Not Your Routine Foreign Body: Endobronchial Tuberculosis in an Infant
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《小儿科》
Department of Pediatrics Division of Pediatric Otolaryngology, Lucile Packard Children's Hospital at Stanford University, Palo Alto, California
ABSTRACT
Foreign-body aspiration is a common cause of respiratory distress among children. Here we describe an 8-month-old, previously 34-week premature, male patient who presented with a 1-day history of fever and increased work of breathing. Of note, 3 weeks before presentation, the patient had been treated with orally administered amoxicillin for presumed pneumonia and exhibited good clinical response. No chest radiograph was obtained at that time. A current chest radiograph revealed hyperexpansion of the left lung, with a mediastinal shift. Although the patient was referred because of possible foreign-body aspiration, no clear history of an aspiration event was obtained, and computed tomographic scans of the chest were recommended. These showed extensive hilar and mediastinal lymphadenopathy, resulting in obstruction of the left bronchus. Bronchoscopy revealed a cheesy granulomatous mass in the left mainstem bronchus, which was ball-valving into the upper bronchus. Removal resulted in improvement of the patient's respiratory status. Pathology, bronchial lavage, and gastric aspirate specimens all revealed acid-fast bacilli, consistent with Mycobacterium tuberculosis infection. This unusual presentation of tuberculosis may become more common in the United States as the incidence of immigrants carrying tuberculosis increases.
Key Words: pediatric foreign body tuberculosis respiratory distress bronchoscopy
Abbreviations: CT, computed tomographic
Mycobacterium tuberculosis is considered by many to be the great imitator. It is especially difficult to diagnose among children, with the distinction between exposure and disease being difficult to make.1 The rates of tuberculosis have been declining nationwide since a peak in 1992, but some states observed elevation of their rates during 2003. This, coupled with a continued high incidence of tuberculosis in certain at-risk populations such as immigrants and minorities, means that pediatricians must be even more vigilant in tuberculin testing and have a higher index of suspicion in cases in which a child does not present with a classic cavitary lesion.2 This case report details an unusual and interesting case in which tuberculosis presented with findings suggesting foreign-body aspiration.
CASE REPORT
An 8-month-old, formerly 34-week premature, male infant presented for treatment of fever to 38.5°C, cough, and increased work of breathing. Three weeks before admission, the patient was diagnosed as having pneumonia and was treated with amoxicillin, with good clinical response. No chest radiograph was obtained at that time. One day before transfer, the patient was admitted to an outside hospital because of similar symptoms. He was transferred to our institution after a chest radiograph revealed hyperexpansion of the left lung, with a mediastinal shift to the right (Fig 1). Although the patient was referred because of possible foreign-body aspiration, no clear history of an aspiration event was obtained.
The patient was born at 34 weeks' gestational age in the Philippines. The mother had a 10-day history of severe coughing, which led ultimately to premature rupture of membranes and delivery. The patient's birth weight was 1.75 kg. He was never intubated during his 2-week hospitalization in the nursery in the Philippines. Immunizations, including BCG vaccine, were up to date. The family immigrated to the United States 3 months before patient presentation. Family members denied any illness. The family history was significant for a 12-year-old cousin with asthma.
On physical examination, the patient was afebrile, with a respiratory rate of 35 breaths per minute and a heart rate of 140 beats per minute. Oxygen saturation measured 100% with room air. The examination results were significant for abdominal breathing with mild subcostal and supraclavicular retractions, decreased breath sounds on the left side, and heart sounds displaced to the right, with a displaced point of maximal impulse. There was no tracheal deviation. The rest of the physical examination results were normal.
