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CASE REPORT
Year : 2012  |  Volume : 29  |  Issue : 2  |  Page : 182-184  

An unusual cause of bronchial obstruction


Department of Respiratory Medicine, St Thomas' Hospital, Guys and Thomas NHS Foundation Trust, London, SE1 7EH, United Kingdom

Date of Web Publication24-Apr-2012

Correspondence Address:
Ahmed Liju
Department of Respiratory Medicine, 1st Floor, Lambeth Wing, St Thomas' Hospital, Guys and Thomas NHS Foundtion Trust, Lambeth Palace Road, London, SE1 7EH
United Kingdom
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-2113.95339

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   Abstract 

We present here a case of bronchial obstruction secondary to late paradoxical reactive enlargement and erosion by mediastinal lymph nodes into the left main bronchus in a 26-year-old woman with tuberculosis lymphadenitis. Bronchial obstruction due to paradoxical reactions, especially in the late phase of treatment, has not been described in adults before.

Keywords: Bronchial obstruction, immune reconstitution inflammatory syndrome, introduction, mediastinal lymphadenopathy, paradoxical reaction, Tuberculosis


How to cite this article:
Liju A, Sharma N, Milburn H. An unusual cause of bronchial obstruction. Lung India 2012;29:182-4

How to cite this URL:
Liju A, Sharma N, Milburn H. An unusual cause of bronchial obstruction. Lung India [serial online] 2012 [cited 2019 Nov 14];29:182-4. Available from: http://www.lungindia.com/text.asp?2012/29/2/182/95339


   Introduction Top


Paradoxical enlargement of lymph nodes in tuberculosis is well established in the early phase of treatment. [1],[2],[3] This is more common in HIV co-infection. Reactive enlargement in the late phase of treatment is unusual and rare. Mediastinal lymphadenopathy resulting in recurrent laryngeal nerve palsy, pulmonary artery occlusion and superior vena caval obstruction has been described.

We report a case of bronchial obstruction in a patient with fully sensitive organism in the late phase of the treatment.


   Case Report Top


A 26-year-old Somalian woman was diagnosed with Mycobacterium tuberculosis infection in January 2008. She presented with cervical and mediastinal lymph node enlargement without any obvious lung parenchymal involvement. Acid fast bacilli (AFB) were seen on fine needle aspiration of the cervical lymph node. Culture showed M. tuberculosis which was fully sensitive. She was HIV negative.

After initial problems with compliance, full standard quadruple therapy was effectively started in April 2008. Maintenance treatment was commenced in June 2008.

The chest X-ray (CXR) on first presentation did show a narrowed left main bronchus in the absence of any clinical signs or symptoms. Furthermore, she had a normal exercise tolerance.

The only relevant past medical history was of childhood asthma, for which she had no hospitalizations and did not use any regular inhaled therapy.

She presented in August 2008 to the accident and emergency department with a one-week history of worsening shortness of breath. The repeat CXR showed narrowing of the left main bronchus. Inhaled steroids and bronchodilators were started for a possible asthma exacerbation and she was discharged home. Her symptoms deteriorated and when seen in the TB clinic four weeks later, her exercise tolerance was limited to about 100 yards.

On examination, a monophonic wheeze was audible on the left side of the chest. A repeat CXR showed marked narrowing of the left main bronchus, confirmed on CT scan which showed almost complete occlusion of the left main stem bronchus. Spirometry showed FEV 1 - 1.09 L/min (36.3% of predicted), FVC 1.44 (41.7% of predicted) [Table 1]a. The flow-volume loop had a characteristic shape of large airway obstruction [Figure 1].
Figure 1: Flow-volume loop of the patient which is characteristic of large airway obstruction

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She was commenced on oral Prednisolone 30 mg once daily. There was no concern with compliance at this time. A bronchoscopy also showed complete occlusion of left main bronchus with white necrotic material [Figure 2].
Figure 2: White necrotic matter seen occluding the left main bronchus at bronchoscopy

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Table 1:

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Histology revealed necrotic material with changes consistent with treated TB. Bronchoalveolar lavage was positive for AFB but microbiological culture did not grow any mycobacteria.

