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Ahmad Z, Masood I, Baneen U, Ejaz S, Rehman S. Endobronchial growth: Tumor or tuberculosis. J Family Med Prim Care 2024; 13:792-796. [PMID: 38605786 PMCID: PMC11006036 DOI: 10.4103/jfmpc.jfmpc_1204_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 09/30/2023] [Accepted: 10/05/2023] [Indexed: 04/13/2024] Open
Abstract
Endobronchial tuberculosis (EBTB) is characterized by tuberculosis infection of the tracheobronchial tree. It has variable presentation but tumorous growth-like presentation in bronchus is very rare. The clinical and radiological features are non-specific, which creates a diagnostic dilemma. Bronchoscopy and biopsy of the lesion are mandatory to confirm the diagnosis. In this case series, we are presenting three unique cases of endobronchial growth diagnosed as EBTB after biopsy and evaluation of bronchoalveolar lavage (BAL) with cartridge-based nucleic acid amplification test (CBNAAT) and other ancillary investigations for tuberculosis. Four patients presented to the outpatient department with non-specific symptoms of fever, cough, hoarseness of voice, and hemoptysis. They were evaluated with chest radiograph (CXR), contrast-enhanced computed tomography (CECT) thorax, and bronchoscopy. Bronchoscopy revealed growth in the bronchus in all three cases. A biopsy was taken and BAL was performed. All cases turned out to be EBTB in histopathological examination and BAL CBNAAT. They were treated with anti-tubercular drugs and all responded well to treatment. Endobronchial tuberculosis presenting as tumorous growth in the tracheobronchial tree is rare. There should be a high index of suspicion while dealing with patients with non-specific clinical and radiological features of tuberculosis. EBTB can be misdiagnosed as malignancy in most cases. Therefore, it should be kept as a differential diagnosis while encountering a mass lesion in the trachea or bronchus during bronchoscopy.
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Affiliation(s)
- Zuber Ahmad
- Department of TB and Respiratory Diseases, JNMCH, AMU, Uttar Pradesh, India
| | - Imrana Masood
- Department of TB and Respiratory Diseases, JNMCH, AMU, Uttar Pradesh, India
| | - Ummul Baneen
- Department of TB and Respiratory Diseases, JNMCH, AMU, Uttar Pradesh, India
| | - Saima Ejaz
- Department of TB and Respiratory Diseases, JNMCH, AMU, Uttar Pradesh, India
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Qiu Q, Li S, Chen Y, Yan X, Yang S, Qiu S, Peng A, Chen Y. Development, assessment and validation of a novel prediction nomogram model for risk identification of tracheobronchial tuberculosis in patients with pulmonary tuberculosis. BMJ Open Respir Res 2023; 10:e001781. [PMID: 37931979 PMCID: PMC10632898 DOI: 10.1136/bmjresp-2023-001781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 10/20/2023] [Indexed: 11/08/2023] Open
Abstract
OBJECTIVE Tracheobronchial tuberculosis (TBTB), a specific subtype of pulmonary tuberculosis (PTB), can lead to bronchial stenosis or bronchial occlusion if not identified early. However, there is currently no available means for predicting the risk of associated TBTB in PTB patients. The objective of this study was to establish a risk prediction nomogram model for estimating the associated TBTB risk in every PTB patient. METHODS A retrospective cohort study was conducted with 2153 PTB patients. Optimised characteristics were selected using least absolute shrinkage and selection operator regression. Multivariate logistic regression was applied to build a predictive nomogram model. Discrimination, calibration and clinical usefulness of the prediction model were assessed using C-statistics, receiver operator characteristic curves, calibration plots and decision analysis. The developed model was validated both internally and externally. RESULTS Among all PTB patients who underwent bronchoscopies (n=2153), 40.36% (n=869) were diagnosed with TBTB. A nomogram model incorporating 11 predictors was developed and displayed good discrimination with a C-statistics of 0.782, a sensitivity of 0.661 and a specificity of 0.762 and good calibration with a calibration-in-the-large of 0.052 and a calibration slope of 0.957. Model's discrimination was favourable in both internal (C-statistics, 0.782) and external (C-statistics, 0.806) validation. External validation showed satisfactory accuracy (sensitivity, 0.690; specificity, 0.804) in independent cohort. Decision curve analysis showed that the model was clinically useful when intervention was decided on at the exacerbation possibility threshold of 2.3%-99.2%. A clinical impact curve demonstrated that our model predicted high-risk estimates and true positives. CONCLUSION We developed a novel and convenient risk prediction nomogram model that enhances the risk assessment of associated TBTB in PTB patients. This nomogram can help identify high-risk PTB patients who may benefit from early bronchoscopy and aggressive treatment to prevent disease progression.
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Affiliation(s)
- Qian Qiu
- Post-Doctoral Research Center, Chongqing Public Health Medical Center, Chongqing, China
| | - Siju Li
- Emergency Department, Chongqing Public Health Medical Center, Chongqing, China
| | - Yong Chen
- Department of Endocrinology, First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Xiaofeng Yan
- Division of Tuberculosis, Chongqing Public Health Medical Center, Chongqing, China
| | - Song Yang
- Division of Tuberculosis, Chongqing Public Health Medical Center, Chongqing, China
| | - Shi Qiu
- Department of Nutrition, The Seventh Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Anzhou Peng
- Division of Tuberculosis, Chongqing Public Health Medical Center, Chongqing, China
| | - Yaokai Chen
- Division of Infectious Diseases, Chongqing Public Health Medical Center, Chongqing, China
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Kim BG, Jeong BH, Kim H. Clinical Factors for Successful Removal of Airway Silicone Stents in Patients With Post-Tuberculosis Tracheobronchial Stenosis. J Korean Med Sci 2023; 38:e308. [PMID: 37821085 PMCID: PMC10562181 DOI: 10.3346/jkms.2023.38.e308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Accepted: 06/07/2023] [Indexed: 10/13/2023] Open
Abstract
BACKGROUND After relieving stenosis with an airway silicone stent in post-tuberculosis bronchial stenosis (PTTS), stent removal is attempted if it is determined that airway patency can be maintained even after stent removal. However, the factors affecting airway stent removal are not well known. We investigate the factors that enable the successful removal of airway silicone stents in patients with PTTS. METHODS We retrospectively analyzed PTTS patients who underwent bronchoscopic intervention from January 2004 to December 2019. Successful stent removal is defined as airway patency maintained when the stent is removed, so that reinsertion of the stent is not required. A multivariate logistic regression analysis was used to identify independent factors associated with successful stent removal at the first attempt. RESULTS Total 344 patients were analyzed. Patients were followed up for a median of 47.9 (26.9-85.2) months after airway stent insertion. Approximately 69% of PTTS patients finally maintained airway patency after the stent was removed. Factors related to successful stent removal at the first attempt were older age and male sex. Absence of parenchymal calcification, segmental consolidation & bronchiolitis, and no trachea involved lesion were relevant to the successful stent removal. Stent dwelling for 12-24 months was associated with successful stent removal compared to a duration of less than 12 months. CONCLUSION For patients whose airway patency is determined to be maintained even without a stent, it is necessary to attempt stent removal in consideration of factors related to successful stent removal.
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Affiliation(s)
- Bo-Guen Kim
- Division of Pulmonary Medicine and Allergy, Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Byeong-Ho Jeong
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hojoong Kim
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
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Yang MJ, He JQ, Guo SL. Tracheobronchial tuberculosis and its sequelae in children and adolescents. THE LANCET. INFECTIOUS DISEASES 2023; 23:786. [PMID: 37207687 DOI: 10.1016/s1473-3099(23)00311-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Revised: 05/09/2023] [Accepted: 05/09/2023] [Indexed: 05/21/2023]
Affiliation(s)
- Ming-Jin Yang
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Jian-Qing He
- Department of Respiratory and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Shu-Liang Guo
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China.
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彭 帅, 张 光, 洪 婧, 丁 浩, 王 崇, 罗 健, 罗 征. [Clinical and bronchoscopy features of tracheobronchial tuberculosis in children]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2023; 25:381-387. [PMID: 37073843 PMCID: PMC10120345 DOI: 10.7499/j.issn.1008-8830.2210116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 01/23/2023] [Indexed: 04/20/2023]
Abstract
OBJECTIVES To study the clinical and bronchoscopic characteristics of tracheobronchial tuberculosis (TBTB) in children and to identify factors influencing residual airway obstruction or stenosis. METHODS The clinical data of children with TBTB were retrospectively collected. The children were divided into two groups based on the last bronchoscopic result within one year of follow-up: a group with residual airway obstruction or stenosis (n=34) and a group without residual airway obstruction or stenosis (n=58). A multivariate logistic regression analysis was used to identify the factors influencing residual airway obstruction or stenosis in children with TBTB. Receiver operating characteristic (ROC) curves were used to analyze the predictive value of the factors influencing residual airway obstruction or stenosis in children with TBTB. RESULTS A total of 92 children with TBTB were included, and the main symptoms were cough (90%) and fever (68%). In children under 1 year old, the incidence rates of dyspnea and wheezing were significantly higher than in other age groups (P<0.008). Chest CT findings included mediastinal or hilar lymph node enlargement (90%) and tracheobronchial stenosis or obstruction (61%). The lymphatic fistula type was the main type of TBTB observed bronchoscopically (77%). All children received interventional treatment, and the effective rate was 84%. During one year of follow-up, 34 children had residual airway obstruction or stenosis. The TBTB diagnostic time and the initiation of interventional treatment were significantly delayed in the group with residual airway obstruction or stenosis compared with the group without residual airway obstruction or stenosis (P<0.05). The multivariate logistic regression analysis showed that the TBTB diagnostic time was closely related to residual airway obstruction or stenosis in children (P<0.05). ROC curve analysis showed that at the cut-off value of 92 days of TBTB diagnostic time, the area under the curve for predicting residual airway obstruction or stenosis in children with TBTB was 0.707, with a sensitivity of 58.8% and a specificity of 75.9%. CONCLUSIONS The clinical manifestations of TBTB are nonspecific, and symptoms are more severe in children under 1 year old. TBTB should be suspected in children with tuberculosis and chest imaging indicating airway involvement. Delayed diagnosis of TBTB is associated with the development of residual airway obstruction or stenosis.