Because of the absence of a clear aspiration event, computed tomographic (CT) scans of the chest were obtained; they showed extensive hilar and mediastinal lymphadenopathy, resulting in obstruction of the left bronchus (Fig 2). A Mantoux skin test was performed for the infant. Bronchoscopy revealed a cheesy granulomatous mass in the left mainstem bronchus, which was ball-valving into the upper bronchus (Fig 3). Removal resulted in improvement of the patient's respiratory status. Pathology, bronchial lavage, and gastric aspirate specimens were smear positive and culture positive for acid-fast bacilli, consistent with M tuberculosis infection. In addition, the Mantoux skin test developed >10 mm of induration. The patient began standard 4-drug therapy with isoniazid, rifampin, ethambutol, and pyrazinamide and was discharged from the hospital with directly observed therapy.
The isolate was sensitive to all antituberculosis drugs, and the patient completed 6 months of treatment. He has not had any additional problems with wheezing, retractions, cough, or difficulty breathing and is growing well.
DISCUSSION
Endobronchial tuberculosis can be found for up to 57% of children with pediatric pulmonary tuberculosis.3 Symptoms are often nonspecific and may include fever, cough, wheezing, prolonged expiratory component, or diminished breath sounds. These lesions are often not evident on simple chest radiographs.4 Because of the decreased incidence of tuberculosis in the United States, it is usually not one of the first things considered when children present with these symptoms. In the pediatric otolaryngology literature, however, endobronchial tuberculosis presenting as suspected foreign-body aspiration has been described.5–7 With bronchoscopy, these patients are described typically as having a polypoid spongy mass, white fibrinous exudate, or granulation tissue in the bronchus. The right upper and right main bronchi are involved most frequently.8
Chest CT scans are often more useful than chest radiographs for the evaluation of endobronchial tuberculosis. There is a risk of development of bronchial stricture with endobronchial tuberculosis, which can result in some degree of permanently increased airway resistance, with dyspnea on exertion. Lee and Chung4 reported that the length of bronchial involvement in endobronchial tuberculosis varied between 10 and 55 mm on chest CT scans for 26 patients. Bronchial stricture was noted in 25 of those cases, and the CT scans were found to be extremely helpful for measuring both the length and severity of the stricture. Other authors found a somewhat lower incidence (58% of 22 patients) of stricture, although these cases were diagnosed with bronchoscopy rather than CT studies.9 Ip et al10 reevaluated 12 of 20 patients after a mean of 27 months of chemotherapy and found 11 of them to have bronchial stricture. The authors did not think steroid therapy was helpful. A prospective, randomized study of 34 patients confirmed no significant differences in healing rate, stenosis, or pulmonary function with the addition of corticosteroids.11 Rikimaru,12,13 however, observed that the progression of bronchial stenosis could be prevented among patients treated with aerosolized steroids. Although it is controversial, many experts would recommend treating pediatric patients with steroids. Steroid treatment might benefit these patients with minimal risk.14
CONCLUSIONS
Despite its relatively low incidence in the United States, pulmonary tuberculosis may present as endobronchial lesions that mimic the findings found in foreign-body aspiration. A high index of suspicion is necessary to diagnose and to treat these cases correctly. Useful adjunctive diagnostic evaluations include chest CT scans, tuberculin skin tests, and acid-fast bacilli stains and cultures of bronchoscopy specimens or gastric aspirates. Serial bronchoscopic or CT evaluations may be helpful after treatment, to assess the degree of bronchial stenosis that is seen commonly despite adequate therapy.
This case highlights one of the many different ways that tuberculosis can present among young infants. Although our patient's clinical appearance and chest radiographs were consistent with foreign-body aspiration, he was a little younger than typical aspirators. Physicians must have a heightened awareness regarding tuberculosis, especially in high-risk populations.
FOOTNOTES
Accepted Nov 16, 2004.
No conflict of interest declared.
