|Year : 2023 | Volume
| Issue : 2 | Page : 167-169
Infantile tubercular endobronchial polypoid obstructive lesion
Vinay Kumar Konamme, BC Gowrishankar, M Narendra Babu
Department of Pediatric Surgery, Indira Gandhi Institute of Child Health, Bengaluru, Karnataka, India
|Date of Submission||16-Jul-2022|
|Date of Decision||17-Nov-2022|
|Date of Acceptance||20-Nov-2022|
|Date of Web Publication||03-Mar-2023|
Vinay Kumar Konamme
Indira Gandhi Institute of Child Health, Bengaluru, Karnataka
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Endobronchial tuberculosis is reported in 18% of adults and 30%–60% of children with primary pulmonary tuberculosis. We are reporting two infants who presented with nonspecific respiratory symptoms due to an obstructive tubercular polypoid mass which was detected on computed tomography. Bronchoscopy showed a pale friable polypoid lesion in the bronchus causing a luminal obstruction. The biopsy of the lesion was suggestive of tuberculosis. On treatment with antitubercular medications, both the babies improved and remained asymptomatic on long-term follow-up.
Keywords: Bronchial obstruction, bronchoscopic biopsy, endobronchial tubercular polypoid lesion, infantile tuberculosis
|How to cite this article:|
Konamme VK, Gowrishankar B C, Babu M N. Infantile tubercular endobronchial polypoid obstructive lesion. J Indian Assoc Pediatr Surg 2023;28:167-9
|How to cite this URL:|
Konamme VK, Gowrishankar B C, Babu M N. Infantile tubercular endobronchial polypoid obstructive lesion. J Indian Assoc Pediatr Surg [serial online] 2023 [cited 2023 Mar 29];28:167-9. Available from: https://www.jiaps.com/text.asp?2023/28/2/167/371173
| Introduction|| |
Endobronchial tuberculosis, which is a tuberculous infection of the tracheobronchial tree, is reported in 18% of adults and 30%–60% of children having primary pulmonary tuberculosis. It has a varied presentation in children. Nonspecific respiratory symptoms such as breathlessness, hurried breathing, and cough are the common modes of presentation. Typical symptoms of pulmonary tuberculosis such as evening rise in temperature, weight loss, and chronic cough might not be present in most of them. Early detection and treatment have good outcomes. In this article, we are reporting two infants with obstructive tubercular polypoid masses who were successfully managed along with a review of the pertinent literature.
| Case Reports|| |
Case report 1
A 6-month-old female child was brought to the hospital with tachypnea and cough for 10 days. Decreased air entry on the left side with no added sounds was noted clinically. X-ray was suggestive of the hyperinflation of the left lung suggestive of a left bronchial obstruction or congenital lobar emphysema [Figure 1]a. Computed tomography (CT) of the chest showed a complex necrotic mass lesion splaying the carina and a doubtful bronchial narrowing/obstruction, leading to hyperinflation of the corresponding lobe [Figure 1]b and [Figure 1]c. Possibilities of lymphoma, tubercular lymphadenitis, and complicated bronchogenic cyst were considered. Complete blood count, peripheral smear, and erythrocyte sedimentation rate were normal. Tuberculosis workup was negative and the child had received Bacillus Calmette–Guérin vaccination as per the immunization schedule. The retroviral status of the baby and the mother was negative.
|Figure 1: (a) X-ray picture at the time of presentation showing left lung hyperinflation, (b and c) coronal CT picture showing subcarinal necrotic mass compressing the left main bronchus, (d) bronchoscopic picture showing a polypoid friable lesion which bleeds on touch, (e) few AFB, and (f) follow-up X-ray after 1 month of antitubercular medications. CT: Computed tomography|
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The baby was planned for diagnostic bronchoscopy followed by thoracoscopic excision of the subcarinal mass if bronchoscopy did not yield any significant information.
On bronchoscopy [Figure 1]d, a pale polypoid lesion in the left main bronchus, leading to luminal obstruction was seen. There was no foreign body. Only scanty tissue could be retrieved for biopsy as the lesion was small, friable, and had a tendency to bleed on touch similar to any granulation tissue. Histopathological examination revealed a few acid-fast bacilli suggestive of endobronchial tuberculosis (paucibacillary type) [Figure 1]e. The baby was started on a 6-month regimen of antitubercular medications. On the 1-month follow-up [Figure 1]f, the obstructive emphysema features resolved and the baby was symptom-free. After completion of treatment, on 1-year follow-up, the child is doing well.
