Tracheobronchial tuberculosis: a clinical review

Long-term outcomes of surgical reconstruction for post-tuberculosis tracheobronchial stenosis: a 7-year follow-up in a tuberculosis-endemic region

Background

Surgical reconstruction is often necessary for severe tracheobronchial stenosis resulting from tuberculosis (TB). However, the long-term efficacy of this approach remains unclear. This study investigated the safety and long-term outcomes of surgery for severe post-TB tracheobronchial stenosis.

Methods

We conducted a retrospective study of 48 patients with severe post-TB tracheobronchial stenosis who underwent surgical reconstruction between 2015 and 2018 in a TB-endemic region. Pre- and postoperative evaluations included Karnofsky performance status, modified Medical Research Council (mMRC) dyspnea scale, spirometry, chest computed tomography (CT) scan, and bronchoscopy. The primary outcome was intervention-requiring restenosis over the long term.

Results

The mean patient age was 30.6±9.9 years, with 91.7% females. Airway fibrosis was the predominant lesion (93.8%), affecting the bronchi (93.8%) and trachea (6.2%). All the patients underwent resection and anastomosis, and 56.2% required lobectomy. Postoperative complications occurred in 13 patients (27.1%), with prolonged air leaks being the most prevalent (12.5%). All complications resolved with conservative management. Significant improvements in performance status, dyspnea, and lung function were observed postoperatively and sustained for over 5 years. Within a median follow-up of 69 months, five cases of intervention-requiring restenosis occurred within the first year. The freedom from restenosis rate was 90% from 1 year onwards.

Conclusions

Surgical reconstruction is safe and effective in treating severe post-TB tracheobronchial stenosis. Larger studies are required to validate these findings.

Successful Avoidance of Cicatricial Tracheobronchial Stenosis in a Patient With Endobronchial Tuberculosis by Early Administration of Systemic High-Dose Corticosteroids: A Case Report

A 63-year-old Japanese woman was referred to our hospital due to dry cough, fever, hoarseness, stridor, and difficulty breathing. Chest computed tomography showed circumferential wall thickening in the trachea, carina, right main bronchus, and right upper lobe bronchus, and granular and nodular shadows in right S2. Flexible laryngofiberscopy showed yellowish dry respiratory secretions adhering to the subglottis. Bronchoscopic findings showed that the tracheobronchial mucosa was swollen, hyperemic, and covered with yellowish-white, cheese-like materials, and ulcerative lesions with white coatings were observed from the subglottis to the trachea, carina, right main bronchus, and right upper lobe bronchus. A diagnosis of endobronchial tuberculosis (EBTB) was confirmed by polymerase chain reaction testing, and cultures were positive for Mycobacterium tuberculosis. In addition to anti-tuberculosis chemotherapy, intravenous high-dose methylprednisolone reduced her severe respiratory symptoms and prevented cicatricial tracheobronchial stenosis. Early administration of systemic high-dose corticosteroids may be effective for EBTB patients with severely active tracheobronchial mucosal and submucosal lesions.

Tracheobronchial mucosal keratosis: A literature review of this rare disorder

Background

Tracheobronchial mucosal keratosis (TBMK) is a rare airway disease that may cause refractory cough and airway stenosis. The characteristics of this disease remain unknown. In the present study, we describe this disorder based on a review of the current literature, emphasizing its diagnostic and therapeutic aspects.

Methods

A comprehensive search of TBMK was performed in Medline, Google Scholar, Web of Science, Cochrane Library (UK), Embase, China National Knowledge Infrastructure (CNKI) (China), and Wan Fang Med Online (China). The following data were collected: patient characteristics, chest imaging findings, bronchoscopy, histopathologic findings, pathogen testing, treatment, and prognosis.

Results

As of 2023, eighteen cases of TBMK have been reported. The main clinical manifestations were cough and expectoration. Chest imaging findings were non-specific. The main bronchoscopy findings were nodular protrusion of airway lumen and yellow-white purulent moss above the nodular lesion. The lesions were mainly located in the trachea and mainstem bronchus. The main pathological manifestations include keratinocytes or keratinocyte beads, squamous metaplasia, and mucosal inflammatory changes. The treatments that were administered include antibiotics, symptomatic treatment, and glucocorticoids. All methods were ineffective except for bronchoscopy-guided high-frequency electric knife and recombinant human epidermal growth factor treatment.

