CASE PRESENTATION

Dr. Nurçin Çimen

Private Beylikdüzü Kolan Hospital-İstanbul

Conflict of Interest Declaration

I hereby declare that;

No stocks, shares or employment in a commercial

No membership in advisory board or focus group

No honorarium payment received for speech, publication or editorials

No education nor research grants

No congress or symposia sponsorship

• U.T

• 22 years, male

• Computer programmer

• Born in İstanbul, lives in İstanbul

COMPLAINTS

• Cough

• Sputum

• Fever

MEDICAL STORY

Complaints began 1 week ago, with cough, dark

colour sputum. He also had fever of about 39 °C.

Postnazal seromucoid secretion and fragility at

Little area was detected in ENT examination.

Cefuroxim aksetil 500 mg tb 2x1, pseudoephedrine

HCL+ Setrizine HCL tb 2x1, had begun to the

patient by ENT because of hemorragic nasal

secretion 3 days ago.

Medical History: No special feature

Family History :No special feature

Habits: No smoking, Rare alcohol intake

PHYSICAL EXAMINATION

Conscious, coopered, oriented

Blood Pressure: 120/70mmHg

Pulse: 100/dak

Fever: 38.5°C

Tiroid palpabl

No peripheral LAP

Respiratory system examination:

RR:18/min

Expiratory duration was increased bilaterally and

respiratory sounds were decreased at right lower lob

Bilateral CDS open

LABORATORYHb:12.7 g/dL (14-17.5)

Hct:% 37.9 (40-52)

WBC:11.1x10³/uL (4.4-11.3)

RBC:4.50x106/uL(4.5-5.9)

PLT:346x10³/uL(135-486)

ESR: 82 mm/h

CRP: 8.65 mg/dL (0.01-0.82)

IgE: 146 IU/mL (<100)

Alb:3.3 g/dL (3.5-5)

Chest X ray (03.06.2011)

CHEST X-RAY:

Enlargement of right hilar zone and irregular

opasity of about 1,5 x1,5 cm at infrahilar area .

WHAT IS YOUR PREDIAGNOSIS?

A-Wegener’s Granulomatosis

B-Pulmonary Artery Aneurysm (Behçet's Disease)

C-Lung Cancer

D-Lymphoma

E-Tuberculosis

Ampicillin- sulbactam 1 g 4X1 (IV) treatment began

to the patient with CAP prediagnosis (3.6.2011).

Fever of the patient did not decreased in 3 days

eventough to the treatment.

There were non significant decrease in CRP levels .

There were no significant improvemet in control chest

X-ray.

Chest X-ray (06.06.2011)

Which diagnostic tests would you perform?

A-Sputum gram staining- culture

B-Sputum ARB (Direct-culture)

C-Thorax CT

D-Bronchoscopy

E-All of them

• Sputum gram staining: Epithelial cells, gram

positive chain forming cocci, rare gram positive

bacilli.

• Aerop culture: Alpha hemolytic streptococci.

• Antibiogram: sensitive to penicillin, ceftriaxsone,

erythromycin, vancomycin, levofloxacine.

• Sputum ARB: 3 times negative

Thorax CT:Subcarinal- paraeosaphageal, right hilar and

intrapulmoner soft tissue (LAP), heterogenous dansity with

air bronchograms at right lung lower lob paramediastinal

area, and parenchymal infiltrations nearby.

Irregularity at lower lob basal segment becouse of LAP and

consolidation.

WHAT IS YOUR PREDIAGNOSIS?

A-Wegener’s granulomatosis

B-Lymphoma

C-Lung cancer

D-Tuberculosis

E-Carcinoid tumor

Sputum tuberculosis culture (MGIT): Sterile

Blood culture: Sterile

Which diagnostic test would you perform ?

A-Sputum Cytology

B-c-ANCA, p-ANCA

C-PET-CT

D-Bronchoscopy

E-Mediastinoscopy

PET-CT (07.06.2011)

PET-CT:

Increased pathological FDG (Early SUV max:16.1 , Late SUV

max: 19.4) at right lower lob paramediastinal heterogenous dansity

consolidation and infiltration areas.

Pathological FDG (Early SUV max: 14.9, Late SUV max: 21.7)

(metastasis?) at subcarinal, paraeosophageal, right hilar and

intrapulmoner conglomerated lymph nodes .

BRONCHOSCOPY (06.06.2011)

BRONCHOSCOPY:

Main carina deviated to the right, norrowing of the left side wall

of the intermediair bronchus by extrinsic compresssion.

Endobronchial lesion at the entrance of right lower lob, causing

bulging at the posterior wall, with nodularity and mucosal

infiltration on it.

Right system lavage , and forceps biopsy from the lesion is taken.

TBNA was not performed because of hemorrage.

YOUR DIAGNOSIS?

A-Lung Cancer

B-Sarcoidosis

C-Lymphoma

D-Tuberculosis

E-Wegener’s Granulomatosis

Right lower lob lesion biopsy: Necrotizing granulomatous bronchitis

PATHOLOGY:

Bronchial Lavage Microbiology :

Gram Staining: Epithelial cells, gram positive chain

forming cocci, rare gram positive bacilli.

Aerop Culture: Growth of normal flora of throat .

Fungal culture: No growth of pathogen fungi.

EZN Staining: No asid resistant microorganism

Tuberculosis culture (MGIT): Growth of

Mycobacterium tuberculosis.

According to the information obtained from Tuberculosis

Contol Dispansery registrations;

Antitb treatment had begun to the patient at 21.06.2011 at I.U

Istanbul Medical Faculty. There were no problem during follow

up, and kontrol chest X ray was reported to be normal.

