A study on non-resolving pneumonia with special reference to role of fiberoptic bronchoscopy

Severe Central Airway Obstruction Secondary to a Giant Endobronchial Hamartoma: A Case Report

Central airway obstruction refers to the occlusion of more than 50% of the trachea, main stem bronchi, or lobar bronchus. It can potentially become a life-threatening condition. Pulmonary hamartomas (PH) are rare tumors with an incidence of 0.25%, constituting about 8% of all benign lung neoplasms. Only 10% of PH occur endobronchially, while the remaining appear peripherally. We present the case of a women with an endobronchial hamartoma that required emergent resection by bronchoscopy. This is 44-year-old woman, with a history of an endobronchial mass on the right main stem bronchus (RMSB) without histopathological diagnosis or surgical management. She presented with a history of chronic cough and expectoration. Upon admission, a chest X-ray was performed, showing opacities of the right lung and amputations of the RMSB. Bronchoscopy was performed and a tumor-like mass that occludes the RMSB was found, with valve effect causing intermittent occlusion. In anesthetic induction, she presents severe airway obstruction and cardiorespiratory arrest. During resuscitation maneuvers, the lesion that was obstructing the light is seen and resection was performed with electrocautery and cryotherapy probes. Histopathological report described an endobronchial chondromesenchymal hamartoma, with no signs of malignancy. The control X-ray showed adequate re-expansion of the right lung. In conclusion, although endobronchial hamartoma has a low incidence and has a slow growth rate, it can manifest as severe airway obstruction. To achieve a complete resection of an endobronchial lesion, both rigid and/or flexible bronchoscopy plus multimodal interventions are recommended.

An elderly male with nonresolving consolidation

An 81-year-old male presented with a background history of progressive shortness of breath for 3 years with recent worsening in the past 6 months. Clinicoradiological investigations were consistent with a nonresolving consolidation involving predominantly right lung. This clinicopathologic conference discusses the differential diagnoses of pneumonia of long-standing duration and their management options.

Expert panel consensus statement on the applications and precaution strategies of bronchoscopy in patients with COVID-19

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a novel coronavirus with higher transmissibility compared with SARS coronavirus (SARS-CoV) and Middle East respiratory distress syndrome coronavirus. Coronavirus disease 2019 (COVID-19) caused by SARS-CoV-2 is an unprecedented global crisis that has not been experienced, which is still disrupting health systems, economies, and societies around the world by the rapid spread. Bronchoscopy plays an important role in diagnosis and therapy of pulmonary diseases, especially in patients with severe pulmonary infection, however, application of bronchoscopy in patients suspected or confirmed SARS-CoV-2 infection is extremely limited for the potential airborne transmission from aerosol generated during the procedure. This consensus statement was completed by expert panel of Interventional & Minimally Invasive Respiratory Committee of China Medical Education Association, and the issues were summarized as seven key topics to define the indications of bronchoscopy and matters needing attentions on the bronchoscopy procedures in patients with COVID-19, as well as the protective precaution strategies to avoid nosocomial SARS-CoV-2 infection.

Nonresolving pneumonia in the setting of malignancy

PURPOSE OF REVIEW

This article reviews recent literature and experience in the diagnosis of nonresolving and slowly resolving pneumonia as it pertains to malignancy.

RECENT FINDINGS

Malignancy must be considered as an important cause of pneumonia that resolves slowly or has incomplete resolution. Airway obstruction is more common than malignant infiltration as a cause of pneumonia that does not resolve appropriately. Infection due to resistant or unusual organisms must also be considered in the differential diagnosis.

SUMMARY

Nonresolving pneumonia remains an important clinical challenge. Bronchoscopic evaluation in conjunction with computed tomography and PET scanning is still the most important technique for diagnosis.

Role of Percutaneous Computed Tomography-guided Lung Biopsy in Non-resolving Consolidation and Identification of Clinical and High-resolution Computed Tomography Characteristics Predicting Outcome

Objective:

Non-resolving consolidation (NRC) with inconclusive sputum, bronchoscopy, and bronchoalveolar lavage results poses a diagnostic dilemma. This retrospective analytical study was conducted to evaluate diagnostic yield and complications of percutaneous computed tomography (CT)-guided lung biopsy (PCLB) in NRC. Assessment of clinical features and high-resolution CT (HRCT) characteristics was also done which may predict outcome.

Materials and Methods:

Data of PCLB performed for lung consolidation from January 2010 to January 2019 were retrospectively evaluated. For the determination of diagnostic yield, a positive result from any one specimen obtained by PCLB (tissue core, aspiration cytology, or microbiology) was sufficient to considered procedure diagnostic if it was concordant with clinical features, imaging findings, response to treatment, and subsequent follow-up. Student’s t-test and Fisher’s exact test were used for statistical analysis.

Results:

Out of total 56 patients, final diagnosis was achieved in 48 (19 malignant and 29 benign). Diagnostic yield was 69.6%. Complications were noted in 10 patients including mild hemoptysis and pneumothorax, which were managed conservatively. No clinical feature was having statistically significant association with final diagnosis. HRCT findings significantly associated with malignant outcome were larger size of consolidation, multiple contiguous lobe involvement, multiple air-filled cysts inside consolidation, and associated ground-glass areas or multiple ground-glass nodules. The absence of air bronchogram was more common in benign cases.