REFERENCES
Van Hest R, De Vries G, Morbano G, Pijnenburg M, Hartwig N, Baars H. Cavitating tuberculosis in an infant: case report and literature review. Pediatr Infect Dis J.2004; 23 :667 –670
Division of Tuberculosis Elimination, National Center for HIV, STD, and TB Prevention, Centers for Disease Control and Prevention. Trends in tuberculosis: United States, 1998–2003. MMWR Morb Mortal Wkly Rep.2004; 53 :209 –214
de Blic J, Azevedo I, Burren CP, Le Bourgeois M, Lallemand D, Scheinmann P. The value of flexible bronchoscopy in childhood pulmonary tuberculosis. Chest.1991; 100 :688 –692
Lee JH, Chung HS. Bronchoscopic, radiologic and pulmonary function evaluation of endobronchial tuberculosis. Respirology.2002; 5 :411 –417
Park AH, Fowler SS, Challapalli M. Suspected foreign body aspiration in a child with endobronchial tuberculosis. Int J Pediatr Otorhinolaryngol.2000; 53 :67 –71
Caglayan S, Coteli I, Acar U, Erkin S. Endobronchial tuberculosis simulating foreign body aspiration. Chest.1989; 95 :1164
Wood GS, Gonzalez C, Done S, Albus RA. Endobronchial tuberculosis in children: a case report and review. Int J Pediatr Otorhinolaryngol.1990; 20 :241 –245
Lee JH, Park SS, Lee DH, Shin DH, Yang SC, Yoo BM. Endobronchial tuberculosis: clinical and bronchoscopic features in 121 cases. Chest.1992; 102 :990 –994
Hoheisel G, Chan BK, Chan CH, Chan KS, Teschler H, Costabel U. Endobronchial tuberculosis: diagnostic features and therapeutic outcome. Respir Med.1994; 88 :593 –597
Ip MS, So SY, Lam WK, Mok CK. Endobronchial tuberculosis revisited. Chest.1986; 89 :727 –730
Park IW, Choi BW, Hue SH. Prospective study of corticosteroid as an adjunct in the treatment of endobronchial tuberculosis in adults. Respirology.1997; 2 :275 –281
Rikimaru T. Therapeutic management of endobronchial tuberculosis. Expert Opin Pharmacother.2004; 5 :1463 –1470
Rikimaru T. Endobronchial tuberculosis. Expert Rev Anti Infect Ther.2004; 2 :245 –251
Iseman, M. Clinician Guide to Tuberculosis. Baltimore, MD: Lippincott, Williams & Wilkins; 2000:140(Swati Agarwal, MD, David )
ABSTRACT
Foreign-body aspiration is a common cause of respiratory distress among children. Here we describe an 8-month-old, previously 34-week premature, male patient who presented with a 1-day history of fever and increased work of breathing. Of note, 3 weeks before presentation, the patient had been treated with orally administered amoxicillin for presumed pneumonia and exhibited good clinical response. No chest radiograph was obtained at that time. A current chest radiograph revealed hyperexpansion of the left lung, with a mediastinal shift. Although the patient was referred because of possible foreign-body aspiration, no clear history of an aspiration event was obtained, and computed tomographic scans of the chest were recommended. These showed extensive hilar and mediastinal lymphadenopathy, resulting in obstruction of the left bronchus. Bronchoscopy revealed a cheesy granulomatous mass in the left mainstem bronchus, which was ball-valving into the upper bronchus. Removal resulted in improvement of the patient's respiratory status. Pathology, bronchial lavage, and gastric aspirate specimens all revealed acid-fast bacilli, consistent with Mycobacterium tuberculosis infection. This unusual presentation of tuberculosis may become more common in the United States as the incidence of immigrants carrying tuberculosis increases.
Key Words: pediatric foreign body tuberculosis respiratory distress bronchoscopy
Abbreviations: CT, computed tomographic
Mycobacterium tuberculosis is considered by many to be the great imitator. It is especially difficult to diagnose among children, with the distinction between exposure and disease being difficult to make.1 The rates of tuberculosis have been declining nationwide since a peak in 1992, but some states observed elevation of their rates during 2003. This, coupled with a continued high incidence of tuberculosis in certain at-risk populations such as immigrants and minorities, means that pediatricians must be even more vigilant in tuberculin testing and have a higher index of suspicion in cases in which a child does not present with a classic cavitary lesion.2 This case report details an unusual and interesting case in which tuberculosis presented with findings suggesting foreign-body aspiration.
