilization, were investigated retrospectively. Two radiologists determined whether the extent of air pockets on CT scans was associated with clinical success, which was defined as maintenance of a prosthesis-free airway for more than 2 years after stent removal. Radiologic features were compared for outcome by using a Wilcoxon two-sample test or Fisher exact test.

RESULTS

Stents were removed successfully in 31 patients (76%). Air pockets longer than 1 cm or longer than 2 cm were associated with successful stent removal (P = .04 and P = .006, respectively). The sensitivity and specificity of air pocket length in the prediction of successful stent removal were 84% and 50%, respectively, for air pockets longer than 1 cm and 68% and 70% for air pockets longer than 2 cm.

CONCLUSION

The extent of air pockets at chest CT shows correlation with the success of stent removal, indicates regression of stenosis, and may help guide the optimal time for stent removal.

Mycobacterium kansasii endobronchial ulcer in a nonimmunocompromised patient

In this report we describe the case of an immunocompetent patient found to have an endobronchial, ulcerated lesion due to Mycobacterium kansasii. Predisposing factors could have been severe endobronchial stenosis of the main stem bronchi and distortion of the carina, due to healed endobronchial tuberculosis. Diagnosis was set through fiberoptic bronchoscopy and the patient responded well to treatment. Endobronchial non tuberculous mycobacterial infection should be considered in both HIV seropositive and seronegative patients, especially in endemic areas and in the proper clinical setting. Prompt recognition is important for the effective control and prevention of an unfavorable outcome in an otherwise easily treatable disease.

[Endobronchial tuberculosis -- clinical and bronchoscopic features]

Endobronchial tuberculosis (ET) is a serious complication of pulmonary tuberculosis and is a major cause of morbidity. The aim of our retrospective study was to characterize the clinical, radiological, microbiological and bronchoscopic features of ET. Between January 1999 and June 2002 a total of 14 patients were diagnosed as having ET in our hospital. There were 8 (57%) men and 6 women with a median age of 39.6 +/- 18.1 years (range from 20 to 78 years). Cough was the most common complain and it was present in 71.4% of patients. Only 5 patients were sputum smear positive. Five patients (35.7%) had parenchymal infiltration and this was the most common roentgenographic appearance. Forms of ET were classified into subtypes: actively caseating (n=4), granular (n=3), tumorous (n=3), edematous-hyperemic (n=2) and ulcerative (n=2). The upper lobes were affected in 9 (64.3%) patients. Nine patients had involvement of the left bronchial tree, 3 of the right and in 2 there were bilateral lesions. The diagnosis could be established in 11 (78.6%) cases by bronchial biopsy. All patients had positive bronchial lavage cultures for acid-fast bacilli. Clinical manifestations and roentgenographic appearance of ET are not specific and so bronchoscopy is mandatory for the prompt diagnosis and follow-up of its evolution.

Therapeutic management of endobronchial tuberculosis

Endobronchial tuberculosis (EBTB) is defined as tuberculous infection of the tracheobronchial tree. Common symptoms are cough, haemoptysis, sputum production, wheezing, chest pain and fever in active disease and dyspnoea and wheezing in the fibrous stage. This form of tuberculosis is difficult to diagnose because the lesion is not evident in the chest radiograph, frequently delaying treatment. Computed tomography is very useful in evaluating bronchial lesions such as stenosis or obstruction. The most important goal of treatment in active EBTB is eradication of tubercle bacilli. The second most important goal is prevention of bronchial stenosis. Corticosteroid therapy for the prevention of bronchial stenosis in EBTB remains controversial. However, the healing time of ulcerous lesions was shorter and bronchial stenosis was less severe, in patients treated with aerosol therapy, consisting of streptomycin 100 mg, a corticosteroid (dexamethasone 0.5 mg) and naphazoline 0.1 mg administered twice-daily along with conventional oral therapy. In inactive disease, treatment to restore full patency is appropriate. As steroids or other medications are unable to reverse stenosis from fibrous disease, airway patency must be restored mechanically by surgery or endobronchial intervention. Effectiveness and complications remain important issues with the mechanical techniques as use and evaluation continue. Corticosteroid therapy for prevention of bronchial stenosis in EBTB remains controversial. Our observations suggest that progression of bronchial stenosis can be prevented in patients who are treated with aerosol therapy with corticosteroids.

Changes of plasma interleukin-1 receptor antagonist, interleukin-8 and other serologic markers during chemotherapy in patients with active pulmonary tuberculosis

BACKGROUND

The human immune response to Mycobacterium tuberculosis is mediated by macrophages and T-lymphocytes. The alveolar macrophage phagocyting mycobacterium produces interleukin (IL)-1 as an inflammatory mediator, and IL-8 as a cytokine for leukocyte recruitment and granuloma formation. Interleukin-1 receptor antagonist (IL-1ra) is an internal antagonist of IL-1.

METHODS

Plasma levels of IL-1ra and IL-8 and other serologic markers were measured in 18 patients with active tuberculosis before treatment and after 2 months and 6 months of treatment.

RESULTS

During treatment with antituberculous medication, patients showed significant changes in hemoglobin, hematocrit, white blood cells (WBC), platelet, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), ferritin and plasma IL-1ra. After 2 months of treatment, ESR and CRP diminished significantly; after 6 months, hemoglobin increased while WBC, platelet, ESR, CRP and ferritin decreased significantly compared to their pre-treatment levels. There were two groups: patients with delayed therapeutic responses, and patients with early responses. At each point of observation, the former group of patients showed lower body weight and lower levels of hemoglobin and hematocrit, and higher levels of WBC, platelet, ESR, IL-8 and IL-1ra than the latter group. During the course of the treatment, we observed considerable differences in body weight, body mass index, hemoglobin, hematocrit, WBC and platelet counts, ESR, CRP and ferritin in both the early-response and delayed-response groups.

CONCLUSION

We believe that the plasma concentrations of IL-1ra and IL-8, which showed different peaks during the course of treatment, reflected their different functions and patterns of secretion. Moreover the concentrations did not seem as sensitive as other inflammatory markers to evaluate disease activity during antituberculosis treatment. However, IL-1ra can be considered a marker for disease activity and response to treatment.