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Konamme VK, Gowrishankar BC, Babu MN. Infantile Tubercular Endobronchial Polypoid Obstructive Lesion. J Indian Assoc Pediatr Surg 2023; 28:167-169. [PMID: 37197232 PMCID: PMC10185030 DOI: 10.4103/jiaps.jiaps_98_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Revised: 11/17/2022] [Accepted: 11/20/2022] [Indexed: 05/19/2023] Open
Abstract
Endobronchial tuberculosis is reported in 18% of adults and 30%-60% of children with primary pulmonary tuberculosis. We are reporting two infants who presented with nonspecific respiratory symptoms due to an obstructive tubercular polypoid mass which was detected on computed tomography. Bronchoscopy showed a pale friable polypoid lesion in the bronchus causing a luminal obstruction. The biopsy of the lesion was suggestive of tuberculosis. On treatment with antitubercular medications, both the babies improved and remained asymptomatic on long-term follow-up.
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Affiliation(s)
- Vinay Kumar Konamme
- Department of Pediatric Surgery, Indira Gandhi Institute of Child Health, Bengaluru, Karnataka, India
| | - B. C. Gowrishankar
- Department of Pediatric Surgery, Indira Gandhi Institute of Child Health, Bengaluru, Karnataka, India
| | - M. Narendra Babu
- Department of Pediatric Surgery, Indira Gandhi Institute of Child Health, Bengaluru, Karnataka, India
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Zhuang R, Yang M, Xu L, Li Y, Li Y, Hu T, Chen Y, Nie X, Yan X, Kong X, Yang S, Guo S. Characteristics analysis of 157 cases of central airway stenosis due to tracheobronchial tuberculosis: A descriptive study. Front Public Health 2023; 11:1115177. [PMID: 36817912 PMCID: PMC9932966 DOI: 10.3389/fpubh.2023.1115177] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Accepted: 01/17/2023] [Indexed: 02/05/2023] Open
Abstract
Background Tracheobronchial stenosis, particularly central airway stenosis, which frequently results in severe complications such as lung damage, occurs in patients with tracheobronchial tuberculosis (TBTB). Objectives To analyze the clinical characteristics of patients with central airway stenosis due to tuberculosis (CASTB). Methods Retrospective analysis was performed on the clinical features, radiological features, bronchoscopic features and treatment of 157 patients who were diagnosed with CASTB in two tertiary hospitals in Chongqing, China, from May 2020 to May 2022. Results CASTB mostly occurs in young patients and females. Patients with CASTB exhibited different symptoms repeatedly during the disease, especially varying degrees of dyspnea, prompting many patients to undergo bronchoscopic intervention and even surgery. Patients with cicatricial strictures constituted the highest proportion of the TBTB subtype with CASTB and 35.7% of the patients with CASTB were found to have tracheobronchomalacia (TBM) under bronchoscopy. CASTB and TBM mainly involved the left main bronchus. Patients with lower levels of education had higher rates of TBM. Patients with TBM manifested shortness of breath more frequently than patients without TBM. Patients with TBTB who had undergone bronchoscopic interventions have a higher rate of TBM. Conclusions Despite mostly adequate anti-tuberculosis chemotherapy, patients with TBTB can present with CASTB involving severe scarring stenosis, bronchial occlusion, tracheobronchomalacia and even destroyed lung.
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Affiliation(s)
- Rongjuan Zhuang
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Mingjin Yang
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Li Xu
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yishi Li
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Ying Li
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Tingting Hu
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical and Pharmaceutical College, Chongqing, China
| | - Yan Chen
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical and Pharmaceutical College, Chongqing, China
| | - Xiao Nie
- Department of Respiratory and Critical Care Medicine, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
| | - Xiaofeng Yan
- Department of Tuberculosis, Chong Qing Public Health Medical Center, Chongqing, China
| | - Xianghua Kong
- Department of Tuberculosis, Chong Qing Public Health Medical Center, Chongqing, China
| | - Song Yang
- Department of Comprehensive Internal Medicine, Chong Qing Public Health Medical Center, Chongqing, China
| | - Shuliang Guo
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China,*Correspondence: Shuliang Guo ✉
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García-Martínez L, Laín Fernández A, Iglesias-Serrano I, Giné Prades C, Soriano-Arandes A, López M. Endobronchial tuberculosis in children: Defining the role of interventional bronchoscopy. Pediatr Pulmonol 2022; 57:2688-2695. [PMID: 35950618 DOI: 10.1002/ppul.26084] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 06/07/2022] [Accepted: 07/16/2022] [Indexed: 11/11/2022]
Abstract
INTRODUCTION Endobronchial tuberculosis (EBTB) can lead to bronchopulmonary complications when diagnosis is delayed. Bronchoscopic treatment in children can be challenging due to small airway size. We report our experience treating children with EBTB. METHODS Retrospective study (2014-2020) of patients diagnosed with EBTB. Flexible bronchoscopy (FB) was performed in patients with previous diagnosis of pulmonary tuberculosis (PTB), after respiratory/radiological worsening was observed in spite of medical treatment. Treatment consisted in oral corticotherapy in all patients, and interventional bronchoscopy in selected cases. Our aim is to describe the endoscopic findings, interventional bronchoscopy alternatives, and outcome. RESULTS Of 45 patients with PTB, 13 (28.9%, 7 M/6 F) were diagnosed with EBTB, with a mean age of 3.9 years (0.4-12.8). Four bronchoscopic patterns were observed. Endobronchial granuloma (N:9; 69.2%): Excision with rigid bronchoscopy was achieved in five (1-5 procedures per patient), while corticotherapy alone was preferred in the remaining four due to small size/distal location of the granuloma. Caseum obstruction (2; 15.4%): dense mucous molds were removed with flexible/rigid bronchoscopy (6 and 8 procedures, respectively). Bronchial stenosis (1; 7.7%): two balloon dilatations with mitomycin-C application were performed. Extrinsic compression (1; 7.7%): oral corticotherapy alone was initiated. One patient developed bronchoscopy-related complications (pneumothorax requiring thoracic tube 48 h). With a medium follow-up of 4.6 years (1.8-7.6), three patients developed bronchiectasis while the remaining 10 improved clinically and radiologically. CONCLUSION Bronchoscopic findings in EBTB include granuloma, stenosis, caseum obstruction and external compression. In selected cases, interventional bronchoscopy can minimize long-term bronchopulmonary complications.
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Affiliation(s)
- Laura García-Martínez
- Pediatric Surgery Department, Hospital Universitari Vall d'Hebron, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Ana Laín Fernández
- Pediatric Surgery Department, Hospital Universitari Vall d'Hebron, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Ignacio Iglesias-Serrano
- Pediatric Respiratory Medicine Department, Hospital Universitari Vall d'Hebron, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Carles Giné Prades
- Pediatric Surgery Department, Hospital Universitari Vall d'Hebron, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Antoni Soriano-Arandes
- Paediatric Infectious Diseases and Immunodeficiencies Departament, Hospital Universitari Vall d'Hebron, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Manuel López
- Pediatric Surgery Department, Hospital Universitari Vall d'Hebron, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
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The Atypical Manifestation of Pulmonary Tuberculosis in Patients with Bronchial Anthracofibrosis. J Clin Med 2022; 11:jcm11195646. [PMID: 36233513 PMCID: PMC9571957 DOI: 10.3390/jcm11195646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 09/19/2022] [Accepted: 09/22/2022] [Indexed: 11/16/2022] Open
Abstract
It has been stated that bronchial anthracofibrosis (BAF) has an important relationship with pulmonary tuberculosis (TB), and the coexistence of TB and BAF is high. The purpose of this study was to compare the differences in computed tomography (CT) characteristics of pulmonary TB according to the presence of underlying BAF. Total of 202 consecutive patients who were diagnosed with pulmonary TB and underwent bronchoscopy and CT in our institution were retrospectively reviewed. We classified the patients into two groups according to the presence of BAF and compared the clinicoradiological findings between the two groups (anthracofibrosis group vs. nonanthracofibrosis group). Elderly and female patients were significantly higher in anthracofibrosis group (mean age 79 ± 7 (64−94) vs. 56 ± 17 (16−95), p < 0.001; female 89% vs. 29%, p < 0.001). The frequency of internal low-density area or focal contour bulge within atelectasis (64% vs. 1%, p < 0.001), lower lobe predominance (43% vs. 9%, p < 0.001), endobronchial involvement (46% vs. 15%, p < 0.001), and lymphadenopathy (57% vs. 28%, p = 0.002) were significantly higher in anthracofibrosis group. In contrast, the anthracofibrosis group showed lower frequency of upper lobe predominance (32% vs. 81%, p < 0.001) and cavitation (14% vs. 51%, p = 0.001). In conclusion, being aware of these atypical manifestations of pulmonary TB in the presence of BAF will be of great help in early detection of TB.
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Li F, Tian S, Huang H, Zhang W, Huang Y, Wu N, Wang Q, Wang X, Dong Y, Bai C. Post-tuberculosis tracheobronchial stenosis: long-term follow-up after self-expandable metallic stents placement and development of a prediction score-the Restenosis Score. Eur J Med Res 2022; 27:133. [PMID: 35897118 PMCID: PMC9327164 DOI: 10.1186/s40001-022-00765-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 07/18/2022] [Indexed: 11/30/2022] Open
Abstract
Background The insertion of self-expandable metallic stents (SEMS) for post-tuberculosis tracheobronchial stenosis (PTTS) was controversial. This study aimed to evaluate the efficacy and safety of SEMS for treating PTTS, and developed a scoring system for predicting the occurrence of restenosis after stenting in PTTS patients. Methods We conducted a retrospective review of 87 patients who were diagnosed with PTTS and experienced SEMS insertion between January 2000 and December 2017. All procedures were performed via flexible bronchoscopy under conscious sedation and local anesthesia. Results A total of 85 SEMS were successfully placed in 77 patients. Comparing with pre-stenting, there were significant improvements in the lumen diameters of the stenotic segment, mMRC scale and lung function after short-term SEMS placement. During the long-term (average 163.32 months) follow-up, 48 patients (62.3%) did not develop restenosis after stenting; the other 29 patients (37.7%) developed and eventually, 12 remained under interventional therapies and 11 had bronchial atresia. Multivariate Cox regression analysis revealed that the difference value between SEMS length and the stenosis-segment length, stenosis type, and the number of pre-stenting thermal ablation were independently related to restenosis occurrence and were subsequently used to establish the Restenosis Score. The model’s development group (0.83, 95% CI 0.74–0.92) and external validation set (0.94, 95% CI 0.77–1.00) showed excellent discrimination. Conclusion SEMS placement could serve as a safe and effective treatment option for most patients with PTTS. Further, we built a prediction model depending on the independent predictors of restenosis occurrence, the Restenosis Score. This validated tool might provide a decision support and a better management for PTTS patients who underwent SEMS implantation.