Conclusion:

PCLB is a safe and useful method for obtaining specimen in NRC. Differentiation of benign from malignant outcome is not possible based on clinical findings; however, certain HRCT findings raise suspicion of malignancy.

Predictors of Initial Smear-Negative Active Pulmonary Tuberculosis with Acute Early Stage Lung Injury by High-Resolution Computed Tomography and Clinical Manifestations: An Auxiliary Model in Critical Patients

This study evaluated the diagnostic use of high-resolution computed tomography (HRCT), chest X-ray (CXR), and clinical manifestations (CM) to identify initial smear-negative (iSN) active pulmonary tuberculosis (aPTB) [iSN-aPTB] in patients with iSN-pulmonary diseases (PD) and acute lung injury (ALI). In the derivation cohort, the [iSN-PD] with ALI patients were divided into the [iSN-aPTB] (G1, n = 26) and [non-aPTB-PD] (G2, n = 233) groups. Lung morphology, number, and lobar (segmental) distribution were evaluated using CXR and HRCT. A multivariate analysis was performed to identify independent variables associated with G1, which were used to generate predictive score models for G1. The predictive model was validated in a separate population of patients (n = 372) with [iSN-PD] and (ALI). The validated model for [HRCT (CXR + Hypoalbuminemia)] had 93.5% (25.8%) sensitivity, 99.5% (89.4%) specificity, and a negative predictive value of 99.5% (93.0%). For [iSN-aPTB], the post-test probability in the derivation cohort (prevalence = 10%), validation cohort (prevalence = 8.3%), and the given prevalence (prevalence = 1%) was 88.7%, 94.4%, and 41.5%, respectively. The HRCT model effectively identified the [iSN-aPTB] subjects among the [iSN-PD] with ALI, regardless of CM. The [non-aPTB-PD] were also correctly classified by the HRCT and [CXR + Hypoalbuminemia] models.

Bronchial Wash Gene Xpert MTB/RIF in Lower Lung Field Tuberculosis: Sensitive, Superior, and Rapid in Comparison with Conventional Diagnostic Techniques

BACKGROUND

Lower lung field tuberculosis (LLF TB) is an atypical presentation of tuberculosis (TB). LLF TB is common, and a proportionate number of non-resolving pneumonia cases are diagnosed to have pulmonary TB.

MATERIALS AND METHODS

The prospective observational study was conducted during June 2013 to December 2015 in the Department of Pulmonary Medicine, MIMSR Medical College, Latur, India; the objective of the study is clinical, microbiological, and radiological presentation of LLF TB and the comparison of yield of conventional diagnostic techniques and bronchoscopy-guided modalities in LLF TB. Additional important objective of the study is to find LLF TB in patients with nonresolving pneumonia (NRP). A total of 2,600 patients with pulmonary TB were included in the study after inclusion and exclusion criteria. Ethical clearance was taken from the ethical committee of the institutional review board. Consent was taken from the patients before inclusion in the study. Statistical analysis was done using chi-square test.

RESULTS

In the present study, 300 (11.53%) cases of LLF TB of total 2600 pulmonary tuberculosis were included, females constitutes 66.66% (200/300) with mean age of 58.4 ± 11.8 years and males constitutes 33.34% (100/300) with mean age of 56.8 ± 10.6 years. Constitutional symptoms were observed as cough in 93% cases, fever in 83% cases, shortness of breath in 72% cases, anorexia in 91% cases, and weight loss in 84% cases. Radiological assessment of study cases documented the involvement of right lower zone in 84% cases and left lower zone in only 16% cases. In the studied LLF TB cases, 57 cases (20.66%) were diagnosed by routine sputum microscopic examination for acid fast bacilli (AFB) and 80 cases (28%) were diagnosed by induced sputum microscopic examination for AFB. In the study of 170 LLF TB cases, head-to-head comparison between conventional diagnostic techniques (sputum microscopy and Induced sputum microscopy for AFB) made diagnosis in 60 cases, while bronchoscopy-guided sampling techniques (BAL for AFB and BAL for Gene Xpert MTB/RIF) made diagnosis in 155 cases (91.17%) (P < 0.00001). Comorbid conditions such as human immunodeficiency virus (HIV) coinfection in 36 cases (12.00%), Diabetes mellitus in 64 cases (21.33%), and chronic kidney disease (CKD) in 22 cases (7.33%) were observed. Comorbidities were observed in 41.67% of the studied cases and found very significant assessment to have successful treatment outcome (P < 0.00001). In the study of 300 LLF TB cases, 60 cases were having NRP pattern. In LLF TB cases with NRP pattern, bronchoscopy-guided bronchial wash microscopy for AFB made diagnosis in 18 cases (42%), while bronchoscopy-guided BAL for Gene Xpert MTB/RIF made diagnosis in 58 cases (96.66%) (P < 0.00001).

CONCLUSION

LLF TB is usually underdiagnosed because of diverse clinical and radiological presentation, less diagnostic yield of conventional diagnostic modalities, and these modalities used routinely and universally. Bronchoscopy-guided diagnostic techniques are superior, sensitive, and reliable to confirm LLF TB. Gene Xpert MTB/RIF in bronchial wash samples is found to be best diagnostic modality in evaluating LLF TB and should be used routinely to have successful treatment outcome. A proportionate number of NRP cases are having LLF TB and a high index of suspicion is a must while evaluating these cases.