Case presentation Treatment of Endobronchial Tuberculosis

Ri //Vs

Chief complaint
This is a 35 year old female Progressive dyspnea and discomfort in recent days

Past history
Old TB with complete treatment in 2005 Peptic ulcer history Herpes zoster, at trigeminal nerve V1 territory, left Allergy: Targocid, vancomycin

Brief history
2005.07: endotracheal bronchial tuberculosis (EBTB) mainly at left bronchus, dx at hospital 2006-4-13:
Dyspnea and chest tightness

bronchoscopy + Tracheostomy 2009-4-24: left main bronchus dilatation and stenting for chest tube

Brief history
2006-4-24: LMB dilatation and stenting with endotracheal tube 2006-5-23:
LMB with diameter 10mm

HOOD bronchial stent at left main bronchus Remove tracheostomy 2006-10-23:

Total obstruction of LMB and sputum MRSA(+)

Hood stent removal and new-on tracheostomy stent 2007-2-2:

Remove granulation tissue

Brief history
2007-5-10 : Nd-YAG laser resection of granulation tissue Hemoptysis and continuous oozing from the tracheostomy (Bosmin) Angiography: hyperemic change at the distal trachea (intra-arteral vasopressin) 2007-7-6 Balloon dilatation 2007-8-15: Exertional dyspnea and productive cough

Physical examination
General appearance: fair Consciousness: clear Vital signs: stable HEENT: gross normal, conjunctiva: pinky, Sclera: anicteric Neck: supple, LAP(-), JVE(-). Chest: symmetric expansion, breath sounds: bilateral wheezing, expecially left Heart: RHB, heart sound: no murmur Abdomen: inspection: soft, flat, tenderness(-), Bowel sound: normoactive Extremities: no edema

Lab
WBC: 12820/uL Sputum culture:
Pseudomonas aeruginosa (2+) Staphylococcus aureus (2+)

Chest X-ray
No definite focal lung lesion and sharp CP angles. Normal heart size. Mild scoliosis.

CT

Bronchoscopy
severe stenosis of left main bronchial orifice

Clinical course
8/16: mild vesicles on forehead and headache 8/17: acyclovir for recurrent herpes zoster 8/27: operation

Operation note
Op dx: recurrent left main bronchus stenosis s/p tracheostomy stenting & dilation Op method: posterolateral thoracotomy for Lt main bronchus segmental resection & end to end anastomosis Op finding: a 3 cm long stenosis from LMB orifice to second carina: fibrosis and wall thickening, adhesion (-) the stenosis was very severe and only a small hole at orifice.

Discussion
Treatment of Endobronchial Tuberculosis

Epidemiology of EBTB
extensive pulmonary TB, particularly cavitary lesions Asia Female LMB

Pathogenesis
inoculation of tubercle bacilli from pulmonary parenchymal tuberculosis directly into the bronchus. direct infiltration from adjacent mediastinal nodes with adenopathy. (children)

Symptoms and sign

barking cough bronchorrhea Wheezing and hemoptysis chest pain Dyspnea

Differential diagnosis
bacterial pneumonia, asthma foreign body aspiration bronchogenic carcinoma

Treatment of EBTB
Anti-tuberculous chemotherapy (with steroids ? ) Balloon dilation Staged dilatation and stenting laser photoresection surgical resection

Staged dilatation and stenting

The Journal of Thoracic and Cardiovascular Surgery

December 2003

Complication of Stenting
Granulation Migration Recurrence Infection Bronchospasm Mucosa laceration

J R Soc Med 2005;98:2628

Surgery treatment
1 died from pulmonary edema 7 anastomotic stenosis
1 re-op 6 endoscopic dilatation 1 died massive bleeding after endosopic dilatation

Slight to moderate stenosis

Restoring pulmonary function

Surgery for EBTB

32 patients in VGH
13 segmental resection or lobectomy with bronchoplasty
1 anastomotic stenosis ,s/p pneumonectomy 5 years later 1 patient had wound infection.

19 patients underwent pulmonary resection without bronchoplasty. All of the patient are symptom free and with significant improved FEV
Scand Cardiovasc J. 1997;31(2):79-82

Surgery treatment
19 patients in Department of Surgery, Kanazawa University School of Medicine
5 pneumonectomy 7 sleeve + lobectomy All of the patient with brochoplaty have long term survival without evidence of recurrence
World J. Surg. Vol. 21, No. 5, June 1997

Surgery treatment
Active phase/ Healing phase No definite indication Inagaki et al. : performed surgery in 41 (22.9%) of 179
pneumonectomy in 13, lobectomy in 7, tracheobronchoplasty in 21.
World J. Surg. Vol. 21, No. 5, June 1997

 Surgery followed by anti-TB treatment is the best modality to EBTB bronchus stenosis.

World J. Surg. Vol. 21, No. 5, June 1997

Current problem
Chest tightness and SOB on 8/29
Bronchoscopy remove granulation tissue Chest care: siruta, venalot, transamine

Pain control
Depain, neurontin, naposin, sinequan

Current bronchosopy

Plan
Post op chest care Pain control Infection control

Thanks for your attention

World J. Surg. Vol. 21, No. 5, June 1997