CASE REPORT
An 8-month-old, formerly 34-week premature, male infant presented for treatment of fever to 38.5°C, cough, and increased work of breathing. Three weeks before admission, the patient was diagnosed as having pneumonia and was treated with amoxicillin, with good clinical response. No chest radiograph was obtained at that time. One day before transfer, the patient was admitted to an outside hospital because of similar symptoms. He was transferred to our institution after a chest radiograph revealed hyperexpansion of the left lung, with a mediastinal shift to the right (Fig 1). Although the patient was referred because of possible foreign-body aspiration, no clear history of an aspiration event was obtained.
The patient was born at 34 weeks' gestational age in the Philippines. The mother had a 10-day history of severe coughing, which led ultimately to premature rupture of membranes and delivery. The patient's birth weight was 1.75 kg. He was never intubated during his 2-week hospitalization in the nursery in the Philippines. Immunizations, including BCG vaccine, were up to date. The family immigrated to the United States 3 months before patient presentation. Family members denied any illness. The family history was significant for a 12-year-old cousin with asthma.
On physical examination, the patient was afebrile, with a respiratory rate of 35 breaths per minute and a heart rate of 140 beats per minute. Oxygen saturation measured 100% with room air. The examination results were significant for abdominal breathing with mild subcostal and supraclavicular retractions, decreased breath sounds on the left side, and heart sounds displaced to the right, with a displaced point of maximal impulse. There was no tracheal deviation. The rest of the physical examination results were normal.
Because of the absence of a clear aspiration event, computed tomographic (CT) scans of the chest were obtained; they showed extensive hilar and mediastinal lymphadenopathy, resulting in obstruction of the left bronchus (Fig 2). A Mantoux skin test was performed for the infant. Bronchoscopy revealed a cheesy granulomatous mass in the left mainstem bronchus, which was ball-valving into the upper bronchus (Fig 3). Removal resulted in improvement of the patient's respiratory status. Pathology, bronchial lavage, and gastric aspirate specimens were smear positive and culture positive for acid-fast bacilli, consistent with M tuberculosis infection. In addition, the Mantoux skin test developed >10 mm of induration. The patient began standard 4-drug therapy with isoniazid, rifampin, ethambutol, and pyrazinamide and was discharged from the hospital with directly observed therapy.
The isolate was sensitive to all antituberculosis drugs, and the patient completed 6 months of treatment. He has not had any additional problems with wheezing, retractions, cough, or difficulty breathing and is growing well.
DISCUSSION
Endobronchial tuberculosis can be found for up to 57% of children with pediatric pulmonary tuberculosis.3 Symptoms are often nonspecific and may include fever, cough, wheezing, prolonged expiratory component, or diminished breath sounds. These lesions are often not evident on simple chest radiographs.4 Because of the decreased incidence of tuberculosis in the United States, it is usually not one of the first things considered when children present with these symptoms. In the pediatric otolaryngology literature, however, endobronchial tuberculosis presenting as suspected foreign-body aspiration has been described.5–7 With bronchoscopy, these patients are described typically as having a polypoid spongy mass, white fibrinous exudate, or granulation tissue in the bronchus. The right upper and right main bronchi are involved most frequently.8
Chest CT scans are often more useful than chest radiographs for the evaluation of endobronchial tuberculosis. There is a risk of development of bronchial stricture with endobronchial tuberculosis, which can result in some degree of permanently increased airway resistance, with dyspnea on exertion. Lee and Chung4 reported that the length of bronchial involvement in endobronchial tuberculosis varied between 10 and 55 mm on chest CT scans for 26 patients. Bronchial stricture was noted in 25 of those cases, and the CT scans were found to be extremely helpful for measuring both the length and severity of the stricture. Other authors found a somewhat lower incidence (58% of 22 patients) of stricture, although these cases were diagnosed with bronchoscopy rather than CT studies.9 Ip et al10 reevaluated 12 of 20 patients after a mean of 27 months of chemotherapy and found 11 of them to have bronchial stricture. The authors did not think steroid therapy was helpful. A prospective, randomized study of 34 patients confirmed no significant differences in healing rate, stenosis, or pulmonary function with the addition of corticosteroids.11 Rikimaru,12,13 however, observed that the progression of bronchial stenosis could be prevented among patients treated with aerosolized steroids. Although it is controversial, many experts would recommend treating pediatric patients with steroids. Steroid treatment might benefit these patients with minimal risk.14
CONCLUSIONS
Despite its relatively low incidence in the United States, pulmonary tuberculosis may present as endobronchial lesions that mimic the findings found in foreign-body aspiration. A high index of suspicion is necessary to diagnose and to treat these cases correctly. Useful adjunctive diagnostic evaluations include chest CT scans, tuberculin skin tests, and acid-fast bacilli stains and cultures of bronchoscopy specimens or gastric aspirates. Serial bronchoscopic or CT evaluations may be helpful after treatment, to assess the degree of bronchial stenosis that is seen commonly despite adequate therapy.
