Case presentation Treatment of Endobronchial Tuberculosis

1
Case presentationTreatment of Endobronchial
Tuberculosis

• Ri ???/Vs???

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Chief complaint

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

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Past history

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

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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

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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

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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

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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

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Lab

• WBC 12820/uL
• Sputum culture
• Pseudomonas aeruginosa (2)
• Staphylococcus aureus (2)

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Chest X-ray

• No definite focal lung lesion and sharp CP
  angles. Normal heart size. Mild scoliosis.  

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CT
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Bronchoscopy

• severe stenosis of left main bronchial orifice

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Clinical course

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

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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.

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Discussion

• Treatment of Endobronchial Tuberculosis

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Epidemiology of EBTB

• extensive pulmonary TB, particularly cavitary
  lesions
• Asia
• Female
• LMB

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Pathogenesis

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

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Symptoms and sign

• barking cough
• bronchorrhea
• Wheezing and hemoptysis
• chest pain
• Dyspnea

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Differential diagnosis

• bacterial pneumonia,
• asthma
• foreign body aspiration
• bronchogenic carcinoma

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Treatment of EBTB

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

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Staged dilatation and stenting
The Journal of Thoracic and Cardiovascular
Surgery ? December 2003
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Complication of Stenting

• Granulation
• Migration
• Recurrence
• Infection
• Bronchospasm
• Mucosa laceration

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J O U
J R Soc Med 2005982628
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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

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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. 199731(2)79-82
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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
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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
27

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

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

• Chest tightness and SOB on 8/29
• Bronchoscopy remove granulation tissue
• Chest care siruta, venalot, transamine
• Pain control
• Depain, neurontin, naposin, sinequan

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Current bronchosopy
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Plan

• Post op chest care
• Pain control
• Infection control

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Thanks for your attention
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World J. Surg. Vol. 21, No. 5, June 1997