Endobronchial tuberculosis-a review

Destroyed lung contributes to the recurrence of hemoptysis after bronchial artery embolization in patients with post-tuberculosis bronchiectasis

BACKGROUND

Bronchiectasis has high rates of hemoptysis and recurrent hemoptysis, which is inconsistent among various etiologies. Idiopathic bronchiectasis and post-tuberculous bronchiectasis are two important etiologies in China, but the differences in clinical features and risk factors of recurrent hemoptysis have not been elucidated.

METHODS

Patients hospitalized for idiopathic bronchiectasis or post-tuberculosis bronchiectasis were included. Patients were followed up for at least 24 months post-BAE. Demographic characteristics and clinical data were collected and analyzed between idiopathic bronchiectasis and post-tuberculosis bronchiectasis. Based on the outcomes of recurrent severe hemoptysis in patients with post-tuberculosis bronchiectasis, Cox regression models were used to identify risk factors for recurrence.

RESULTS

Among 417 patients including 352 idiopathic bronchiectasis and 65 post-tuberculous bronchiectasis, 209 (50.1%) were females. Compared with the idiopathic group, the proportion of patients with female (54.5% vs. 26.2%, p < 0.001), with sputum (79.5% vs. 36.9%, p < 0.001), isolation of Pseudomonas aeruginosa (28.7% vs. 7.7%, p < 0.001), and the number of bronchiectatic lobes≥ 3(98.3% vs 50.8%, p < 0.001) were lower, and the proportion of destroyed lung (4.5% vs. 26.6%, p < 0.001) and recurrence of severe hemoptysis (22.4% vs. 41.5%, p = 0.001) were higher in the post-tuberculous group. Among patients with post-tuberculosis bronchiectasis, destroyed lung [HR: 3.2(1.1,9.1), p = 0.026] and abnormal esophageal proper artery [HR: 2.8(1.1,7.0), p = 0.032] were two independent risk factors for the recurrence of hemoptysis.

CONCLUSIONS

The recurrence rate of severe hemoptysis in patients with post-tuberculous bronchiectasis receiving BAE is high, and the proper esophageal artery should be actively evaluated and standardized treatment should be given.

Endobronchial growth: Tumor or tuberculosis

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.

Endobronchial optical coherence tomography helps to estimate the cartilage damage of the central airway in TBTB patients

Purpose

At present, there are few examination methods used to evaluate tracheobronchial cartilage damage. In our study, we explored whether endobronchial optical coherence tomography (EB-OCT) can be used to estimate central airway cartilage damage in tracheobronchial tuberculosis (TBTB) patients.

Methods

In our study, we used the OCTICS Imaging system to perform EB-OCT scanning for TBTB patients. The thickness of the central airway wall and cartilage was measured by the OCTICS software system workstation.

Results

There were 102 TBTB patients included in our study cohort. Their EB-OCT images of the central airway cartilage showed that abnormal cartilage manifests as thinning of the cartilage, cartilage damage, cartilage destruction, and even cartilage deficiency. The cartilage morphology becomes irregular and discontinuous. Some parts of the cartilage become brighter in grayscale. The intima of the cartilage is thickened and discontinuous, and the boundary with submucosa and mucosa is unclear.

Conclusion

Our study conducted EB-OCT examination of the central airway cartilage of TBTB patients in vivo for the first time. EB-OCT helps to estimate the cartilage damage of the central airway in TBTB patients to some extent.

Development, assessment and validation of a novel prediction nomogram model for risk identification of tracheobronchial tuberculosis in patients with pulmonary tuberculosis

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.