Conclusions

TBMK is a rare respiratory disease with atypical clinical manifestations and chest computed tomography findings. Bronchoscopy revealed that nodular hyperplasia of the airway and purulent fur-covered lesions are typical manifestations. The final diagnosis needs to be confirmed by histopathological examination. There is a lack of effective treatment for this disease, and bronchoscopy-guided intervention therapy may be a candidate treatment.

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.

Challenges in the Management of Laryngo-Tracheo-Bronchial Stenosis Secondary to Tuberculosis

Laryngo-tracheo-bronchial tuberculosis may be primary or secondary to pulmonary tuberculosis. It causes stenosis of the airway, leading to life threatening airway obstruction. We herein describe the challenges in managing a case of laryngo-tracheo-bronchial stenosis in a 22-year-old patient who presented with stridor post antituberculous therapy secondary to a malacic airway.

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.

Main Bronchus Stenosis Due to Tuberculosis and Ogilvie's Syndrome: A Case Report of Two Unusual Diseases in the Same Patient

Main bronchus stenosis as a sequel of pulmonary tuberculosis is infrequent and should raise suspicion of other presentations of the infection. Given its non-specific symptomatology and the absence of a specific diagnostic method, tracheobronchial tuberculosis is usually not suspected and diagnosed despite its great impact on quality of life due to the high incidence of stenosis as a consequence. Ogilvie's syndrome, an uncommon condition, requires careful management and surveillance given the risk of ischemia and colonic perforation intrinsic to the disease. We present a case of a patient with main bronchus stenosis secondary to tuberculosis infection and Ogilvie's syndrome post-surgery.

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

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

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

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

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

Key determinants of misdiagnosis of tracheobronchial tuberculosis among senile patients in contemporary clinical practice: A retrospective analysis

BACKGROUND

Tracheobronchial tuberculosis (TBTB) is a common subtype of pulmonary tuberculosis. Concomitant diseases often obscure the diagnosis of senile TBTB.

AIM

To characterize senile patients with TBTB and to identify the potential causes of misdiagnosis.

METHODS

One hundred twenty patients with senile TBTB who were admitted to the Anhui Chest hospital between May 2017 and May 2019 were retrospectively analyzed. Patients were classified as diagnosed group (n = 58) and misdiagnosed group (n = 62). Clinical manifestations, laboratory results, radiographic data, and endoscopic findings were compared between the two groups.

RESULTS

Patients in the misdiagnosed group were most commonly diagnosed as pulmonary tuberculosis (non-TBTB, 29/62, 46.8%), general pneumonia (9/62, 14.5%), chronic obstructive pulmonary disease (8/62, 12.9%), and tracheobronchial carcinoma (7/62, 11.3%). The time elapsed between disease onset and confirmation of diagnosis was significantly longer in the misdiagnosed group [median (first quartile, third quartile): 6.32 (4.94, 16.02) mo vs 3.73 (2.37, 8.52) mo]. The misdiagnosed group had lower proportion of patients who underwent bronchoscopy [33.87% (21/62) vs 87.93% (51/58)], chest computed tomography (CT) scan [69.35% (43/62) vs 98.28% (57/58)], and those who showed CT signs of tuberculosis [27.91% (12/62) vs 50% (29/58)] as compared to that in the diagnosed group (P < 0.05). There were no significant between-group differences with respect to age, gender, occupation, clinical manifestations, or prevalence of comorbid chronic diseases (P > 0.05).

CONCLUSION

Insufficient or inaccurate radiographic or bronchoscopic assessment was the predominant cause of delayed diagnosis of TBTB. Increased implementation and better interpretation of CT scan and early implementation of bronchoscopy can help reduce misdiagnosis of senile TBTB.

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.