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Affiliation(s)
- Fuqi Li
- Department of Respiratory and Critical Care Medicine, Shanghai Changhai Hospital, The First Affiliated Hospital of Second Military Medical University, Shanghai, 200433, China.,Department of Pathology, Shanghai Changhai Hospital, The First Affiliated Hospital of Second Military Medical University, Shanghai, 200433, China
| | - Sen Tian
- Department of Respiratory and Critical Care Medicine, Shanghai Changhai Hospital, The First Affiliated Hospital of Second Military Medical University, Shanghai, 200433, China
| | - Haidong Huang
- Department of Respiratory and Critical Care Medicine, Shanghai Changhai Hospital, The First Affiliated Hospital of Second Military Medical University, Shanghai, 200433, China
| | - Wei Zhang
- Department of Respiratory and Critical Care Medicine, Shanghai Changhai Hospital, The First Affiliated Hospital of Second Military Medical University, Shanghai, 200433, China
| | - Yi Huang
- Department of Respiratory and Critical Care Medicine, Shanghai Changhai Hospital, The First Affiliated Hospital of Second Military Medical University, Shanghai, 200433, China
| | - Ning Wu
- Department of Respiratory and Critical Care Medicine, Shanghai Changhai Hospital, The First Affiliated Hospital of Second Military Medical University, Shanghai, 200433, China
| | - Qin Wang
- Department of Respiratory and Critical Care Medicine, Shanghai Changhai Hospital, The First Affiliated Hospital of Second Military Medical University, Shanghai, 200433, China
| | - Xiangqi Wang
- Department of Respiratory and Critical Care Medicine, Shanghai Changhai Hospital, The First Affiliated Hospital of Second Military Medical University, Shanghai, 200433, China
| | - Yuchao Dong
- Department of Respiratory and Critical Care Medicine, Shanghai Changhai Hospital, The First Affiliated Hospital of Second Military Medical University, Shanghai, 200433, China
| | - Chong Bai
- Department of Respiratory and Critical Care Medicine, Shanghai Changhai Hospital, The First Affiliated Hospital of Second Military Medical University, Shanghai, 200433, China.
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Fu J, Li J, Liu Z, Zheng S, Li X, Ning X, Wang J, Gao W, Li G. Sex-Specific Differences in the Clinical Profile Among Patients with Tracheobronchial Tuberculosis: A Hospital-Based Cross-Sectional Study in Shenzhen, China. Int J Gen Med 2022; 15:5741-5750. [PMID: 35761894 PMCID: PMC9233510 DOI: 10.2147/ijgm.s367070] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Accepted: 06/01/2022] [Indexed: 11/23/2022] Open
Abstract
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.
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Affiliation(s)
- Jiapeng Fu
- Department of the Third Pulmonary Disease, The Third People's Hospital of Shenzhen, Shenzhen, Guangdong, People's Republic of China.,The Second Affiliated Hospital of Southern University of Science and Technology, Shenzhen, Guangdong, People's Republic of China.,National Clinical Research Center for Infectious Diseases, Shenzhen, Guangdong, People's Republic of China
| | - Jian Li
- Department of the Third Pulmonary Disease, The Third People's Hospital of Shenzhen, Shenzhen, Guangdong, People's Republic of China.,The Second Affiliated Hospital of Southern University of Science and Technology, Shenzhen, Guangdong, People's Republic of China.,National Clinical Research Center for Infectious Diseases, Shenzhen, Guangdong, People's Republic of China
| | - Zhi Liu
- Department of the Third Pulmonary Disease, The Third People's Hospital of Shenzhen, Shenzhen, Guangdong, People's Republic of China.,The Second Affiliated Hospital of Southern University of Science and Technology, Shenzhen, Guangdong, People's Republic of China.,National Clinical Research Center for Infectious Diseases, Shenzhen, Guangdong, People's Republic of China
| | - Shasha Zheng
- Department of the Third Pulmonary Disease, The Third People's Hospital of Shenzhen, Shenzhen, Guangdong, People's Republic of China.,The Second Affiliated Hospital of Southern University of Science and Technology, Shenzhen, Guangdong, People's Republic of China.,National Clinical Research Center for Infectious Diseases, Shenzhen, Guangdong, People's Republic of China
| | - Xue Li
- Department of the Third Pulmonary Disease, The Third People's Hospital of Shenzhen, Shenzhen, Guangdong, People's Republic of China.,The Second Affiliated Hospital of Southern University of Science and Technology, Shenzhen, Guangdong, People's Republic of China.,National Clinical Research Center for Infectious Diseases, Shenzhen, Guangdong, People's Republic of China
| | - Xianjia Ning
- Center of Clinical Epidemiology, The Third People's Hospital of Shenzhen, Shenzhen, Guangdong, People's Republic of China.,Laboratory of Epidemiology, Tianjin Neurological Institute, Tianjin, 300052, People's Republic of China
| | - Jinghua Wang
- Center of Clinical Epidemiology, The Third People's Hospital of Shenzhen, Shenzhen, Guangdong, People's Republic of China.,Laboratory of Epidemiology, Tianjin Neurological Institute, Tianjin, 300052, People's Republic of China
| | - Wenying Gao
- Department of the Third Pulmonary Disease, The Third People's Hospital of Shenzhen, Shenzhen, Guangdong, People's Republic of China.,The Second Affiliated Hospital of Southern University of Science and Technology, Shenzhen, Guangdong, People's Republic of China.,National Clinical Research Center for Infectious Diseases, Shenzhen, Guangdong, People's Republic of China
| | - Guobao Li
- Department of the Third Pulmonary Disease, The Third People's Hospital of Shenzhen, Shenzhen, Guangdong, People's Republic of China.,The Second Affiliated Hospital of Southern University of Science and Technology, Shenzhen, Guangdong, People's Republic of China.,National Clinical Research Center for Infectious Diseases, Shenzhen, Guangdong, People's Republic of China
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12
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Zhou Y, Dang L, Ruan C, Cai H, Jin Q, Kang L, Guo Z. Identification of potential genes in endobronchial tuberculosis after bronchoscopic cryotherapy by transcriptome sequencing. INFECTION, GENETICS AND EVOLUTION : JOURNAL OF MOLECULAR EPIDEMIOLOGY AND EVOLUTIONARY GENETICS IN INFECTIOUS DISEASES 2022; 100:105269. [PMID: 35301169 DOI: 10.1016/j.meegid.2022.105269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Revised: 03/09/2022] [Accepted: 03/10/2022] [Indexed: 06/14/2023]
Abstract
BACKGROUND Bronchoscopic cryotherapy facilitates the treatment of endobronchial tuberculosis (EBTB) and helps suppress progressive bronchial stenosis. However, the molecular mechanism of bronchoscopic cryotherapy in EBTB patients has not been reported. METHODS Transcriptome sequencing was performed to explore differentially expressed mRNAs (DEGs) in EBTB patients before and after bronchoscopic cryotherapy. Gene Ontology (GO) and KEGG analyses were carried out. Five genes (MKLN1, HIGD1A, PTGES, SKIL, and MCEMP1) were selected and validated using real-time qPCR (RT- qPCR). RESULTS In transcriptome analysis, 448 DEGs with p < 0.05 and|logFC| > 1 were identified; of these, 171 and 277 DEGs were significantly up- and down-regulated after bronchoscopic cryotherapy, respectively. Results displayed 337 biological process (GO-BP), 48 cellular component (GO-CC) and 62 molecular function (GO-MF) terms and 20 KEGG pathways. RT- qPCR results were consistent with the sequencing data. CONCLUSION These data provide informative evidence and recommendations for further scientific research on bronchoscopic cryotherapy for EBTB.
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Affiliation(s)
- Yong Zhou
- Endoscopy Clinic Center, Xi'an Chest Hospital, Xi'an 710100, Shaanxi, China
| | - Liyun Dang
- Department of Tuberculosis, Xi'an Chest Hospital, Xi'an 710100, Shaanxi, China
| | - Chao Ruan
- Endoscopy Clinic Center, Xi'an Chest Hospital, Xi'an 710100, Shaanxi, China
| | - Huafeng Cai
- Endoscopy Clinic Center, Xi'an Chest Hospital, Xi'an 710100, Shaanxi, China
| | - Qian Jin
- Endoscopy Clinic Center, Xi'an Chest Hospital, Xi'an 710100, Shaanxi, China
| | - Lei Kang
- Department of Laboratory Medicine, Xi'an Chest Hospital, Xi'an 710100, Shaanxi, China
| | - Zhaolei Guo
- Endoscopy Clinic Center, Xi'an Chest Hospital, Xi'an 710100, Shaanxi, China.
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13
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Nyanti LE, Wong ZH, Sachdev Manjit Singh B, Chang AKW, Jobli AT, Chua HH. Pulmonary tuberculosis and COVID-19 coinfection: Hickam's Dictum revisited. Respir Med Case Rep 2022; 37:101653. [PMID: 35469213 PMCID: PMC9022463 DOI: 10.1016/j.rmcr.2022.101653] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Revised: 03/12/2022] [Accepted: 04/13/2022] [Indexed: 12/21/2022] Open
Abstract
COVID-19 and pulmonary tuberculosis (PTB) coinfection is associated with increased mortality and presents a unique diagnostic challenge to the clinician. We describe three cases of newly diagnosed PTB in COVID-19 patients treated at our centre and their clinical and radiological features. The challenges associated with diagnosis and management are also explored. Patient 1 was a case of smear positive, endobronchial tuberculosis incidentally diagnosed due to CT changes, and eventually made good recovery. Patient 2 was a case of COVID-19 who succumbed but was diagnosed posthumously due to a positive sputum culture for tuberculosis. Patient 3 showed radiographic features of PTB and was treated empirically for TB. In conclusion, COVID-19 and PTB coinfection should be suspected in the presence of constitutional symptoms, prior immunocompromised states, prolonged respiratory symptoms or fever, or unresolved radiological abnormalities, more so in regions where TB is endemic.