Case report 2
A 4-month-old female child was brought with a 10 days history of cough, fever, and hurried breathing. There was reduced air entry with occasional crepitations in the right lower zone. X-ray showed features of the right lower lobe collapse with consolidation [Figure 2]a. The baby was treated as a case of pneumonia with IV antibiotics for 7 days. Since there was no improvement seen on repeat X-ray, a CT thorax was done [Figure 2]b. It was suggestive of the right lower lobe collapse with a possible right main bronchial obstruction. A probable diagnosis of mucus plug/endobronchial tumor/tuberculosis/foreign body aspiration was considered.
|Figure 2: (a) X-ray showing the right lower and middle lobe consolidation, (b) HRCT picture showing consolidation with air bronchogram in the right middle and lower lobe with a polypoid mass-like lesion in the right main bronchus, (c) polypoid mass lesion in the right main bronchus on bronchoscopy, (d) ZN stain showing few acid-fast bacilli (arrow), and (e) areas of extensive necrosis (black arrow) and ill-formed epithelioid granuloma (white arrow). HRCT: High-resolution computed tomography|
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Bronchoscopy [Figure 2]c revealed a pale friable polypoid lesion in the right main bronchus causing an obstruction which would bleed on touch, similar to the lesion described in the previous child. Moreover, a biopsy was suggestive of endobronchial tuberculosis (paucibacillary type) with ill-formed granulomas [Figure 2]d and [Figure 2]e. The baby was started on a 6-month protocol regimen of antitubercular drugs and on follow-up, the X-ray showed satisfactory expansion of the right lower lobe. The child is doing well and asymptomatic on a 6-month follow-up.
| Discussion|| |
Tracheobronchial involvement in tuberculosis was first reported by an English physician, Richard Morton in 1698. Most of the symptoms are nonspecific in children which may lead to a delay in the diagnosis. The common symptoms are breathlessness, cough, or failure to thrive. X-ray is the initial investigation. CT scan is a useful modality which will help in deciding on early bronchoscopy. A bronchoscopic biopsy is the most important investigation in diagnosis.
In all children from countries like India who present with luminal obstruction of the bronchus requiring a bronchoscopy, if a small fleshy, friable, polypoid lesion is seen; we believe that the tissue sample must be collected for histopathological analysis early in the procedure. This prevents specimen loss by repeated suctioning, thereby leaving behind very little tissue later on for analysis. It must not be mistaken for granulation tissue over chronic foreign bodies. This may cause a delay in diagnosis and treatment.
The possible pathological mechanisms for the formation of a tuberculous obstructing polypoid lesion are – (a) the erosion of lymph nodes into the bronchus, particularly in children due to its small caliber and weak wall, (b) direct extension from an adjacent parenchymal focus, (c) proliferation and implantation of organisms from the infected sputum, (d) hematogenous dissemination, and (e) lymphatic spread.
Chung and Lee, in their prospective study, reported the evolution of endobronchial tuberculosis. Serial bronchoscopies performed after diagnosis showed an initial nonspecific bronchitic form, followed by submucosal tubercle formation giving an appearance of edema-hyperemia and the biopsy showed caseous necrosis and epithelioid granuloma. Finally, ulcers are formed in the bronchial mucosa and evolve into hyperplastic inflammatory polyps. These later heal by fibrostenosis.
In India, the treatment of endobronchial tuberculosis involves a 6-month course of antitubercular drugs as part of the governmental Revised National Tuberculosis Control Program (RNTCP). In the Intensive phase (Two months)- Isoniazid, Rifampicin, Ethambutol, Pyrazinamide are given. Followed by the continuous phase (Four months)- Isoniazid and Rifampicin are given. These children, even with appropriate treatment frequently progress to bronchostenosis. Hence, a high index of suspicion is a must during the treatment and requires prompt follow-up.
In our study, both infants recovered well with antitubercular therapy. Their X-ray showed the resolution of obstructive emphysema in the first child and adequate right lower lobe expansion in the second. Regular follow-ups of these children for about 2 years did not show any changes in the X-ray pattern after improvement and also did not have any other symptoms. Hence, repeat bronchoscopy was not done on them.
Bronchial stenosis is a well-known complication which can develop in spite of effective antitubercular therapy which is difficult to treat even with chemotherapy or steroids. In these situations, airway patency can be maintained by bronchoscopic interventions or may need major surgical corrections. The role of corticosteroids in the prevention of bronchostenosis is controversial. This highlights the need for long-term follow-up for about 2 years to avoid complications.
| Conclusion|| |
Endobronchial tuberculosis is a rare presentation of tuberculosis in infants and the presentation may be nonspecific. A high index of suspicion and bronchoscopic biopsy is the key to establishing the diagnosis. Appropriate antitubercular treatment results in a good outcome. There is a need for long-term follow-up for identifying delayed complications.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]