Endobronchial tuberculosis is a specific inflammatory lesion of the bronchial wall caused by M. tuberculosis and usually complicates the course of tuberculosis of the intra–thoracic lymph nodes (VGLU) and lungs. Disease is characterized by an uncupable paroxysmal cough with the release of scanty sputum, chest pain, shortness of breath, hemoptysis. The diagnosis is made taking into account the data of X-ray tomography, bronchography and bronchoscopy, tuberculin diagnostics. Treatment of endobronchial tuberculosis is carried out with anti-tuberculosis antibiotics, which can be administered systemically and topically (inhalation, intratracheobronchial).
ICD 10
A16.4 Tuberculosis of the larynx, trachea and bronchi without mention of bacteriological or histological confirmation
Meaning
Endobronchial tuberculosis is a clinical and morphological form of tuberculosis of the respiratory organs, the leading sign of which is infiltrative, ulcerative or fistulous lesion of the walls of the bronchi. It may occur during the primary tuberculosis process or develop a second time, as a complication of active pulmonary tuberculosis and HCV. It is often combined with tuberculosis of the trachea and larynx. Sex and age differences in the incidence of endobronchial tuberculosis are not pronounced, however, it is known that vaccinated children have bronchial lesions 2.4 times less often than unvaccinated children.
According to statistics, most often (in 13-20% of cases) tracheobronchial tuberculosis is complicated by fibrous-cavernous pulmonary tuberculosis, somewhat less often (in 9-12%) cavernous and disseminated, even less often (in 4%-12%) – infiltrative and focal tuberculosis. All this dictates increased alertness regarding the possible development of endobronchial tuberculosis in persons with other forms of respiratory tuberculosis.
Causes of endobronchial tuberculosis
As an independent form, endobronchial tuberculosis is rare. More often, they complicate the course of destructive forms of pulmonary tuberculosis, tuberculous bronchoadenitis and primary tuberculosis complex. Infection of the bronchial tree with Mycobacterium tuberculosis can occur in the following ways:
- contact – with the germination of granulations from the affected lymph nodes into the bronchial wall;
- bronchogenic – when infected sputum is excreted through the bronchi in patients with destructive forms of tuberculosis;
- lymphogenic – when mycobacteria are dispersed along the peribronchial lymphatic pathways in patients with tuberculosis of VGLU;
- hematogenic – with the spread of mycobacteria through the peribronchial blood vessels in extrapulmonary or miliary tuberculosis.
Pathogenesis
When the bronchus is perforated with caseous masses, infiltration of the bronchial mucosa is noted at the initial stage, against which specific epithelioid granulomas are formed. The perforation can be so microscopic that it is not even visualized during bronchoscopy. Nevertheless, together with caseous particles, a significant amount of MW can enter the bronchial lumen, leading to aspiration of infected material and the development of aspiration caseous pneumonia. Healing occurs with the formation of scar tissue at the site of perforation, which leads to deformation and stenosis of the trachea and bronchi, the development of pneumosclerosis and violations of pulmonary ventilation.
In the case of bronchogenic infection, the bronchi draining the cavity are primarily involved in the process. At the same time, hyperemia and swelling of the bronchial mucosa, swelling of the submucosal layer develops; the function of the atrial epithelium and bronchial glands is disrupted, as a result of which a large amount of mucous secretion accumulates in the bronchial lumen. Sometimes ulcerative defects form against the background of bronchial infiltration, which heal with the formation of a scar. In tuberculosis of the bronchi, segmental-subsegmental branches or large bronchi (lobular, intermediate, main, bifurcation area) may be affected.
Classification
In phthisiopulmonology, infiltrative, ulcerative and fistulous (fistulous) pathomorphological forms of endobronchial tuberculosis are distinguished.
- Infiltrative form. The lesion of the bronchial wall can be traced for a limited length; the area of thickening and hyperemia has a rounded or elongated shape; at this point, the cartilaginous pattern of the bronchus is not differentiated, but the lumen of the bronchus may not change. Bacillus excretion, as a rule, is not observed.
- Ulcerative form. The mouths of segmental and lobar bronchi are more often affected. With productive inflammatory reactions, ulcerative defects are limited, superficial, having a smooth or granulated bottom. If the inflammatory reaction has an exudative-necrotic character, the ulcers are deep, bleeding, with a bottom covered with a dirty gray coating. Bacterial excretion is noted more often.
The fistulous form of endobronchial tuberculosis is formed when a lymph node breaks into the bronchial wall. The lymphobronchial fistula has a funnel-shaped shape; when pressed, whitish-yellow caseous masses are released. Calcium crystals can penetrate through the fistula from the lymph nodes into the bronchi. Bronchitis can obstruct small bronchi, contributing to the development of lung atelectasis and, in the future, bronchogenic cirrhosis of the lung.
Symptoms of endobronchial tuberculosis
In the vast majority of cases (98%) tuberculosis is chronic, subacute and acute course is rarely observed (2%). The clinical picture of endobronchial tuberculosis is determined by its form, localization, the presence of complications, lung tissue lesions.