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Affiliation(s)
- Larry Ellee Nyanti
- Infectious Disease Unit, Medical Department, Sarawak General Hospital, Jalan Hospital, 93586, Kuching, Sarawak, Malaysia
- Faculty of Medicine and Health Sciences, Universiti Malaysia Sabah, Kota Kinabalu, Sabah, Malaysia
- Corresponding author. Faculty of Medicine and Health Sciences, Universiti Malaysia Sabah, Kota Kinabalu, Sabah, Malaysia.
| | - Zhun Han Wong
- Infectious Disease Unit, Medical Department, Sarawak General Hospital, Jalan Hospital, 93586, Kuching, Sarawak, Malaysia
| | - Benjamin Sachdev Manjit Singh
- Infectious Disease Unit, Medical Department, Sarawak General Hospital, Jalan Hospital, 93586, Kuching, Sarawak, Malaysia
| | - Andrew Kean Wei Chang
- Infectious Disease Unit, Medical Department, Sarawak General Hospital, Jalan Hospital, 93586, Kuching, Sarawak, Malaysia
| | - Ahmad Tirmizi Jobli
- Faculty of Medicine and Health Sciences, University Malaysia Sarawak, Kota Samarahan, Sarawak, Malaysia
| | - Hock Hin Chua
- Infectious Disease Unit, Medical Department, Sarawak General Hospital, Jalan Hospital, 93586, Kuching, Sarawak, Malaysia
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14
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Zhao Y, Zhang T, Yang N, Xu Y, Guo W. Efficacy and safety of CO 2 cryotherapy in the treatment of infants with tracheobronchial tuberculosis. Front Pediatr 2022; 10:984738. [PMID: 36299689 PMCID: PMC9591804 DOI: 10.3389/fped.2022.984738] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Accepted: 08/02/2022] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE This study aimed to investigate the efficacy and safety of CO2 cryotherapy for lymph node fistula tracheobronchial tuberculosis (TBTB) in infants. PATIENTS AND METHODS A retrospective analysis was undertaken on seven patients with lymph node fistula tracheobronchial tuberculosis who underwent fiberoptic bronchoscopy (FB) interventional therapy in the respiratory department of Tianjin Children's Hospital from July 2012 to July 2020. The efficacy, safety, and prognosis of CO2 cryotherapy intervention for the treatment of lymph node fistula TBTB in infants were summarized and analyzed. RESULTS Seven patients with lymph node fistula TBTB were included in this study. Their ages ranged from 6-13 months. The course of the disease from onset to TBTB ranged from 20 to 70 days. The pathological diagnoses of seven cases by FB combined with tissue biopsy were lymph node fistula TBTB, of which 28.57% (two cases) were in the early stage of rupture and 71.43% (five cases) were in the rupture stage. All patients were treated with CO2 cryotherapy combined with foreign body forceps and local injection drugs based on systemic antituberculosis chemotherapy. Two patients were treated once with CO2 cryotherapy, and five were treated three times. According to the comparison of the clinical symptoms, imaging results, and endoscopic presentations before and after the intervention, six patients achieved clinical cure, and one achieved clinical improvement. No severe intraoperative or postoperative complications were observed. The clinical symptoms, endoscopic findings, radiological manifestations, and quality of life of all patients showed marked improvement. No recurrence occurred after 3-6 months of follow-up with FB. CONCLUSION CO2 cryotherapy can improve the treatment effect of lymph node fistula in infants with TBTB and reduce the incidence of complications. This treatment is safe and reliable in infants.
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Affiliation(s)
- Yidi Zhao
- Children's Clinical College of Tianjin Medical University, Tianjin Children's Hospital/Tianjin University Children's Hospital, Tianjin, China
| | - Tongqiang Zhang
- Department of Pulmonology, Tianjin Children's Hospital/Tianjin University Children's Hospital, Tianjin, China
| | - Nan Yang
- Department of Imaging, Tianjin Children's Hospital/Tianjin University Children's Hospital, Tianjin, China
| | - Yongsheng Xu
- Department of Pulmonology, Tianjin Children's Hospital/Tianjin University Children's Hospital, Tianjin, China
| | - Wei Guo
- Department of Pulmonology, Tianjin Children's Hospital/Tianjin University Children's Hospital, Tianjin, China
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15
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Chen RY, Yu X, Smith B, Liu X, Gao J, Diacon AH, Dawson R, Tameris M, Zhu H, Qu Y, Zhang R, Pan S, Jin X, Goldfeder LC, Cai Y, Arora K, Wang J, Vincent J, Malherbe ST, Thienemann F, Wilkinson RJ, Walzl G, Barry CE. Radiological and functional evidence of the bronchial spread of tuberculosis: an observational analysis. THE LANCET. MICROBE 2021; 2:e518-e526. [PMID: 34617068 PMCID: PMC8478663 DOI: 10.1016/s2666-5247(21)00058-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Direct bronchial spread of tuberculosis was extensively described in pre-antibiotic human pathology literature but this description has been overlooked in the post-antibiotic era, in which most pathology data come from animal models that emphasise the granuloma. Modern techniques, such as [18F]2-fluoro-2-deoxy-D-glucose (FDG) PET-CT scans, might provide further insight. Our aim was to understand normal early tuberculosis resolution patterns on pulmonary PET-CT scans in treated patients with tuberculosis who were subsequently cured. METHODS In this observational analysis, we analysed data from PredictTB, an ongoing, prospective, randomised clinical trial that examined sequential baseline and week 4 FDG-PET-CT scans from participants successfully treated (sputum culture negative 18 months after enrolment) for drug-susceptible pulmonary tuberculosis in South Africa and China. Participants who were aged 18-75 years, GeneXpert MTB/RIF positive for tuberculosis and negative for rifampicin resistance, had not yet started tuberculosis treatment, had not been treated for active tuberculosis within the previous 3 years, and met basic safety laboratory criteria were included and participants with diabetes, HIV infection, or with extrapulmonary tuberculosis including pleural tuberculosis were excluded. Scans were assessed by two readers for the location of tuberculosis lesions (eg, cavities and consolidations), bronchial thickening patterns, and changes from baseline to week 4 of treatment. FINDINGS Among the first 124 participants (enrolled from June 22, 2017, to Sept 27, 2018) who were successfully treated, 161 primarily apical cavitary lesions were identified at baseline. Bronchial thickening and inflammation linking non-cavitary consolidative lesions to cavities were observed in 121 (98%) of 124 participants' baseline PET-CT scans. After 4 weeks of treatment, 21 (17%) of 124 participants had new or expanding lesions linked to cavities via bronchial inflammation that were not present at baseline, particularly participants with two or more cavities at baseline and participants from South Africa. INTERPRETATION In participants with pulmonary tuberculosis who were subsequently cured, the location of cavitary and non-cavitary lesions at baseline and new lesions at week 4 of treatment suggest a cavitary origin of disease and bronchial spread through the lungs. Bronchial spread from cavities might play a larger role in the spread of pulmonary tuberculosis than has been appreciated. Elucidating cavity lesion dynamics and Mycobacterium tuberculosis viability within cavities might better explain treatment outcomes and why some patients are cured and others relapse. FUNDING Bill & Melinda Gates Foundation, European and Developing Countries Clinical Trials Partnership, China Ministry of Science and Technology, National Natural Science Foundation of China, and National Institutes of Health. TRANSLATIONS For the Chinese, Afrikaans and Xhosa translations of the abstract see Supplementary Materials section.
