Endobronchial Tuberculosis as a Cause of Refractory Wheezing

Abstract

INTRODUCTION: Endobronchial tuberculosis is more common in children than adults. It can present as bronchial ulcerations, hyperemia and mass lesions with obstruction. In patients with pulmonary tuberculosis, endobronchial involvement can be seen in 20-30% of the patients, with a higher incidence in women and HIV positive patients. We report a rare case of endobronchial tuberculosis masquerading as refractory asthma. CASE PRESENTATION: A 48 years old Guyanese female, non-smoker with history of hypertension and recently diagnosed mild intermittent asthma on albuterol MDI as needed, presented with complaints of worsening of her wheezing over four weeks. She denied weight loss, fever, chills or night sweats. No known Tuberculosis exposure. Her vitals were normal. Physical examination significant for diffuse bilateral expiratory wheezing. Laboratory investigations revealed normal complete blood count, kidney and liver functions. CXR showed bilateral upper lobe reticular nodular changes. A CT scan of the chest revealed bilateral cavitary lesions. Urine histoplasma antigen, ANCA, aspergillus antibody,HIV and hypersensitivity panel were negative. A tuberculin skin test and Quantiferon TB Gold test were positive. Three sputum samples for acid-fast smear were negative. High dose corticosteroids were started and a fiberoptic bronchoscopy was performed. Left bronchial inspection showed a large whitish fungating endobronchial lesion, occluding about 85% of the left main bronchus lumen. Inspection of the remaining bronchial tree similarly showed scattered whitish fungating patches that would not clear with normal saline washings. Biopsies of this large lesion showed necrotizing granuloma. Stains for acid-fast bacilli were positive. DISCUSSION: The association of endobronchial tuberculosis with hyperreactive airways has been described in patients with a known history of pulmonary tuberculosis. The differential diagnosis includes endobronchial tumors, wegeneraTMs granulomatosis, coccidiomycosis, histoplasmosis, and actinomycosis. Early introduction of antituberculous therapy is crucial to cure the patient. Endobronchial TB is treated with rifampin, isoniazid, ethambutol and pyrazinamide for nine months. Addition of corticosteroids is appropriate when airway compromise is present. Inhalation therapy with isoniazid or streptomycin was shown to be helpful in preventing stenosis in selected cases. For bronchial stenosis, bronchoscopic balloon dilatation with or without stent placement is needed. Our patient improved dramatically with her antituberculosis regimen. The corticosteroids she received initially may have had a role in preventing the complications of bronchial stenosis. CONCLUSIONS: We advocate including endobronchial tuberculosis in the differential diagnosis of immunocompetent patients presenting with a refractory wheeze.