Rigid Bronchoscopy for Post-tuberculosis Tracheobronchial Stenosis

The healing process of tracheobronchial tuberculosis (TB) results in tracheobronchial fibrosis causing airway stenosis in 11% to 42% of patients. In Korea, where pulmonary TB is still prevalent, post-TB tracheobronchial stenosis (PTTS) is one of the main causes of benign airway stenosis causing progressive dyspnea, hypoxemia, and often life-threatening respiratory insufficiency. The development of rigid bronchoscopy replaced surgical management 30 years ago, and nowadays PTTS is mainly managed by bronchoscopic intervention in Korea. Similar to pulmonary TB, tracheobronchial TB is treated with combination of anti-TB medications. The indication of rigid bronchoscopy is more than American Thoracic Society (ATS) grade 3 dyspnea in PTTS patients. First, the narrowed airway is dilated by multiple techniques including ballooning, laser resection, and bougienation under general anesthesia. Then, most of the patients need silicone stenting to maintain the patency of dilated airway; 1.5 to 2 years after indwelling, the stent could be removed, this has shown a 70% success rate. Acute complications without mortality develop in less than 10% of patients. Subgroup analysis showed successful removal of the stent was significantly associated with male sex, young age, good baseline lung function and absence of complete one lobe collapse. In conclusion, rigid bronchoscopy could be applied to PTTS patients with acceptable efficacy and tolerable safety.

Infantile Tubercular Endobronchial Polypoid Obstructive Lesion

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.

Characteristics analysis of 157 cases of central airway stenosis due to tracheobronchial tuberculosis: A descriptive study

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.

Endobronchial Tuberculosis Simulating Acute Foreign Body Inhalation: A Case Report

Endobronchial tuberculosis is a rare form of pulmonary tuberculosis, that can be due to the rupture of an infected lymph node through bronchial wall or lymphatic spread to the lining of the bronchial tree. Clinical presentation is non-specific, and can simulate inhalation of a foreign body. Otolaryngologists should be aware of its presentation often atypical. The following case is an unusual presentation of endobronchial tuberculosis in a 23-month-old patient initially diagnosed as a foreign body in the respiratory tract with acute dyspnea with unilateral wheezing and suspected foreign body on chest computed tomography. Bronchoscopy revealed a granulomatous mass in carina and both primary bronchi. Granuloma ablation improved patient's respiratory status. The pathology revealed an epithelioid and gigantic cellular with caseous necrosis compatible with tuberculosis. This unusual presentation of tuberculosis should be known to otolaryngologists and pediatricians in view of the frequency of tuberculosis in our context as well as increase in its incidence.

Management of stent-related tracheoesophageal fistula in complex post-tuberculosis tracheobronchial stenosis: A case report

Background

The covered self-expandable metallic stents (SEMS) have been used to manage benign tracheobronchial stenosis, especially the complex post-tuberculosis (TB) tracheobronchial stenosis (PTTS) with cartilage destruction or malacia. This procedure could lead to stent-related tracheoesophageal fistula (TEF).

Case presentation

A 21-year-old woman, who had one covered Y-shaped SEMS inserted to manage complex PTTS 2 years ago, presented with dyspnea and frequent coughing on drinking water. The bronchoscopy confirmed extensive granulation tissue hyperplasia and a TEF on the upper edge of the covered SEMS. The covered SEMS was removed in three steps, and another fully covered Y-shape SEMS (Microtech Co., Ltd., Nanjing, China) was inserted to restore patency in the tracheobronchial tree and occlude the TEF orifice. Recombinant bovine basic fibroblast growth factor (rbFGF) (6,000 IU/time) was sprayed into and around the fistula through the V-System single-use cannula via the flexible bronchoscope every other week. The patient showed sustained clinical and radiographic improvement, and the TEF healed.

Conclusion

We presented a three-step bronchoscopic approach to managing a stent-related TEF in a patient with complex PTTS. Subsequently, regular bronchoscopic debridement of granulation tissue developing on the upper edge of SEMS is necessary to maintain the stent patency and reduce the risk of recurrent stent-related TEF. A fully covered SEMS associated with the local administration of rbFGF seems to offer an alternative simplified one-stage procedure for the temporary management of TEF combined with complex PTTS in non-surgical candidates.