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Affiliation(s)
- Ray Y Chen
- Tuberculosis Research Section, Laboratory of Clinical Immunology and Microbiology, Division of Intramural Research, National Institute of Allergy and Infectious Disease, National Institutes of Health, Bethesda, MD, USA
- Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Xiang Yu
- Tuberculosis Research Section, Laboratory of Clinical Immunology and Microbiology, Division of Intramural Research, National Institute of Allergy and Infectious Disease, National Institutes of Health, Bethesda, MD, USA
| | - Bronwyn Smith
- DST-NRF Centre of Excellence for Biomedical Tuberculosis Research, South African Medical Research Council Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Department of Biomedical Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Xin Liu
- Henan Provincial Chest Hospital, Zhengzhou, Henan, China
| | - Jingcai Gao
- Sino-US Tuberculosis Collaborative Research Program, Zhengzhou, Henan, China
| | - Andreas H Diacon
- Department of Medicine, Stellenbosch University, Cape Town, South Africa
- TASK Applied Science, Cape Town, South Africa
| | - Rodney Dawson
- Division of Pulmonology, Department of Medicine, University of Cape Town Lung Institute, University of Cape Town, Cape Town, South Africa
| | - Michele Tameris
- South African Tuberculosis Vaccine Initiative, University of Cape Town, Cape Town, South Africa
| | - Hong Zhu
- Sino-US Tuberculosis Collaborative Research Program, Zhengzhou, Henan, China
| | - Yahong Qu
- Kaifeng City Institute of Tuberculosis Prevention and Control, Kaifeng, Henan, China
| | - Ruanqing Zhang
- Xinxiang City Institute of Tuberculosis Prevention and Control, Xinxiang, Henan, China
| | - Shouguo Pan
- Zhongmu County Health and Epidemic Prevention Station, Zhongmu, Henan, China
| | - Xiaowei Jin
- Xinmi City Institute of Tuberculosis Prevention and Control, Xinmi, Henan, China
| | - Lisa C Goldfeder
- Tuberculosis Research Section, Laboratory of Clinical Immunology and Microbiology, Division of Intramural Research, National Institute of Allergy and Infectious Disease, National Institutes of Health, Bethesda, MD, USA
| | - Ying Cai
- Tuberculosis Research Section, Laboratory of Clinical Immunology and Microbiology, Division of Intramural Research, National Institute of Allergy and Infectious Disease, National Institutes of Health, Bethesda, MD, USA
| | - Kriti Arora
- Tuberculosis Research Section, Laboratory of Clinical Immunology and Microbiology, Division of Intramural Research, National Institute of Allergy and Infectious Disease, National Institutes of Health, Bethesda, MD, USA
| | - Jing Wang
- Clinical Monitoring Research Program Directorate, Frederick National Laboratory for Cancer Research, Frederick, MD, USA
| | - Joel Vincent
- Tuberculosis Research Section, Laboratory of Clinical Immunology and Microbiology, Division of Intramural Research, National Institute of Allergy and Infectious Disease, National Institutes of Health, Bethesda, MD, USA
| | - Stephanus T Malherbe
- DST-NRF Centre of Excellence for Biomedical Tuberculosis Research, South African Medical Research Council Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Department of Biomedical Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Friedrich Thienemann
- Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
- Department of Internal Medicine, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Robert J Wilkinson
- Wellcome Centre for Infectious Diseases Research in Africa, University of Cape Town, Cape Town, South Africa
- Francis Crick Institute, London, UK
- Department of Infectious Diseases, Imperial College London, London, UK
| | - Gerhard Walzl
- DST-NRF Centre of Excellence for Biomedical Tuberculosis Research, South African Medical Research Council Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Department of Biomedical Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Clifton E Barry
- Tuberculosis Research Section, Laboratory of Clinical Immunology and Microbiology, Division of Intramural Research, National Institute of Allergy and Infectious Disease, National Institutes of Health, Bethesda, MD, USA
- Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
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16
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Froessl LJ, Abdeen Y. Pseudomembranous Tracheobronchitis due to Mycobacterium tuberculosis. Cureus 2021; 13:e17173. [PMID: 34532194 PMCID: PMC8436727 DOI: 10.7759/cureus.17173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/14/2021] [Indexed: 11/05/2022] Open
Abstract
Although the incidence is declining in the western world, Mycobacterium tuberculosis remains one of the most common infectious organisms responsible for significant morbidity and mortality worldwide. Pulmonary tuberculosis (TB) is the most commonly seen presentation; however, TB can affect nearly any of the body's organ systems. Endobronchial TB (EBTB) can complicate pulmonary TB or more rarely present as an isolated finding. It is essential to recognize and treat this condition promptly, as it can develop into tracheobronchial stenosis and chronic respiratory failure. Here we discuss the case of a 43-year-old female with a left upper lobe cavitary lesion who presented with weight loss, dyspnea, and hoarseness. After failing multiple courses of antibiotics, the patient underwent bronchoscopy, and pseudomembranous tracheobronchitis (PMTB) was diagnosed. Cultures of endobronchial samples grew Mycobacterium tuberculosis. Standard anti-TB quadruple therapy was initiated, and the patient clinically improved. Several subtypes of EBTB have been identified earlier. However, to the best of our knowledge, tuberculous PMTB has not previously been reported. This case allows us to consider the diagnostic and therapeutic implications of this condition.
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Affiliation(s)
- Luise J Froessl
- Medicine/Pulmonary, Baylor College of Medicine, Houston, USA
| | - Yazan Abdeen
- Pulmonary and Critical Care Medicine, Pulmonary and Sleep Physicians of Houston, Webster, USA
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17
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Toyoshima H, Tanigawa M. Asymptomatic endobronchial tuberculosis represented as a solitary airway stenosis without tree-in-bud appearance on computed tomography. Clin Case Rep 2021; 9:e04742. [PMID: 34594550 PMCID: PMC8462059 DOI: 10.1002/ccr3.4742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Revised: 07/16/2021] [Accepted: 08/10/2021] [Indexed: 11/09/2022] Open
Abstract
Bronchoscopy is a crucial tool for diagnosing endobronchial tuberculosis in patients with airway stenosis. Early diagnosis and treatment may reduce airway sequelae and prevent the spread of infection.
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Affiliation(s)
- Hirokazu Toyoshima
- Department of Infectious DiseasesJapanese Red Cross Ise HospitalIseJapan
| | - Motoaki Tanigawa
- Department of Respiratory MedicineJapanese Red Cross Ise HospitalIseJapan
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18
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CT findings of non-neoplastic central airways diseases. Jpn J Radiol 2021; 40:107-119. [PMID: 34398372 DOI: 10.1007/s11604-021-01190-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Accepted: 08/10/2021] [Indexed: 01/02/2023]
Abstract
Non-neoplastic lesions of central airways are uncommon entities with different etiologies, with either focal or diffuse involvement of the tracheobronchial tree. Clinical symptoms of non-neoplastic tracheobronchial diseases are non-specific, and diagnosis is difficult, especially in the early stages. Three-dimensional computed tomography (3D-CT) is an evaluable tool as it allows to assess and characterize tracheobronchial wall lesions and meanwhile it enables the evaluation of airways surrounding structures. Multiplanar reconstructions (MPR), minimum intensity projections (MinIP), and 3D Volume Rendering (VR) (in particular, virtual bronchoscopy) also provide information on the site and of the length of airway alterations. This review will be discussed about (1) primary airway disorders, such as relapsing polychondritis, tracheobronchophathia osteochondroplastica, and tracheobronchomegaly, (2) airway diseases, related to granulomatosis with polyangiitis, Chron's disease, Behcet's disease, sarcoidosis, amyloidosis, infections, intubation and transplantation, (3) tracheobronchial malacia, and (4) acute tracheobronchial injury. 3D-CT findings, especially with MPR and 3D VR reconstructions, allows us to evaluate tracheobronchial disease morphologically in detail.
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19
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Huan N, Ng KL, Nasaruddin MZ, Muhammad NA, Daut UN, Abdul Rahaman JA. Topical mitomycin-C as an adjuvant to multimodal endoscopic treatment for tracheobronchial stenosis secondary to endobronchial tuberculosis. Respirol Case Rep 2021; 9:e00711. [PMID: 33532074 PMCID: PMC7829630 DOI: 10.1002/rcr2.711] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 12/29/2020] [Accepted: 01/05/2021] [Indexed: 12/02/2022] Open
Abstract
Tracheobronchial stenosis secondary to endobronchial tuberculosis (TSTB) is a rare but debilitating complication of endobronchial tuberculosis (EBTB). Topical mitomycin-C (TMC) has been successfully utilized to restore airway patency and to prevent recurrence of TSTB, although little is known about its exact efficacy. Here, we report the biggest case series to date involving seven patients who received TMC as part of multimodality endoscopic treatment for TSTB with varying levels of success. All patients presented with dyspnoea during or after treatment completion for pulmonary tuberculosis (PTB). Four patients had short-segment concentric membranous TSTB while two patients had concurrent bronchomalacia. Another one patient had a thick fibrotic band adjacent to luminal opening. We hypothesize that TMC is more efficacious in short membranous stenosis without concurrent bronchomalacia and/or thick fibrotic bands. More studies are needed to bridge the current gaps in knowledge regarding the optimal role and benefits of TMC for TSTB patients.
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Affiliation(s)
| | - Khai Lip Ng
- Department of PulmonologySerdang HospitalKajangMalaysia
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20
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Aniwidyaningsih W, Elhidsi M, Sari A, Burhan E. Characteristics and outcomes of endobronchial tuberculosis therapy. Lung India 2021; 38:101-103. [PMID: 33402653 PMCID: PMC8066932 DOI: 10.4103/lungindia.lungindia_132_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Affiliation(s)
- Wahju Aniwidyaningsih
- Department of Pulmonology and Respiratory Medicine, Faculty of Medicine, Universitas Indonesia - Persahabatan National Respiratory Referral Hospital, Jakarta, Indonesia
| | - Mia Elhidsi
- Department of Pulmonology and Respiratory Medicine, Faculty of Medicine, Universitas Indonesia - Persahabatan National Respiratory Referral Hospital, Jakarta, Indonesia
| | - Adistya Sari
- Department of Pulmonology and Respiratory Medicine, Faculty of Medicine, Universitas Indonesia - Persahabatan National Respiratory Referral Hospital, Jakarta, Indonesia
| | - Erlina Burhan
- Department of Pulmonology and Respiratory Medicine, Faculty of Medicine, Universitas Indonesia - Persahabatan National Respiratory Referral Hospital, Jakarta, Indonesia
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21
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Huan N, Ng KL, Nasaruddin MZ, Muhammad NA, Daut UN, Abdul Rahaman JA. Conservative management of airway tear as a complication of silicone endobronchial stenting in bronchomalacia secondary to endobronchial tuberculosis. Respirol Case Rep 2020; 8:e00684. [PMID: 33194207 PMCID: PMC7644387 DOI: 10.1002/rcr2.684] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 10/14/2020] [Accepted: 10/22/2020] [Indexed: 11/12/2022] Open
Abstract
Tracheobronchial stenosis due to tuberculosis (TSTB) is a potentially debilitating complication of endobronchial tuberculosis (EBTB). Endobronchial interventions including silicone stent insertion is an acceptable approach to improve quality of life among patients with TSTB. However, little is known about the optimal management strategy for patients with bronchomalacia secondary to EBTB (B-EBTB) and whether stent-related complication rates are higher among this group of patients. Herein, we report two patients with B-EBTB who unfortunately developed bronchial tear related to silicone endobronchial stenting. Both patients were successfully managed conservatively without the need for emergency open surgery. We hypothesize that endobronchial intervention might be more beneficial for patients with pure TSTB and might be riskier in cases of bronchomalacia with reduced airway thickness and loss of airway cartilaginous support. More future studies are needed to bridge the current gap in knowledge regarding the optimal management and role of endobronchial interventions among patients with B-EBTB.
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Affiliation(s)
| | - Khai Lip Ng
- Department of PulmonologySerdang HospitalKajangMalaysia
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22
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Peng AZ, Yang A, Li SJ, Qiu Q, Yang S, Chen Y. Incidence, laboratory diagnosis and predictors of tracheobronchial tuberculosis in patients with pulmonary tuberculosis in Chongqing, China. Exp Ther Med 2020; 20:174. [PMID: 33093909 PMCID: PMC7571346 DOI: 10.3892/etm.2020.9304] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 07/01/2020] [Indexed: 12/12/2022] Open
Abstract
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.