One not to miss: Tuberculous tracheal stenosis

We describe a patient who developed severe tracheal stenosis while on treatment for pulmonary tuberculosis. Bronchoscopic-guided balloon dilatation succeeded in managing this disorder. Diagnosis of tracheobronchial tuberculosis requires a high index of suspicion because symptoms are usually attributed to co-existing pulmonary disease and airway lesions are not detectable on chest x-ray. Interventional bronchoscopy is employed to restore airway patency once significant stenosis develops. Should bronchoscopic measures fail, surgical options can be considered.

A case of concomitant pulmonary tuberculosis and mucormycosis in an insulin-dependent diabetic patient

Conditions, where the patient's immune system is compromised are the main risk factor for mucormycosis. Approximately 23% of the world's population is estimated to have a latent Mycobacterium tuberculosis infection and more than 10 million new cases were estimated in 2017. Pulmonary mucormycosis and tuberculosis co-infections are very rare. We present the case of a 56-year-old insulin-dependent diabetic patient with a pulmonary mucormycosis and tuberculosis co-infection. While the patient did not suffer from ketoacidosis, she had poor glycemic control. A chest X-ray and a computed tomography showed nodular and cavitary lesions in both lungs. The patient was diagnosed through a biopsy of the bronchial mucosa and an RT-PCR for M. tuberculosis from bronchoalveolar lavage. The patient was treated with the recommended 4-drug regimen for TB (i.e. isoniazid, rifampin, pyrazinamide, and ethambutol); concurrently, amphotericin B deoxycholate was administered to treat the mucormycosis infection. Thirty days after initial hospital admission the patient underwent a lobectomy on the right lung. The case described here is only the sixth case reported in the literature of concomitant pulmonary tuberculosis and mucormycosis and the third case associated with a TB and mucormycosis co-infection involving an uncontrolled DM patient to survive.

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.

Bronchoscopic local steroid spray to prevent bronchial tuberculosis-induced cicatricial bronchial stenosis: A case series

RATONALE

Cicatricial bronchial stenosis or obstruction occurring in the healing process of endobronchial tuberculosis (ET) is a problematic complication of tuberculous airway lesions. Prevention by internal medical treatment is desired.

PATIENT CONCERNS

This case series describes four patients who diagnosed ET with Type IIIb (protruding ulcer-type) based on Arai's classification of bronchoscopic findings of bronchial tuberculosis.

DIAGNOSES

Endobronchial tuberculosis.

INTERVENTIONS

A local steroid spray was applied bronchoscopically to active protruding ulcer-type lesions (which are likely to cause cicatricial stenosis) that extended in the transverse direction and occupied one-half or more of the circumference on bronchoscopy.

OUTCOMES

Cicatricial stenosis was prevented in two of four patients. Treatment was discontinued in athird patient because tolerance could not be achieved, although the patient's condition had improved. In the fourth patient, treatment was switched to systemic steroid administration because of a problem with tolerance and the broad range of the lesion; however, stenosis remained.

LESSONS

Local steroid spray-applied bronchoscopically to bronchial tuberculosis lesions in the ulcer formation and granulation periods may help prevent stenosis.

[Surgical Treatment of Bronchial Stricture due to Endobronchial Tuberculosis: Results in 36 Consecutive Cases]

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。

Reversible platypnoea-orthodeoxia syndrome in post-tuberculosis bronchial stenosis

Bronchial stenosis is known to complicate endobronchial tuberculosis despite medical therapy. It is often associated with dyspnoea. In severe cases, bronchial stenosis results in airflow obstruction, impaired secretion clearance, and can lead to respiratory failure. We present an unusual observation of platypnoea-orthodeoxia syndrome in a young woman with acute atelectasis due to post-tuberculosis bronchial stricture. Imaging revealed complete middle and right lower lobe atelectasis with a partially aerated right upper lobe. In the sitting posture, there was positional worsening of dyspnoea associated with an increase in the alveolar-arterial oxygen gradient and shunt fraction. The likely mechanism was due to gravitational difference in ventilation-perfusion matching. The platypnoea-orthodeoxia syndrome was reversible following balloon dilatation of the bronchial stenosis and expansion of the collapsed lung.