Knockdown of SOX9 alleviates tracheal fibrosis through the Wnt/β-catenin signaling pathway

Trachealfibrosis is an important cause of tracheal stenosis without effective treatments, and new drug targets need to be developed. The role of SOX9 in the injury and repair of the trachea is unknown; this study aims to investigate the role of SOX9 in the regulation of tracheal fibrosis based on clinical samples from patients with tracheal injury and a model of tracheal fibrosis produced by tracheal brushing in rats. The results showed that the expressions of SOX9 and mesenchymal and ECM-related indicators were increased in the injury and fibrosis of the trachea in patients and rats. Serum SOX9 levels exhibited a sensitivity of 83.87% and specificity of 90% in distinguishing patients with tracheal fibrosis from healthy volunteers when the cut‑off value was 13.24 ng/ml. Knockdown SOX9 can markedly inhibit granulation tissue proliferation, reduce inflammation and ECM deposition, promote epithelial regeneration and granulation tissue apoptosis, and attenuate the tracheal fibrosis after injury. Additionally, RNA sequencing showed that the proliferation, migration, and ECM deposition of tracheal granulation tissue were related to the activation of Wnt pathway, activation of the β-catenin, and p-GSK3β after injury can be inhibited by the knockdown of SOX9. In summary, SOX9 is upregulated in tracheas fibrosis and may be a novel factor to promote tracheal fibrosis progression. Inhibiting SOX9 may be used to prevent and treat tracheal fibrosis in the future. KEY MESSAGE : The expression of SOX9 is upregulated the process of injury and repair of the tracheal fibrosis. Knocking down SOX9 can attenuate tracheal fibrosis after injury by inhibiting inflammation response, granulation tissue proliferation, ECM deposition, and promoting granulation tissue apoptosis. The Wnt/β-catenin-SOX9 axis is activated during tracheal injury and fibrosis, and inhibition of SOX9 can partially alleviate tracheal fibrosis. SOX9 may act as a new diagnostic and therapeutic target in patients with tracheal fibrosis in the future.

Clinical, radiological and histopathological profile of patients with endobronchial lesions on fibreoptic bronchoscopy

Various pulmonary diseases, both benign as well as malignant, manifest in the form of endobronchial lesions on bronchoscopy. Malignancy is frequently the provisional diagnosis in the mind of a chest physician undergoing an endobronchial biopsy. Other benign diseases, however, may present similarly on bronchoscopy and computerized tomography (CT) scan. This observational study was conducted to better understand why there is such a wide range of endobronchial lesions with even more diverse radiological and pathological presentations. The research was carried out at the Department of Respiratory Medicine, Himalayan Institute of Medical Science (HIMS), Swami Ram Nagar, Dehradun. Subjects were recruited from HIMS, Dehradun patients over a 12-month period (August 2020 to July 2021). The study included patients (over the age of 18) who had a fibreoptic bronchoscopy and were found to have an endobronchial lesion. After a thorough history, examination, and application of the inclusion and exclusion criteria. 120 patients were enrolled. The majority of patients were between the ages of 56 and 65, with males outnumbering females. The majority of the patients were smokers, and the most common complaint was shortness of breath. Poorly differentiated carcinoma and squamous cell carcinoma were the most common endobronchial lesions in men, while small cell carcinoma was the most common in women. A mass lesion was the most common radiological finding, followed by mediastinal lymphadenopathy, and an exophytic lesion was the most common endobronchial lesion detected in bronchoscopy. We looked at the diseases that cause endobronchial lesions and their clinico-radiological and histopathological profiles. This study clearly demonstrates the importance of studying the histopathological profiles of patients with endobronchial growth, which can mimic malignancy in rare cases.

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

Purpose

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

Methods

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

Results

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

Conclusion

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

Identification of potential genes in endobronchial tuberculosis after bronchoscopic cryotherapy by transcriptome sequencing

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.

Diffuse Tracheobronchial Tuberculosis With Left Pulmonary Tuberculosis Displayed on 18F-FDG PET/CT

ABSTRACT

A 57-year-old woman was admitted to the hospital with persisting cough and sputum for 2 months. Chest CT revealed multiple nodules in the left lung. 18F-FDG PET/CT scan was carried out to further evaluate these pulmonary lesions. In addition to multiple hypermetabolic nodules in the upper lobe of left lung, diffuse thickening of the trachea and left bronchial wall with increased FDG uptake was also found. Inflammatory granulation tissue with Mycobacterium tuberculosis was confirmed through the pathological examination of bronchoscopy.