In its classic version, tracheobronchial tuberculosis proceeds with a persistent cough that does not stop after taking antitussive drugs. Cough is paroxysmal, barking, disturbs the patient day and night, accompanied by the separation of non-abundant viscous mucus of a mucous nature, odorless. With ulcerative form, hemoptysis may occur. In the case of bronchial stenosis, breathing becomes whistling, shortness of breath develops. Other characteristic signs of endobronchial tuberculosis are pain and burning, localized behind the sternum, between the shoulder blades.
The infiltrative form of endobronchial tuberculosis may be asymptomatic or with scant clinical signs. Common infectious symptoms associated with pulmonary tuberculosis (fever, night sweats, weight loss) in tuberculosis of the bronchi, they are expressed moderately or absent. Of the complications of tracheobronchial tuberculosis, bronchopneumonia, tracheal and bronchial stenosis, bronchiectasis are most common. When the bronchial lumen is obstructed by bronchitis, the clinic may resemble bronchitis, a foreign body, a bronchial tumor.
Diagnostics
Patients with endobronchial tuberculosis at the time of diagnosis, as a rule, are already registered with a phthisiologist. Endobronchial tuberculosis is detected much less frequently during routine fluorography, in long-term feverish individuals, patients with persistent cough and unmotivated hemoptysis. Targeted examination is carried out in an antitubercular dispensary.
- Radiation methods of examination. Radiography and CT of the lungs reveals destructive lung damage, bronchial deformity, areas of hypoventilation and atelectasis. Secondary bronchial changes (stenosis, bronchiectasis) they are detected during bronchography.
- Bronchial endoscopy. Fibrobronchoscopy allows you to determine the localization and form of the process: catarrhal endobronchitis, infiltrative, ulcerative, cicatricial mucosal lesion, bronchial fistula. However, even the absence of endoscopic signs of a specific lesion does not exclude the diagnosis of endobronchial tuberculosis. To confirm the fact of bacterial excretion, a study of sputum and lavage fluid for the presence of MBT allows.
- Specific tests. The results of tuberculin diagnostics are most often characterized by a hyperergic reaction, but it most often reflects the activity of the process in the lungs. ELISA diagnostics is used – determination of gamma interferon in the blood (quantiferon test) or sensitized T-lymphocytes (T-SPOT.TB).
Differential diagnosis of endobronchial tuberculosis is performed with nonspecific bronchitis and tracheobronchitis, Beck’s sarcoidosis, bronchial foreign bodies, silicotuberculosis, endobronchial tumor, bronchial syphilis. To verify the nature of changes in the bronchi, bronchoscopy with biopsy and morphological examination of pathological areas are performed.
Endobronchial tuberculosis treatment
The detection of tracheobronchial tuberculosis indicates a complicated course of the pulmonary process, therefore, the therapeutic effect on the body should be complex and enhanced. Various combinations of anti-tuberculosis drugs are used in treatment courses. The duration of treatment of infiltrative or ulcerative tuberculosis of the bronchi is 3-6 months; the fistula form is 8-10 months. Corticosteroids are used as pathogenetic therapy to reduce infiltration and swelling of the mucosa.
In endobronchial tuberculosis, in addition to systemic administration of chemotherapy drugs, local therapy is used: in a localized process, endobronchial administration of chemotherapy drugs, in a widespread lesion, aerosol therapy. Methods of local exposure may also include sanitization bronchoscopy with removal of caseous masses and washing of the bronchi, diathermocoagulation or cauterization of granulations with trichloroacetic acid, laser therapy of the bronchial mucosa. With the development of cicatricial bronchostenosis of the II and III degrees, the question of surgical treatment is raised: stenting, bronchial plasty or lung resection. During the rehabilitation period, sanatorium-resort and climatic treatment are shown.
Forecast
The course and outcome depend on the form of tuberculosis of the lungs and bronchi. In more than 80% of cases, with proper treatment, there is a clinical cure of endobronchial tuberculosis. To prevent relapses during the next 2 years, specific chemoprophylaxis is carried out in spring and autumn.
Literature
- Therapeutic management of endobronchial tuberculosis. Rikimaru T. Expert Opin Pharmacother. 2004 Jul;5(7):1463-70. link
- Endobronchial tuberculosis manifested as obstructive airway disease in a 4-month-old infant. Abdulla F, Dietrich KA. South Med J. 1990 Jun;83(6):715-7. link
- Endobronchial tuberculosis. Lee P. Indian J Tuberc. 2015 Jan;62(1):7-12. link
- Bilateral multiple tumor-like endobronchial tuberculosis, diagnosed with bronchoscopic examination. Saygıdeğer Y, Oktay B, Sevgi E, Sever Ö, Fırat H, Ardıç S. Tuberk Toraks. 2011;59(3):266-70. link
- Actively caseating endobronchial tuberculosis successfully treated with intermittent chemotherapy without corticosteroid: a report of 2 cases. Panigrahi MK, Pradhan G, Mishra P, Mohapatra PR. Adv Respir Med. 2017;85(6):322-327. link
