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Denouement and Discussion: Tuberculosis Pneumonia With Endobronchial Tuberculosis
Figure 1. Anteroposterior chest radiograph shows right upper lobe consolidation.
Figure 2. Chest computed tomogram taken at the level of the carina shows low-density regions in the lung parenchyma, presumed to indicate caseous necrosis in the right upper lobe.
Figure 3. Direct coronal computed tomographic scan shows a polypoid mass (arrow) at the orifice of the right upper lobe bronchus.
Figure 4. Bronchoscopic view of the right main bronchus demonstrates granulation tissue with an ulcerated surface (arrow) obstructing the right upper lobe completely and causing narrowing of the bronchus intermedius.
Gastric lavage showed acid-fast staining bacilli on microscopy on 3 samples and produced growth of Mycobacterium tuberculosis. Endobronchial tuberculosis is present in 18% of adult patients with tuberculosis.1 Although uncommon in children, 30% to 70% of endobronchial lesions have been reported in children younger than 5 years.2,3 Endobronchial tuberculosis occurs without enlarged hilar or mediastinal lymph nodes. If suspicious for this disease, it is important to examine children by bronchoscopy to evaluate for the presence of endobronchial lesions and to achieve an early diagnosis.2,4 In contrast to children with clinically active tuberculosis who do not need isolation precautions, children with endobronchial tuberculosis are highly contagious. Delayed diagnosis in such circumstances leads to further dissemination and exposure of hospital personnel to the risk of infection.
The pathogenesis of endobronchial tuberculous remains speculative, and it is suggested that endobronchial tuberculosis lesions arise from direct implantation of the tubercle bacilli in the bronchus, infiltration from adjacent mediastinal lymph nodes, direct extension of peripheral tuberculous pneumonia, lymphatic or hematogenous spread, or a hypersensitivity reaction producing inflammatory granulation tissue or a polypoid mass.5
The diagnosis of pediatric pulmonary tuberculosis is based on epidemiological data, clinical features, tuberculin test results, chest radiographs, and identification and/or culture of M tuberculosis. Early diagnosis is only possible if tuberculosis is included in the initial differential diagnosis of pulmonary disease, and the strongest evidence of tuberculosis in children is recent exposure to an adult with active disease.
The relatively high incidence of endobronchial tuberculosis involvement in children suggests that bronchoscopy is extremely useful in the early diagnosis of tuberculous pneumonia. Pertinent bronchoscopic findings reported are granulation tissue, obstructive caseum, mucosal inflammation, and bronchial stenosis.2 Analysis of bronchoalveolar lavage (BAL) fluid is most useful for the isolation of M tuberculosis in sputum-negative pulmonary tuberculosis of adult patients. However, in a recent study of infected children comparing gastric and BAL cultures, M tuberculosis was isolated from 50% of gastric lavage samples vs 10% of BAL specimens indicating that gastric lavage remains the method of choice for isolation of tubercle bacilli in young children.6 The chemotherapy of tuberculosis is directed toward eradication of tubercle bacilli and prevention of emergence of drug-resistant strains of M tuberculosis, using multiple drugs for 6 to 9 months.7 There is a high likelihood of developing bronchial stenosis after recovery from active disease. Though corticosteroids have been used as an adjunct in treatment of tuberculous meningitis and pleural or pericardial effusions, their role in the treatment of endobronchial tuberculosis remains controversial.2,4 Endobronchial abnormalities have responded favorably to prednisolone therapy in 6 of 8 children treated,2 but Nemir et al8 reported corticosteroids were ineffective in reducing the incidence of residual fibrosis in children. Because endobronchial lesions are more commonly present in patients with prolonged undiagnosed or inadequately treated tuberculosis, optimal management requires early diagnosis and adequate treatment of the primary pulmonary disease.
Accepted for publication April 4, 1997.
Reprints: Kin-Sun Wong, MD, Department of Pediatrics, Chang Gung Children's Hospital, 5 Fu Hsin St, Taoyuan, Taiwan, Republic of China.
Radiological Case of the Month. Arch Pediatr Adolesc Med. 1998;152(8):822. doi:
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