Bronchoscopic Features and Morphology of Endobronchial Tuberculosis: A Malaysian Tertiary Hospital Experience

The diagnosis of endobronchial tuberculosis (EBTB) is difficult as it is not well visualized radiologically, and bronchoscopy is not routinely performed for tuberculosis (TB) patients. Bronchoscopic characterization via endoscopic macroscopic features can speed up the diagnosis of EBTB and prompt immediate treatment. In this study, we identified the clinical and bronchoscopic morphology of 17 patients who were diagnosed with EBTB from 2018 to 2020. Demographics, radiological, microbiological and histopathological data were recorded. Endobronchial lesions were classified according to Chung classification. The diagnosis was made based on a histopathological examination (HPE) of endobronchial biopsy, and/or positive ‘Acid-fast bacilli’ (AFB) microscopy/Mycobacterium tuberculosis (MTB) culture on microbiological examination of bronchial alveolar lavage (BAL) and/or positive MTB culture on endobronchial biopsy specimens. Furthermore, EBTB was predominant in young women, age 20 to 49 years old, with a male to female ratio of 1 to 2. Underlying comorbidities were found in 53% of the patients. Cough, fever and weight loss were the main symptoms (23.5%). The indications for bronchoscopy are smear-negative TB and persistent consolidation on chest radiographs. Consolidation was the main radiological finding (53%). An active caseating lesion was the main EBTB endobronchial subtype (53%). The leading HPE finding was caseating granulomatous inflammation (47%). All patients showed good clinical response to TB treatment. Repeated bronchoscopy in six patients post TB treatment showed a complete resolution of the endobronchial lesion. EBTB bronchoscopic characterization is paramount to ensure correct diagnosis, immediate treatment and to prevent complication.

The Diagnostic Deceiver: Radiological Pictorial Review of Tuberculosis

Tuberculosis (TB) is a bacterial infection with Mycobacterium tuberculosis; it is a public health problem worldwide and one of the leading causes of mortality. Since December 2019, the COVID-19 pandemic has created unprecedented health challenges and disrupted the TB health services, especially in high-burden countries with ever-increasing prevalence. Extrapulmonary and even pulmonary TB are an important cause of nonspecific clinical and radiological manifestations and can masquerade as any benign or malignant medical case, thus causing disastrous conditions and diagnostic dilemmas. Clinical manifestations and routine laboratory tests have limitations in directing physicians to diagnose TB. Medical-imaging examinations play an essential role in detecting tissue abnormalities and early suspecting diagnosis of TB in different organs. Radiologists and physicians should be familiar with and aware of the radiological manifestations of TB to contribute to the early suspicion and diagnosis of TB. The purpose of this article is to illustrate the common radiologic patterns of pulmonary and extrapulmonary TB. This article will be beneficial for radiologists, medical students, chest physicians, and infectious-disease doctors who are interested in the diagnosis of TB.

Pulmonary tuberculosis and COVID-19 coinfection: Hickam's Dictum revisited

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.

Pseudomembranous Tracheobronchitis due to Mycobacterium tuberculosis

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.

Anti-PL-7 antibody-positive dermatomyositis with progressive interstitial pneumonia complicated with tracheal ulcer

Tracheobronchial lesions are rare extramuscular complications for idiopathic inflammatory myopathies including dermatomyositis. We herein report a 65-year-old woman with tracheal ulcer during the progression of dermatomyositis-associated interstitial lung disease. Treatment with corticosteroids combined with immunosuppressive agents resulted in improvement of the tracheal ulcer and pulmonary involvement. We believe that the tracheal ulceration might reflect the disease behaviour of dermatomyositis and dermatomyositis-associated interstitial pneumonia.

Asthma and pulmonary tuberculosis: misdiagnosis or coexistence

Asthma and pulmonary tuberculosis (PTB) are disease entities with different pathogenesis. However, endobronchial tuberculosis (EBTB), a peculiar form of PTB, can mimic the symptoms of asthma. Although uncommon, the coexistence of asthma and PTB can appear. We report three cases of PTB. The first two cases with EBTB were misdiagnosed as asthma and the third case with asthma developed PTB four months after high-dose inhaled corticosteroid (ICS) therapy. The first two cases presented with chronic cough up mucopurulent/purulent sputum and localized wheezing which revealed diagnostic clues. The third case presented with dry cough and showed a positive bronchodilator response and the right pulmonary apical fibrosis which could be associated with quiescent tuberculous infection. EBTB should be included in the differential diagnosis of asthma. Although rare, physicians should be aware that PTB can also be developed during the treatment course of asthma.