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Affiliation(s)
- An-Zhou Peng
- Department of Tuberculosis Laboratory, Public Health Medical Center, Chongqing 400036, P.R. China
| | - Ao Yang
- Department of Traffic Injury Prevention Research Office, Daping Hospital, Army Medical Center of The PLA, Chongqing 400042, P.R. China
| | - Si-Ju Li
- Department of Tuberculosis Laboratory, Public Health Medical Center, Chongqing 400036, P.R. China
| | - Qian Qiu
- Department of Tuberculosis Laboratory, Public Health Medical Center, Chongqing 400036, P.R. China
| | - Song Yang
- Department of Tuberculosis Laboratory, Public Health Medical Center, Chongqing 400036, P.R. China
| | - Yong Chen
- Department of Tuberculosis Laboratory, Public Health Medical Center, Chongqing 400036, P.R. China.,Department of Endocrinology, First Affiliated Hospital of Anhui Medical University, Hefei, Anhui 230022, P.R. China
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23
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Avula A, Ngu S, Mansour W, Gurala D, Maroun R. A Case of Laryngeal Tuberculosis, Endobronchial Tuberculosis and Pulmonary Tuberculosis Coexistent in an Immunocompetent Host. Cureus 2020; 12:e10713. [PMID: 33133876 PMCID: PMC7594666 DOI: 10.7759/cureus.10713] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Historically associated with poor prognosis seen in advanced disease, laryngeal tuberculosis (LTB) now represents only 1% of all cases of tuberculosis (TB). The incidence of LTB has decreased drastically with the introduction of anti-tubercular drugs. LTB can be primary or secondary to pulmonary tuberculosis. LTB can mimic laryngeal cancer. We present a case of primary laryngeal TB with descending tracheobronchial spread in an immunocompetent 71-year-old female who developed progressive dysphonia over several months with unintentional weight loss and non-productive cough. Non-contrast enhanced computed tomography (CT) revealed clustering of subcentimeter stellate nodules in the right upper lung field with an enlarging ground-glass opacity in the right lower lung but did not show structural abnormalities within the neck. Positron emission tomography (PET) showed pathologic fluorodeoxyglucose (FDG) uptake within the larynx and trachea with extension into the left mainstream bronchus as well as the proximal left upper and lower lobe bronchi. Diffuse standardized uptake value (SUV) was greatest in the larynx (20.5). Polymerase chain reaction (PCR) on bronchoscope sputum specimen confirmed Mycobacterium tuberculosis. Findings were consistent with primary laryngeal TB with endobronchial extension. She was started on a four-drug regimen comprising of isoniazid, rifampin, ethambutol, and pyrazinamide with a good response. Her close contacts were treated as well. This case highlights the unusual spread of primary laryngeal TB in an immunocompetent host. Early diagnosis can limit adverse complications and unnecessary exposure to healthcare workers. To our knowledge, this is the first case of primary LTB with proximal spread to the tracheobronchial and pulmonary tuberculosis.
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Affiliation(s)
- Akshay Avula
- Internal Medicine, Northwell Health-Staten Island University Hospital, Staten Island, USA
| | - Sam Ngu
- Internal Medicine, Northwell Health-Staten Island University Hospital, Staten Island, USA
| | - Wissam Mansour
- Pulmonary and Critical Care Medicine, Northwell Health-Staten Island University Hospital, Staten Island, USA
| | - Dhineshreddy Gurala
- Internal Medicine, Northwell Health-Staten Island University Hospital, Staten Island, USA
| | - Rabih Maroun
- Pulmonary and Critical Care Medicine, Northwell Health-Staten Island University Hospital, Staten Island, USA
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24
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Abstract
Endobronchial tuberculosis (EBTB) is an infection of the tracheobronchial tree by Mycobacterium tuberculosis. It is common among young females. Patient can present with fever, cough, wheeze, with or without any constitutional symptoms. It presents as a diagnostic dilemma, as patient sputum smear can be false negative. CT scan may or may not show any abnormality, or any endobronchial lesion. Bronchoscopy with bronchoalveolar lavage and biopsy offers the diagnostic choice. We hereby report a case of a young immunocompetent Asian female who was found to have endobronchial pathology, leading to diagnosis and timely therapy.
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Affiliation(s)
- Nadeem M Kassam
- Internal Medicine, Aga Khan University Medical College, Dar es Salaam, TZA
| | - Omar M Aziz
- Internal Medicine, Aga Khan Hospital, Dar es Salaam, TZA
| | - Samina Somji
- Internal Medicine, Aga Khan University Medical College, Dar es Salaam, TZA
| | - Grace Shayo
- Internal Medicine, Muhim Bili University of Health and Allied Sciences, Dar es Salaam, TZA
| | - Salim Surani
- Internal Medicine, Corpus Christi Medical Center, Corpus Christi, USA.,Internal Medicine, University of North Texas, Dallas, USA
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25
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Mishra NR, Panigrahi MK, Bhatt GC, Das RR. Corticosteroid as an Adjunct in the Treatment of Endobronchial Tuberculosis: A Systematic Review & Meta-analysis. Curr Pediatr Rev 2020; 16:53-60. [PMID: 31622209 DOI: 10.2174/1573396315666191016100615] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Revised: 01/08/2019] [Accepted: 09/16/2019] [Indexed: 11/22/2022]
Abstract
BACKGROUND Corticosteroid exerts anti-inflammatory action and can prevent tissue damage resulting from various causes. Studies have shown that corticosteroids may prevent the damaging effect of tuberculosis (TB) in various organs, but there is no published meta-analysis specifically looking for the effect of corticosteroid in endobronchial TB. OBJECTIVE To synthesize the evidence regarding the usefulness of corticosteroid in endo-bronchial TB. METHODS A comprehensive search was performed of the major electronic databases till 30th November 2018. Randomized trials comparing treatment with corticosteroid as an adjunct to antitubercular drugs (ATT) versus placebo/no treatment in endobronchial TB were included. Three authors independently applied eligibility criteria, assessed the studies for methodological quality, and extracted data. The review is registered at PROSPERO database [CRD42016047063]. RESULTS Out of 525 search results, 4 trials including 205 patients (151 children) were eligible for inclusion. Oral prednisolone was used in various dose schedules. Rifampicin containing ATT regimen was used in 3 trials. The bronchoscopy findings showed no significant improvement at 1 month (effect size could not be calculated due to 0 event in the intervention group, p = 0.05), 2 months (RR 1.26, 95% CI 0.89 to 1.8), and at completion of ATT (RR 0.63, 95% CI 0.1 to 4.14) in steroid-treated group compared to the control group. The need for repeat bronchoscopy was significantly decreased in the steroid group (RR 0.13, 95% CI 0.02 to 0.9). Among the adverse events, the infection rate was significantly lesser in the steroid group (RR 0.53, 95% CI 0.29 to 0.97); but other adverse events (mortality, hypertension, and abdominal distension) showed no significant difference between the two groups. The GRADE evidence generated was of very low quality. CONCLUSION The present meta-analysis showed that oral steroid does not help patients with endobronchial tuberculosis. However, the quality of evidence was very low. Future trials with robust design and a larger sample size would be required to provide any firm recommendation regarding the use of oral prednisolone in endobronchial tuberculosis.
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Affiliation(s)
| | | | | | - Rashmi R Das
- Department of Pediatrics, AIIMS, Bhubaneswar, India
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26
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Henson T, Matayeva E, Chua W, Iqbal J. A 76-Year-Old Woman With Incidental Right Middle Lobe Atelectasis. Chest 2019; 155:e137-e140. [PMID: 31060710 DOI: 10.1016/j.chest.2018.10.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Revised: 10/20/2018] [Accepted: 10/26/2018] [Indexed: 11/18/2022] Open
Abstract
CASE PRESENTATION A 76-year-old nonsmoking woman visiting from Honduras for the last 6 months with no known medical history originally presented to the ED complaining of abdominal pain. While in the ED, an incidental right middle lobe collapse was found on CT abdomen scan. Review of systems was positive for a chronic productive cough with white sputum for 3 years. She denied association with fevers, chills, night sweats, hemoptysis, appetite changes, or weight loss.
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Affiliation(s)
| | | | - Walter Chua
- Nassau University Medical Center, East Meadow, NY
| | - Javed Iqbal
- Nassau University Medical Center, East Meadow, NY
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27
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Venturini E, Montagnani C, Boldrini A, Moroni M, Chiappini E, de Martino M, Galli L. Congenital tuberculosis after in vitro fertilization presenting with endobronchial granuloma. Pediatr Neonatol 2019; 60:105-107. [PMID: 29724565 DOI: 10.1016/j.pedneo.2018.02.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Revised: 10/28/2017] [Accepted: 02/02/2018] [Indexed: 11/24/2022] Open
Affiliation(s)
- Elisabetta Venturini
- Department of Health Sciences, University of Florence, Meyer Children's University Hospital, Florence, Italy.
| | - Carlotta Montagnani
- Department of Health Sciences, University of Florence, Meyer Children's University Hospital, Florence, Italy.
| | - Antonio Boldrini
- U.O. Neonatology, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy.
| | - Marco Moroni
- Neonatal Intensive Care Unit, Department of Pediatrics, Meyer Children's University Hospital, Florence, Italy.
| | - Elena Chiappini
- Department of Health Sciences, University of Florence, Meyer Children's University Hospital, Florence, Italy.
| | - Maurizio de Martino
- Department of Health Sciences, University of Florence, Meyer Children's University Hospital, Florence, Italy.
| | - Luisa Galli
- Department of Health Sciences, University of Florence, Meyer Children's University Hospital, Florence, Italy.