It ıs the tracheobronchial tree tuberculosis infection

proved with microbiologic and histopathologic findings*.

According to the autopsy results bronchial tuberculosis

causing atelectasis and consolidation in lung parenchyma

and involving the bronchi is about 40-80% **.

* Yılmaz A, Alıcı O.İ, Demirci N.Y ve ark. Radyolojik Olarak Maligniteyi Taklit Eden Endobronşiyal Tüberküloz

Olgularının Klinik ve Bronkoskopik Özellikleri.Solunum 2011; 13(3): 170–175

** Yosunkaya Ş, Gök M. Akciğer kanseri ile karışan iki endobronşial tüberküloz olgusu . Genel Tıp Derg

2005;15(3):125-128

Endobronchial Tuberculosis (EBTB)

It is one of the complications of pulmonary tuberculosis *.

Endobronchial tuberculosis development insidence is about

5.88 % **.

Real insidence?

* Park MJ, Woo IS, Son JW, et al. Endobronchial tuberculosis with expectoration of tracheal cartilages. Eur RespirJ 2000;15:800-2.

**Chung HS, Lee JH. Bronchoscopic assessment of the evolution of endobronchial tuberculosis. Chest2000;117:385-92.

In our country age distrubution is different from west countries.

In the study of Tahaoğlu and coworkers ıt is reported to be more

frequent in the second and third decades*.

* Tahaoğlu K, Kızkın Ö, Karagöz T ve ark. Endobronşial tüberküloz. Solunum 1993;18:146-53.

Pathogenesis of EBTB is not fully understood.

Five potential mechanisms*:

• Direct extension from adjacent parenchymal focus,

• Implantation of organisms from the infected sputum,

• Hematogenous dissemination,

• Lymph node erosion into the bronchus,

• Through lymphatic drainage from parenchyma to the

peribronchial region.

*Kashyap S, Mohapatra PR, Saini V. Endobronchial tuberculosis.Indian J Chest Dis Allied Sci 2003;45:247-256

Clinical findings are various* ;

cough and sputum production, wheezing , chest pain and fever is

mostly seen during active disease ,

at fibrosis stage dyspnea and wheezing are the main symptoms.

Most frequent symptom is cough **.

* Baran A, Akbaba B, Bilgin S ve ark. Endobronşiyal Tüberküloz: Klinik ve Bronkoskopik Özellikleri.Akciğer Arşivi 2007; 8: 44-7.

** Akman M, Yılmaz T, Çelik N ve ark. Akciğer kanserini taklit eden endobronşiyal tüberküloz. Solunum Hastalıkları 1995;6:441-9.

Differantial Diagnosis of EBTB

• Lung Cancer

• Pneumonia

• Bronchial asthma

• Foreign body

• Athelectasis

• Karsinoid tumour

• Fungal infections

• Lymphoma

• Sarcoidosis

Bacteriologic diagnosis is limited in endobronchial tuberculosis *.

In studies performed in our country bacille positiviy rate is about

14-50% **

* Ip MSM, So SY, Lam WK, Mok CK. Endobronchial tuberculosis revisited. Chest 1986; 89:727-30.

** Kırkıl G, Deveci F, Muz H ve ark Akciğer Kanserini Taklit Eden Endobronşiyal Tüberküloz Olgusu Solunum Hastalıkları2006;17: 88-91.

Radiologic findings are various*;

hilar and perihilar mass,

athelectasis and mediastinal enlargement.

Right lung involvement, especially upper lob is more frequent .

*Kurasawa T, Kuze F, Kawai M, et al. Diagnosis and management of endobronchial tuberculosis. Intern Med 1992;31:593-8.

Saygı et al reported twenty-nine patients with EBTB aged between

12-76. Bronchoscopic examination revealed involvement of

EBTB most frequently at right upper and right main bronchus in

51.7% of the subjects.

In the differential diagnosis of chronic cough resistant to

antitussive therapy, EBTB must be explored in order to prevent

complications*.

*Saygı A, Süngün F, Çağlayan B ve ark. Endobronşial Tüberküloz Olgularının Retrospektif İncelenmesi . İstanbul Tabip

Odası-Klinik Gelişim Dergisi  Cilt 9 / No: 12 / Aralık1996 

The most frequent bronchoscopic finding is ulceration with mucosal hyperemia and erosion , and granulation tissue *.

Chung and co-workers classified to seven subtypes according to bronchoscopic findings **.

* Saleemi S, Khalid M, Zeitouni M, Al-Dammas S. Tuberculosis presenting as endobronchial tumor. Saudi Med J 2004;25:1103-5.

** Chung HS, Lee JH, Han SK, et al. Classification of endobronchial tuberculosis by the bronchoscopic features. Tuberc Respir Dis 1991;38:108-15.

Classified to seven subtypes according to bronchoscopic findings (I) Actively caseating , (II) Edematous - hyperemic,

(III) Fibrostenotic, (IV) Tumorous, (V) Granular, (VI) Ulserative, (VII) Nonspecific bronchitis (Atatürk Göğüs

Hastalıkları ve Göğüs Cerrahisi Eğitim ve Araştırma Hastanesi 7. Göğüs Hastalıkları Kliniği arşivinden)*

*Yılmaz A, Alıcı O.İ, Demirci N.Y ve ark. Radyolojik Olarak Maligniteyi Taklit Eden Endobronşiyal Tüberküloz

Olgularının Klinik ve Bronkoskopik Özellikleri. Solunum 2011; 13(3): 170–175

I II III

IV V VI VII

THANK YOU …