Endobronchial Tuberculosis and Bronchostenosis: A Rare Case of Bronchial Occlusion in a Patient With History of Tuberculosis

Pulmonary tuberculosis is common worldwide, and many of these patients develop endobronchial tuberculosis (EBTB). Bronchostenosis is a known complication of EBTB though most patients with endobronchial stenosis do not develop severe bronchostenosis or occlusion. We present a rare case of a patient with a right upper lobe bronchus occlusion and a history of tuberculosis.

CT Findings of Central Airway Lesions Causing Airway Stenosis-Visualization and Quantification: A Pictorial Essay

The tracheobronchial tree is a system of airways that allows the passage of air to aerate the lungs and entire body. Several pathological conditions can affect this anatomical region. Multidetector CT (MDCT) helps identify and characterize various large airway diseases. Post-processing tools, such as virtual bronchoscopy and automatic lung analysis, can help enhance the performance of imaging studies. In this pictorial essay review, we provide imaging findings of various bronchial lesions manifested as wall thickening and endoluminal nodules on conventional MDCT and advanced image visualization and analysis.

Proteomic profiling of biomarkers by MALDI-TOF mass spectrometry for the diagnosis of tracheobronchial stenosis after tracheobronchial tuberculosis

Tracheobronchial tuberculosis (TB) leads to airway stenosis, irreversible airway damage and even death. The present study aimed to identify biomarkers for the diagnosis of tracheobronchial stenosis (TBS) secondary to tracheobronchial TB. A cohort was recruited, including patients with TBS after tracheobronchial TB, TBS after tracheal intubation or tracheotomy (TIT) and no stenosis of early-stage lung cancer,. Proteomic profiling was performed to gain insight into the mechanisms of the pathological processes. Differentially expressed proteins in the serum and bronchial alveolar lavage fluid (BALF) from patients were detected by matrix-assisted laser desorption ionization time-of-flight mass spectrometry (MALDI-TOF MS). Subsequently, ELISA was performed to validate the changes of protein levels in an additional cohort. MALDI-TOF MS revealed that 8 peptides in the serum, including myeloid-associated differentiation marker, keratin type I cytoskeletal 18, fibrinogen α-chain, angiotensinogen (AGT), apolipoprotein A-I (APOAI), clusterin and two uncharacterized peptides, and nine peptides in BALF, including argininosuccinate lyase, APOAI, AGT and five uncharacterized peptides, were differentially expressed (molecular-weight range, 1,000-10,000 Da) in the TB group compared with the TIT group. The ELISA results indicated that the changes in the protein levels had a similar trend as those identified by proteomic profiling. In conclusion, the present study identified proteins that may serve as potential biomarkers and provide novel insight into the molecular mechanisms underlying TBS after tracheobronchial TB.

Performance of the Xpert® MTB/RIF assay in the rapid diagnosis of tracheobronchial tuberculosis using bronchial washing fluid

Objective

To assess the diagnostic value of the Xpert® MTB/RIF (GeneXpert) assay for tracheobronchial tuberculosis (TBTB) using bronchial washing fluid (BWF).

Methods

This retrospective study enrolled patients suspected of having TBTB and patients with non-TB pulmonary disease as controls. BWF were used to undertake acid-fast bacillus (AFB) smears, the GeneXpert assay and the Lӧwenstein–Jensen (LJ) culture method. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were compared among BWF AFB smears, BWF GeneXpert and the BWF LJ culture method.