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28
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Nguyen Ho L, Tran Van N, Le Thuong V, Hoang Chan P, Kantrow SP, Duong Duy K, Smith DL. Hilar asymmetry in endobronchial tuberculosis patients: An often-overlooked clue. Int J Infect Dis 2019; 80:80-83. [PMID: 30639404 DOI: 10.1016/j.ijid.2019.01.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Revised: 01/03/2019] [Accepted: 01/04/2019] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Endobronchial tuberculosis (EBTB) is a challenging diagnosis because of its varied clinical and radiological manifestations. Hilar asymmetry on chest radiograph (CXR) may be found in patient with EBTB but is often overlooked, which may lead to delayed diagnosis. CASE REPORT We present five cases with EBTB. Clinicians failed to identify unilateral hilar abnormalities on CXR, and these patients were treated initially for pharyngitis, bronchitis, or pneumonia with no improvement. Subsequently, they visited the pulmonary clinic and bronchoscopy revealed endobronchial lesions and microbial/histopathological evidence of tuberculous infection consistent with EBTB. Anti-tuberculosis therapy resulted in complete clinical resolution in four of the five patients; one patient had persistent bronchial stenosis. CONCLUSION Hilar asymmetry on CXR may occur with EBTB and may suggest this diagnosis in the appropriate clinical setting. Bronchoscopy has an important role in establishing the final diagnosis.
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Affiliation(s)
- Lam Nguyen Ho
- Department of Internal Medicine, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam.
| | - Ngoc Tran Van
- Department of Internal Medicine, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam
| | - Vu Le Thuong
- Department of Internal Medicine, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam
| | | | - Stephen P Kantrow
- Department of Medicine, Louisiana State University Health Sciences Center, New Orleans, LA, USA
| | - Khoa Duong Duy
- Department of Internal Medicine, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam
| | - David L Smith
- Department of Radiology, Louisiana State University Health Sciences Center, School of Medicine, New Orleans, LA, USA
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29
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Liu X, Xu L, Jiang G, Huang S. Pleural effusion resulting from bronchial tuberculosis: A case report. Medicine (Baltimore) 2018; 97:e12713. [PMID: 30290674 PMCID: PMC6200503 DOI: 10.1097/md.0000000000012713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
RATIONALE The clinical manifestations in patients with bronchial tuberculosis (BTB) are nonspecific and may pose a great diagnostic challenge. PATIENT CONCERNS Here we describe the case of a 57-year-old man presented with right chest pain, chest tightness, and discomfort for 2 days. DIAGNOSIS Bronchoscopic biopsy was performed which revealed subepithelial and epithelioid cell granuloma of Langerhans cell structure. The definitive diagnosis was BTB with pleural effusion. INTERVENTIONS Treatment with a quadruple combinational antituberculous therapy was initiated. OUTCOMES Two months later, the patient's chest distress and discomfort significantly decreased. Repeat chest radiograph revealed that the pleural fluid had been absorbed. The patient recovered after 15 months of antituberculosis treatment. LESSONS The patient exemplifies the difficulty of diagnosing BTB, particularly the low reliability of imaging modalities. The diagnosis of BTB currently relies on bronchoscopy as well as bacteriological or pathological evidence. This report will help to lower the incidences of misdiagnosis of this disease.
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Affiliation(s)
- Xuchun Liu
- Department of Respiratory Medicine, Chizhou People's Hospital
| | - Litao Xu
- Department of Respiratory Medicine, Chizhou People's Hospital
| | - Guohua Jiang
- Department of Respiratory Medicine, Chizhou People's Hospital
| | - Shubin Huang
- Department of Pathology, Chizhou People's Hospital, Chizhou, Anhui, China
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30
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Zhao L, Guan R, Yu H, Lin J, Peng C, Yao H, Zhang X, Ye X. Endobronchial anthracofibrosis: possibly a new indication of aggressive treatment for active endobronchial tuberculosis. J Thorac Dis 2018; 10:E511-E515. [PMID: 30174922 DOI: 10.21037/jtd.2018.07.03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Anthracofibrosis, which was defined as a luminal narrowing associated with overlying anthracotic mucosa on bronchoscopy, has been infrequently reported. Recently, we have identified a case of patient who had a history of pulmonary tuberculosis (TB), manifested left main bronchial stenosis and hyperpigmentation. Despite repeated and multiple cryotherapy, the condition was still progressing. Given to the potential relationship between active endobronchial tuberculosis (EBTB) and anthracofibrosis, the patient received a diagnostic anti-tuberculosis (anti-TB) treatment due to initial failed cryotherapy, resulting in improvement of hyperpigmentation and stenosis of the left main bronchus. Eventually, the patient recovered well with regular anti-TB combined with intermittent cryotherapy. Our study suggests that even without etiological evidence, there might be an indication of therapeutic trial of anti-TB medication in case of repeated bronchial stenosis due to anthracofibrosis in patients with past history of TB and other causes are excluded. Yet, the recommendation of aggressive treatment should reply on the effect of diagnostic treatment and further research.
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Affiliation(s)
- Li Zhao
- Department of Respiratory Medicine, Guizhou Provincial People's Hospital, Guiyang 550002, China.,State Key Laboratory of Respiratory Diseases, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital, Guangzhou Medical University, Guangzhou 510030, China
| | - Ruijuan Guan
- State Key Laboratory of Respiratory Diseases, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital, Guangzhou Medical University, Guangzhou 510030, China
| | - Hong Yu
- Department of Respiratory Medicine, Guizhou Provincial People's Hospital, Guiyang 550002, China
| | - Jieru Lin
- Department of Respiratory Medicine, Guizhou Provincial People's Hospital, Guiyang 550002, China
| | - Chunhong Peng
- Department of Respiratory Medicine, Guizhou Provincial People's Hospital, Guiyang 550002, China
| | - Hongmei Yao
- Department of Respiratory Medicine, Guizhou Provincial People's Hospital, Guiyang 550002, China
| | - Xiangyan Zhang
- Department of Respiratory Medicine, Guizhou Provincial People's Hospital, Guiyang 550002, China
| | - Xianwei Ye
- Department of Respiratory Medicine, Guizhou Provincial People's Hospital, Guiyang 550002, China
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31
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Ruan J, Zhang T, Li F, Duan Y, Han M, Wang Z. [Surgical Treatment of Bronchial Stricture due to Endobronchial Tuberculosis:
Results in 36 Consecutive Cases]. ZHONGGUO FEI AI ZA ZHI = CHINESE JOURNAL OF LUNG CANCER 2018; 21:320-322. [PMID: 29587916 PMCID: PMC5973344 DOI: 10.3779/j.issn.1009-3419.2018.04.19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
背景与目的 支气管结核是肺结核常见的并发症,本研究目的是探讨支气管结核的临床特点,手术指征及总结外科治疗经验。 方法 对36例诊断明确且造成支气管狭窄或肺不张的支气管结核患者,给予药物及内镜腔内治疗无效而进行外科治疗,术前规律抗结核治疗6个月以上,术后继续抗结核治疗9个月-12个月。其中全肺切除8例,肺叶切除23例,袖状肺叶切除5例。 结果 36例患者均治愈,无手术死亡,6例患者术后出现并发症,给与对应治疗痊愈出院,无支气管胸膜瘘及结核播散。随访1年以上无复发。 结论 对于药物及内镜治疗无效,伴有肺内不可逆病变的支气管结核患者应考虑积极手术。
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Affiliation(s)
- Junzhong Ruan
- Department of Thoracic Surgery, Beijing Chest Hospital, Capital Medical University, Beijing 101149, China
| | - Tianhui Zhang
- Department of Thoracic Surgery, Beijing Chest Hospital, Capital Medical University, Beijing 101149, China
| | - Fugen Li
- Department of Thoracic Surgery, Beijing Chest Hospital, Capital Medical University, Beijing 101149, China
| | - Yong Duan
- Department of Thoracic Surgery, Beijing Chest Hospital, Capital Medical University, Beijing 101149, China
| | - Ming Han
- Department of Thoracic Surgery, Beijing Chest Hospital, Capital Medical University, Beijing 101149, China
| | - Zitong Wang
- Department of Thoracic Surgery, Beijing Chest Hospital, Capital Medical University, Beijing 101149, China
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32
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Mondoni M, Repossi A, Carlucci P, Centanni S, Sotgiu G. Bronchoscopic techniques in the management of patients with tuberculosis. Int J Infect Dis 2017; 64:27-37. [PMID: 28864395 DOI: 10.1016/j.ijid.2017.08.008] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Revised: 07/28/2017] [Accepted: 08/15/2017] [Indexed: 12/27/2022] Open
Abstract
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).
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Affiliation(s)
- Michele Mondoni
- Respiratory Unit, ASST Santi Paolo e Carlo, San Paolo Hospital, Department of Scienze della Salute, Università degli Studi di Milano, Milan, Italy
| | - Alice Repossi
- Respiratory Unit, Humanitas Gavazzeni Institute, Bergamo, Italy
| | - Paolo Carlucci
- Respiratory Unit, ASST Santi Paolo e Carlo, San Paolo Hospital, Department of Scienze della Salute, Università degli Studi di Milano, Milan, Italy
| | - Stefano Centanni
- Respiratory Unit, ASST Santi Paolo e Carlo, San Paolo Hospital, Department of Scienze della Salute, Università degli Studi di Milano, Milan, Italy
| | - Giovanni Sotgiu
- Clinical Epidemiology and Medical Statistics Unit, Dept of Biomedical Sciences, University of Sassari, Sassari, Italy.
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33
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Khvilivitzky K, Trivedi PN, McFadden PM. Tuberculous tracheobronchial stenosis: avoiding resection-when less is more. J Thorac Dis 2017; 9:E779-E782. [PMID: 29221342 DOI: 10.21037/jtd.2017.08.104] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
A case of tracheobronchial stenosis due to tuberculosis in a young woman is presented. Compromised pulmonary function due to near-total obstruction of the proximal left main bronchus was diagnosed. Treatment options included surgical resection, endobronchial dilation or stenting, and argon photocoagulation. An approach was chosen to address symptoms without aggressive resection or commitment to stenting. She remains monitored and, while possibly committed to future intervention, no bridges have been burned with respect to more definitive and invasive therapies. We propose this "less is more" initial approach in all patients when possible. Reserving the more aggressive alternatives for high-risk surgical candidates and those that have been unresponsive to lesser procedures.
