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Case Report |
1 Department of Medicine, University of Alberta, Aberhart Centre 1, 3rd Floor,
Room 8325, 11402 University Avenue, Edmonton, Alberta, Canada T6G 2J3.
2 Department of Radiology, University of Alberta, Edmonton, Alberta,
Canada.
Received February 6, 2004;
accepted after revision March 26, 2004.
Address correspondence to R. Long
(richard.long{at}ualberta.ca).
Introduction
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In Alberta, a province of Canada that accepts more than 15,000 new
immigrants annually, we diagnosed two cases of anthracofibrosis-related
pulmonary TB in adult female immigrants from East India. These cases
constituted 7.7% (2/26) of all culture-positive pulmonary TB cases diagnosed
in adult (
14 years), female, foreign-born persons in the province in
calendar year 2002. We report the pretreatment and posttreatment
contrast-enhanced CT scan and bronchoscopic findings of this syndrome.
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Fiberoptic bronchoscopy was performed the day after the CT scan and revealed patchy areas of blue-black mucosal hyperpigmentation. The right bronchial tree was generally hyperemic and bled easily when touched by the bronchoscope. The bronchus intermedius was narrowed and its mucosa appeared thickened and irregular. The right upper lobe anterior segmental bronchus and the right middle lobe bronchus were narrowed. Bronchoscopic washings were positive for acid-fast bacilli on smear and drugsusceptible Mycobacterium tuberculosis on culture. Cytologic preparations were negative for malignant cells.
The patient was placed on a 9-month course of directly observed isoniazid, rifampin, and ethambutol antituberculosis drug treatment. After two months of treatment, a bronchoscopy was performed again. Bronchial hyperpigmentation persisted (Fig. 1D), the right upper lobe anterior segmental bronchus appeared normal, and the bronchus intermedius and right middle lobe lateral segmental bronchus remained narrowed. After 6 months of treatment, a repeat enhanced CT scan was performed that showed clearing of the right middle lobe consolidation and widening of the diameter of the right middle lobe bronchus. The right upper lobe anterior segmental bronchus was no longer narrowed and distal parenchymal disease had largely cleared (Figs. 1E and 1F). A nonenhanced CT performed after completion of curative treatment was unchanged from the study performed after 6 months of treatment, and spirometry, arterial blood gases, and acid-base balance were normal.
In the same year that this case was diagnosed, we diagnosed another similar case—a 62-year-old HIV-seronegative, nonsmoking, previously tuberculin positive, East Indian female immigrant to Canada with smear- and culture-positive pulmonary TB presenting as anthracofibrosis. The patient had no history of TB or occupational exposure to coal dust, but had had domestic wood-smoke exposure. Her initial isolate of M. tuberculosis was drug-susceptible and she completed a curative course of directly observed treatment. Pretreatment and posttreatment enhanced thoracic CT scans (Figs. 2A, 2B, 2C, 2D and 2E) showed prominent middle lobe disease. In contrast to the first patient, however, multiple intrathoracic nodes were present that only partially resolved with treatment. Moreover, the right middle lobe bronchostenosis did not improve with treatment. Calcification was present in a subcarinal node. Pretreatment biopsy of the mucosa of the bronchus intermedius revealed chronic nonspecific inflammation. Pretreatment needle aspirate of a subcarinal node and pre- and posttreatment washings and brushings of the right middle lobe were negative for malignant cells. Prominent, patchy, bilateral mucosal hyperpigmentation was present before and after treatment (Fig. 2F).
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TB associated with anthracofibrosis and tuberculous endobronchial disease
is generally reported more often in women than men (ratio 2.4:1 and 5.4:1,
respectively) [1,
2,
5]. In our East Indian
patients, the distribution of disease was similar to that reported in Korean
patients [1,
2]. In the latter, multiple
sites were usually involved, the right lung more often than the left, and the
right middle lobe more often than any other lobe. CT findings were similar to
those described in patients with tuberculous bronchial stenosis and no airway
hyperpigmentation [7].
Characteristic findings of mediastinal tuberculous lymphadenitis and nodes
2 cm in diameter with central areas of low density and peripheral rim
enhancement were absent in our cases, in all cases in one Korean series
[1], and in an unknown number
in the other Korean series
[2].
The radiologic and bronchoscopic response of tuberculous lesions to treatment is important in excluding coexistent malignancy. As expected, exudative parenchymal lesions in our patients cleared with treatment [8]. The first patient's airway stenoses responded to treatment and were consistent with edematous-hyperemic endobronchial disease [5]. The second patient's adenopathy-related bronchial disease did not completely resolve with treatment, but a variable response of such disease has been reported in patients with no airway hyperpigmentation [5, 9].
The association of bronchostenosis, especially in conjunction with hilar and/or mediastinal adenopathy, should always raise suspicion of malignancy. However, when more than one segmental or lobar bronchus is stenotic, and/or lymph nodes are calcified, and there is associated airway hyperpigmentation, TB should be considered. This association is especially important to recognize in nonsmoking Asian women. The two cases reported here document the occurrence of this syndrome in Asian immigrants to North America from a country other than Korea. The airway narrowing of anthracofibrosis-related TB may or may not be reversible with treatment of the TB.
Acknowledgments
We thank Susan Evans-Davies for her preparation of the manuscript and the
Tuberculosis Program Evaluation and Research Unit, University of Alberta, for
its support of this report.
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