Results

A total of 130 patients with TBTB and 102 patients with non-TB pulmonary disease were enrolled in the study. Sputum AFB smears were positive in 62 of 130 patients (47.7%) with TBTB. Using the clinical diagnosis of TBTB as the gold standard, the sensitivity, specificity, PPV and NPV of the three methods using BWF were as follows: 93.1%, 99.0%, 99.2% and 91.8% for BWF GeneXpert; 73.1%, 100.0%, 100.0% and 74.5% for BWF LJ cultures; 53.8%, 99.0%, 98.6% and 62.7% for BWF AFB smears. The diagnostic yield of BWF GeneXpert was significantly higher compared with BWF cultures for type III and IV TBTB.

Conclusion

The Xpert® MTB/RIF assay using BWF exhibited higher sensitivity than bacteriological diagnostic methods and was particularly useful for the early diagnosis of smear-negative TBTB.

Endobronchial tuberculosis polyps

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

Airway stenting: Technological advancements and its role in interventional pulmonology

AS offers rapid and sustained relief of symptoms in most patients treated for malignant or benign CAO and can also be curative in itself in cases of benign tracheobronchial stenosis. In the past 30 years, this field has seen significant progress, from the misuse of vascular non-covered metallic stents to the development of silicone airway stents with an increasingly large panel of shapes and of hybrid, partially or fully covered, SEMS customized to the airways. This study aims to offer an overview on: (i) the respective advantages and drawbacks of these two main categories of devices; (ii) the main indications for AS and the rationale behind the choice of stent in each situation; and (iii) the main promises borne from the progress made in the field in the past few years, including the development of drug-eluting, biodegradable or patient-specific customized AS.

Corticosteroid as an Adjunct in the Treatment of Endobronchial Tuberculosis: A Systematic Review & Meta-analysis

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.

[An unusual development following anti-tuberculous treatment: Obstructive inflammatory granuloma]

Tuberculosis is a disease that is still a too frequent. Its treatment depends on prolonged, multi-antibiotic, chemotherapy. Progress following treatment is generally good but there is the possibility of parenchymatous or pleural sequelae such as bronchial stenosis due to post tuberculous bronchial fibrosis or bronchiolithiasis. On the other hand, bronchial obstruction after treatment by an inflammatory granuloma is rare. It causes wheezing dyspnoea. In this case, relapse of the tuberculosis was feared, possibly with the development of multi-drug resistance. Treatment with corticosteroids allowed a rapid improvement.

Improved cough- and sputum-related quality of life after initiation of treatment in pulmonary tuberculosis

BACKGROUND

Cough and sputum are the major symptoms of pulmonary tuberculosis (TB). However, the relationship between these symptoms and treatment for TB is not fully understood. The aim of this prospective study was to clarify the cough- and sputum-related quality of life (QOL) in patients with pulmonary TB before and after initiation of treatment.

METHODS

The study included 85 patients with active pulmonary TB who were hospitalized from July 2014 to August 2015. They completed the Leicester Cough Questionnaire (LCQ: range 3-21, the higher the better) and the Cough and Sputum Assessment Questionnaire (CASA-Q: range 0-100, the higher the better) on admission and at discharge after 2 months of treatment.

RESULTS

The LCQ and CASA-Q scores were reduced on admission. A multivariate linear regression analysis revealed that younger age, more than two cavitary lesions, and the presence of bronchial TB were associated with reduced LCQ total score. However, each score significantly improved at discharge, regardless of the initial grade of the sputum smear, site of the lesion, number of cavitary lesions, and presence of bronchial TB. The change in the mean LCQ total score was 2.28 (95% confidence interval, 1.56-3.00). The changes in the mean CASA-Q cough symptoms, cough impact, sputum symptoms, and sputum impact scores were 22.84 (18.44-27.25), 10.96 (7.20-14.71), 17.25 (13.33-21.18), and 5.25 (2.49-8.00), respectively.

CONCLUSIONS

Cough- and sputum-related QOL was impaired in patients with pulmonary TB before treatment but improved after initiation of treatment regardless of the clinical characteristics.