This case highlights one of the many different ways that tuberculosis can present among young infants. Although our patient's clinical appearance and chest radiographs were consistent with foreign-body aspiration, he was a little younger than typical aspirators. Physicians must have a heightened awareness regarding tuberculosis, especially in high-risk populations.
FOOTNOTES
Accepted Nov 16, 2004.
No conflict of interest declared.
REFERENCES
Van Hest R, De Vries G, Morbano G, Pijnenburg M, Hartwig N, Baars H. Cavitating tuberculosis in an infant: case report and literature review. Pediatr Infect Dis J.2004; 23 :667 –670
Division of Tuberculosis Elimination, National Center for HIV, STD, and TB Prevention, Centers for Disease Control and Prevention. Trends in tuberculosis: United States, 1998–2003. MMWR Morb Mortal Wkly Rep.2004; 53 :209 –214
de Blic J, Azevedo I, Burren CP, Le Bourgeois M, Lallemand D, Scheinmann P. The value of flexible bronchoscopy in childhood pulmonary tuberculosis. Chest.1991; 100 :688 –692
Lee JH, Chung HS. Bronchoscopic, radiologic and pulmonary function evaluation of endobronchial tuberculosis. Respirology.2002; 5 :411 –417
Park AH, Fowler SS, Challapalli M. Suspected foreign body aspiration in a child with endobronchial tuberculosis. Int J Pediatr Otorhinolaryngol.2000; 53 :67 –71
Caglayan S, Coteli I, Acar U, Erkin S. Endobronchial tuberculosis simulating foreign body aspiration. Chest.1989; 95 :1164
Wood GS, Gonzalez C, Done S, Albus RA. Endobronchial tuberculosis in children: a case report and review. Int J Pediatr Otorhinolaryngol.1990; 20 :241 –245
Lee JH, Park SS, Lee DH, Shin DH, Yang SC, Yoo BM. Endobronchial tuberculosis: clinical and bronchoscopic features in 121 cases. Chest.1992; 102 :990 –994
Hoheisel G, Chan BK, Chan CH, Chan KS, Teschler H, Costabel U. Endobronchial tuberculosis: diagnostic features and therapeutic outcome. Respir Med.1994; 88 :593 –597
Ip MS, So SY, Lam WK, Mok CK. Endobronchial tuberculosis revisited. Chest.1986; 89 :727 –730
Park IW, Choi BW, Hue SH. Prospective study of corticosteroid as an adjunct in the treatment of endobronchial tuberculosis in adults. Respirology.1997; 2 :275 –281
Rikimaru T. Therapeutic management of endobronchial tuberculosis. Expert Opin Pharmacother.2004; 5 :1463 –1470
Rikimaru T. Endobronchial tuberculosis. Expert Rev Anti Infect Ther.2004; 2 :245 –251
Iseman, M. Clinician Guide to Tuberculosis. Baltimore, MD: Lippincott, Williams & Wilkins; 2000:140(Swati Agarwal, MD, David )