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Affiliation(s)
- Katherine Khvilivitzky
- Department of Surgery, Division of Cardiothoracic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Puja N Trivedi
- Department of Anesthesiology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - P Michael McFadden
- Department of Surgery, Division of Cardiothoracic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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34
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Abdullah H, Quek CZ. Undiagnosed acute phase endobronchial tuberculosis with progression to irreversible tracheobronchial stenosis. BMJ Case Rep 2017; 2017:bcr-2017-219877. [DOI: 10.1136/bcr-2017-219877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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35
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Manal E, Nahid Z, Hanane B, Najiba Y. [Endobronchial tuberculosis]. REVUE DE PNEUMOLOGIE CLINIQUE 2017; 73:55-60. [PMID: 28162798 DOI: 10.1016/j.pneumo.2016.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Accepted: 12/14/2016] [Indexed: 06/06/2023]
Abstract
BACKGROUND/AIM The endobronchial tuberculosis (EBTB) is an uncommon type of tuberculosis. The respiratory symptoms in EBTB are usually nonspecific and misleading. The aim of the study is to determine the clinical features and diagnostic aspects of EBTB. PATIENTS AND METHODS Twenty-eight cases of endobronchial tuberculosis collected from January 2009 to October 2015. RESULTS EBTB was found in 16 females and 12 males. The mean age was 48 years. The history of tuberculosis and tuberculosis contagion were not found in any case. The respiratory symptoms were dominated by cough and dyspnea. Hemoptysis was found in 7 cases. The chest X-ray showed associated pulmonary lesions in 26 cases. Bronchoscopy finded an endobronchial granular lesion in 15 cases, a tumorous pattern in 7 cases; a thickening spurs in 4 cases and ganglio-bronchial fistula in two cases. Bronchial biopsies had found a caseo-follicular tuberculosis in 27 cases. Pleural biopsy confirmed associated pleural tuberculosis in one case. The research of Koch bacillus in the sputum was positive in 13 cases and culture in 6 cases. The antituberculosis treatment was started in all patients and an oral corticosteroids treatment was associated in 5 cases. The evolution was good in 26 cases. CONCLUSION This study showed clinical, radiological and endoscopic bronchial tuberculosis polymorphism making its diagnosis difficult and the importance of a bacteriological and/or histological confirmation.
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Affiliation(s)
- E Manal
- Service des maladies respiratoires, CHU Ibn Rochd, Casablanca, Maroc.
| | - Z Nahid
- Service des maladies respiratoires, CHU Ibn Rochd, Casablanca, Maroc
| | - B Hanane
- Service des maladies respiratoires, CHU Ibn Rochd, Casablanca, Maroc
| | - Y Najiba
- Service des maladies respiratoires, CHU Ibn Rochd, Casablanca, Maroc
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36
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Abstract
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.
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Affiliation(s)
- Wen Ting Siow
- Division of Respiratory and Critical Care Medicine, National University Hospital, National University Health System Tower Block, Singapore 119228, Singapore
| | - Pyng Lee
- Division of Respiratory and Critical Care Medicine, National University Hospital, National University Health System Tower Block, Singapore 119228, Singapore
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37
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Abstract
Endobronchial tuberculosis (EBTB) is a tuberculous infection of the tracheobronchial tree with microbial and histopathological evidence. Patients may present with symptoms secondary to disease itself or from the complication of disease like endobronchial obstruction. Diagnosis requires a high index of suspicion. Computed tomography (CT) and bronchoscopy along with microbiological investigations are the most useful diagnostic tools for the confirmation as well as for the evaluation of the tracheobronchial stenosis. The goals of treatment are eradication of tubercle bacilli with anti-tubercular medications and the prevention of airway stenosis. Interventional Bronchoscopic techniques and surgery is required for those patients who develop severe tracheobronchial stenosis that causing significant symptoms including dyspnea, repeated post obstructive pneumonia or bronchiectasis.
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Affiliation(s)
- Talha Shahzad
- Section of Pulmonary and Critical Care Medicine, Department of Medicine, The Aga Khan University Hospital, Karachi, Pakistan
| | - Muhammad Irfan
- Section of Pulmonary and Critical Care Medicine, Department of Medicine, The Aga Khan University Hospital, Karachi, Pakistan
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38
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Abstract
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.
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Affiliation(s)
- Vikas Pathak
- Departments of Pulmonary Disease and Critical Care Medicine, WakeMed Health and Hospitals, Raleigh, North Carolina, USA
| | - Ray W Shepherd
- Departments of Pulmonary Disease and Critical Care Medicine, Virginia Commonwealth University Medical Center, Richmond, Virginia, USA
| | - Samira Shojaee
- Departments of Pulmonary Disease and Critical Care Medicine, Virginia Commonwealth University Medical Center, Richmond, Virginia, USA
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Faisal M, Harun H, Hassan TM, Ban AYL, Chotirmall SH, Abdul Rahaman JA. Treatment of multiple-level tracheobronchial stenosis secondary to endobronchial tuberculosis using bronchoscopic balloon dilatation with topical mitomycin-C. BMC Pulm Med 2016; 16:53. [PMID: 27080697 PMCID: PMC4832514 DOI: 10.1186/s12890-016-0209-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2016] [Accepted: 03/22/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Tracheobronchial stenosis is a known complication of endobronchial tuberculosis. Despite antituberculous and steroid therapy, the development of bronchial stenosis is usually irreversible and requires airway patency to be restored by either bronchoscopic or surgical interventions. We report the use of balloon dilatation and topical mitomycin-C to successful restore airway patency. CASE PRESENTATION We present a 24-year old lady with previous pulmonary tuberculosis and laryngeal tuberculosis in 2007 and 2013 respectively who presented with worsening dyspnoea and stridor. She had total left lung collapse with stenosis of both the upper trachea and left main bronchus. She underwent successful bronchoscopic balloon and manual rigid tube dilatation with topical mitomycin-C application over the stenotic tracheal segment. A second bronchoscopic intervention was performed after 20 weeks for the left main bronchus stenosis with serial balloon dilatation and topical mitomycin-C application. These interventions led to significant clinical and radiographic improvements. CONCLUSION This case highlights that balloon dilatation and topical mitomycin-C application should be considered in selected patients with tracheobronchial stenosis following endobronchial tuberculosis, avoiding airway stenting and invasive surgical intervention.
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Affiliation(s)
- Mohamed Faisal
- Department of Medicine, Respiratory Unit, Universiti Kebangsaan Malaysia Medical Centre, Jalan Yaacob Latiff, Bandar Tun Razak, 56000, Cheras, Kuala Lumpur, Malaysia.
| | - Hafaruzi Harun
- Respiratory Unit, Serdang Hospital, Jalan Puchong, 43000, Kajang, Selangor Darul Ehsan, Malaysia
| | - Tidi M Hassan
- Department of Medicine, Respiratory Unit, Universiti Kebangsaan Malaysia Medical Centre, Jalan Yaacob Latiff, Bandar Tun Razak, 56000, Cheras, Kuala Lumpur, Malaysia
| | - Andrea Y L Ban
- Department of Medicine, Respiratory Unit, Universiti Kebangsaan Malaysia Medical Centre, Jalan Yaacob Latiff, Bandar Tun Razak, 56000, Cheras, Kuala Lumpur, Malaysia
| | - Sanjay H Chotirmall
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
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Campos J, Ernst G, Borsini E, Garcia A, Blasco M, Bosio M, Salvado A. Tracheobronchial Tuberculosis Without Lung Involvement. J Clin Med Res 2015; 7:646-8. [PMID: 26124914 PMCID: PMC4471755 DOI: 10.14740/jocmr2182w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/22/2015] [Indexed: 02/07/2023] Open
Abstract
Endotracheal tuberculosis (ETTB) is an infrequent form of tuberculosis whose major feature is the infection of the tracheobronchial tree by Mycobacterium tuberculosis. This case presents a 73-year-old man admitted to our hospital with fatigue, weakness, dry cough and weight loss. His chest X-ray was normal but the high resolution computed tomography (HRCT) showed normal parenchyma images with mediastinal and hilar lymphadenopathy. There was inflammation of the tracheal wall and infiltrates in pavement epithelium; however, the tracheal biopsy for acid-fast bacilli was negative. He was finally diagnosed by endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) of the lymph nodes. Four drugs were prescribed and symptoms improved. EBUS-TBNA contributed to prompt diagnosis. The patient was treated and evolved without complications, such as tracheal stenosis.
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Affiliation(s)
| | - Glenda Ernst
- British Hospital, Respiratory Medicine Unit, Argentina
| | | | | | - Miguel Blasco
- British Hospital, Respiratory Medicine Unit, Argentina
| | - Martin Bosio
- British Hospital, Respiratory Medicine Unit, Argentina
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Idrees F, Kamal S, Irfan M, Ahmed R. Endobronchial tuberculosis presented as multiple endobronchial vesicular lesions. Int J Mycobacteriol 2015; 4:154-7. [PMID: 26972885 DOI: 10.1016/j.ijmyco.2015.02.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2015] [Revised: 02/23/2015] [Accepted: 02/24/2015] [Indexed: 11/20/2022] Open
Abstract
Endobronchial tuberculosis (EBTB) is a tuberculous infection of the tracheobronchial tree with microbiological and histopathological evidence, with or without parenchymal involvement. EBTB commonly presents as acute or insidious onset cough, wheeze, low grade fever, and constitutional symptoms. In elderly patients, other differentials like malignancy and pneumonia may lead to misdiagnosis. Hence, bronchoscopy is essential for confirmation of EBTB. Here we report a rare presentation of EBTB in a 65 year old patient who presented with 3 months history of fever and cough and have multiple endobronchial vesicular lesions on bronchoscopy.
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Affiliation(s)
- Farah Idrees
- Department of Medicine, The Aga Khan University Hospital, Karachi, Pakistan
| | - Saima Kamal
- Department of Medicine, The Aga Khan University Hospital, Karachi, Pakistan
| | - Muhammad Irfan
- Department of Medicine, The Aga Khan University Hospital, Karachi, Pakistan.
| | - Rashida Ahmed
- Department of Pathology and Microbiology, The Aga Khan University Hospital, Karachi, Pakistan
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