Cough in pulmonary tuberculosis: Existing knowledge and general insights

Cough is a prominent symptom of pulmonary tuberculosis (TB), one of the oldest and most prevalent infectious diseases. Coughing probably has a pivotal role in transmission of the causative organism Mycobacterium tuberculosis. Despite this, little research to date has addressed this subject. Current knowledge of the mechanisms of cough in TB and how exactly coughing patterns predict infectiousness is scant, but this is changing. This overview summarises the existing evidence for the infectiousness of cough in TB, clinical correlates, and possible causes of cough in TB. Potential unique characteristics of cough in the disease are discussed, as is treatment and the subjective awareness of coughing in the disease.

Hilar asymmetry in endobronchial tuberculosis patients: An often-overlooked clue

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.

Pleural effusion resulting from bronchial tuberculosis: A case report

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.

GeneXpert MTB/RIF for rapid diagnosis and rifampin resistance detection of endobronchial tuberculosis

BACKGROUND AND OBJECTIVE

Delayed diagnosis and treatment of tuberculosis (TB) contribute to poor outcomes, especially for endobronchial TB (EBTB), which typically leads to tracheobronchial stenosis. Finding rapid and accurate diagnostic tools for EBTB is crucial. GeneXpert Mycobacterium tuberculosis (MTB)/rifampin (RIF) was recommended by the World Health Organization (WHO) as a standard molecular biological diagnostic technique for MTB. The aim of this study was to evaluate the efficacy of GeneXpert MTB/RIF for diagnosing EBTB and for evaluating RIF resistance.

METHODS

Biopsy tissue and bronchial brushings from EBTB patients were prospectively assessed with GeneXpert MTB/RIF. The diagnostic yields of auramine O-stained sputum smears and bronchial brush smears were obtained, and the results were compared with the cultures of sputum and biopsy tissues for MTB.

RESULTS

In 61 confirmed cases of EBTB, the sensitivities of sputum smear, bronchial brush smear, sputum culture and tissue culture to diagnose EBTB were 13.1%, 32.8%, 36.1% and 68.9%, respectively. For bronchial brushings and biopsies, our data showed sensitivities of 57.4% and 63.9%, respectively, and a specificity of 100% for GeneXpert MTB/RIF, and these results were superior to those of sputum smears, bronchial brush smears and sputum culture. GeneXpert MTB/RIF for bronchial brushings and biopsies showed complementarity in its diagnostic performance. Resistance to RIF was identified in 17.4% (8/46) of GeneXpert MTB-positive cases.

CONCLUSION

GeneXpert MTB/RIF may enable more rapid EBTB diagnosis and determination of RIF resistance, which are crucial for timely treatment.

A Survey of Anxiety and Depressive Symptoms in Pulmonary Tuberculosis Patients With and Without Tracheobronchial Tuberculosis

Background and Objective: Anxiety/depression and tuberculosis are global public health problems. The incidence of psychiatric morbidities is high among tuberculosis patients. However, little is known about the prevalence of anxiety and depression among Chinese pulmonary tuberculosis (PTB) patients, especially those with tracheobronchial tuberculosis (TBTB). The goal of the present study was to explore the prevalence of and associated factors of anxiety and depressive symptoms among PTB patients with and without TBTB. Methods: A cross-sectional survey of PTB patients from three hospitals in Liaoning, China, was conducted using a structured questionnaire. Depression and anxiety were evaluated by using the Hospital Anxiety and Depression Scale (HADS) and the Patient Health Questionnaire-9 (PHQ-9). Results: According to HADS and PHQ-9, 17.73 and 18.13% of 1252 PTB patients, respectively, had significant depressive symptoms and based on HADS scale, 18.37% had significant anxiety symptoms. Approximately 70% of patients with probable depression also had significant anxiety symptoms, and vice versa, and 69.6% patients with anxiety symptoms were also diagnosed with probable depression in our study population. Dyspnea and TBTB were significantly associated with depressive symptoms. Other depressive symptoms-related factors included age, divorce, abnormal body mass index (BMI), and low income. Patients with lower incomes, symptoms of dyspnea, or a combination of ≥3 clinical symptoms had an increased risk of anxiety symptoms, while patients with occasional or frequent alcohol consumption had a reduced risk of anxiety symptoms. Conclusion: Depressive and anxiety symptoms are common among PTB patients, especially those with TBTB. Screening for depression and anxiety is essential for identifying patients who require further psychosocial assessment and support.