Her treatment was continued with both anti-tuberculous therapy and steroids. Two weeks later her symptoms had markedly improved. Three days prior to the clinic visit she said she had coughed up a large lump of white material and her breathing had returned to near normal since. Her wheeze had completely disappeared. Repeat spirometry showed improvement with an FEV 1 - 1.85 (61.5%), FVC - 2.81(81.6%) [Table 1]b with normalization of the flow volume loop [Figure 3]a. Bronchoscopy was repeated and this showed a patent left main bronchus with some necrotic material on the lateral wall [Figure 3]b.
Figure 3: (a) Flow-volume loop improved with less evidence of airway obstruction, (b) Patent left main bronchus with only a small amount of necrotic matter remaining at repeat bronchoscopy

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She continued with anti-tuberculous treatment for a full one year and steroids were slowly tapered off. Her CXR showed marked improvement in the narrowing of the left main bronchus towards the end of treatment. Spirometry also returned to normal as did her symptoms. One year after stopping treatment she remains healthy.


   Discussion Top


Endobronchial tuberculosis is less common since the advent of effective anti-tuberculous chemotherapy, but mediastinal lymphadenopathy due to mycobacterial infection is still common in developing countries. [1] Paradoxical enlargement of lymph nodes has been well-documented. [2] Paradoxical reactions on the whole are more common with HIV co-infection (28%) than without (10%). [3] Lymph node enlargement is the most common presentation and bronchial obstruction due to mediastinal lymphadenopathy is more common in the pediatric age group. [4] In adults, bronchial obstruction due to reactive enlargement late into treatment has not been described before.

Patients with tuberculous mediastinal lymphadenopathy presenting with recurrent laryngeal nerve palsy, [1] pulmonary artery occlusion [5] and superior vena caval obstruction [6] have been described. These presentations may be due to either external compression or erosion into the surrounding structure. In this particular case, the bronchoscopy showed caseating material eroding into the left main bronchus. Nakvi et al., [4] described this in children, in whom the obstruction was relieved by either aspiration or surgical excision.

Response to steroids has not been consistent in many series described but generally paradoxical reactions, unlike endobronchial TB, are thought to be more steroids responsive. [7],[8] Our patient responded well to steroids. Even after coughing up necrotic debris and relieving endobronchial obstruction, she still had significant airway obstruction on spirometry and radiology. This further improved with steroids.

Late paradoxical reactions should be considered in any patient on anti-tuberculous chemotherapy presenting with stridor.


   Acknowledgments Top


Dr. Ahmed Liju: Diagnosed upper airway obstruction, prepared the manuscript for publication.

Dr. Milburn: Diagnosed patient with tuberculosis and commenced treatment.

Dr. Neel Sharma: Literature search and collected evidence and helped with manuscript.

 
   References Top

1.Meral M, Akgun M, Kaynar H, Mirici A, Gorguner M, Saglam L, et al. Mediastinal Lymphadenopathy due to Mycobacterial infection. Jpn J Infect Dis 2004;57:124-6.  Back to cited text no. 1
    
2.Campbell IA, Dyson AJ. Lymph node tuberculosis: A comparison of various methods of treatment. Tubercle 1977;58:171-9.  Back to cited text no. 2
    
3.Breen RA, Smith CJ, Bettinson H, Dart S, Bannister B, Johnson MA, et al. Paradoxical reactions during tuberculosis treatment in patients with and without HIV co-infection. Thorax 2004;59:704-7.  Back to cited text no. 3
    
4.Nakvi AJ, Nohl-Osler HC. Surgical treatment of bronchial obstruction in primary tuberculosis in children: Report of seven cases. Thorax 1979;34:464-9.  Back to cited text no. 4
    
5.Drake WM, Elkin SL. Pulmonary artery occlusion by tuberculous mediastinal lymphadenopathy. Thorax 1997;52:301-2.  Back to cited text no. 5
    
6.Minguez C, Roca B, Gonzalez-Mino C, Simon E. Superior vena cava syndrome during the treatment of pulmonary tuberculosis in an HIV-1 infected patient. J Infec 2000;40:187-9.  Back to cited text no. 6
    
7.Park IW, Choi BW, Hue SH. Prospective study of corticosteroids as an adjunct in the treatment of endobronchial tuberculosis in adults. Respirology 1997;2:275-81.  Back to cited text no. 7
    
8.Toppet M, Malfroot A, Derde MP, Toppet V, Spehl M, Dab I. Corticosteroids in primary tuberculosis with bronchial obstruction. Arch Dis Child 1990;65:1222-6.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1]


This article has been cited by
1 An unusual cause of bronchial obstruction
Liju, A. and Sharma, N. and Milburn, H.
Lung India. 2012; 29(4): 393-394
[Pubmed]
2 Comments on "an unusual cause of bronchial obstruction"
Mehta, A.
Lung India. 2012; 29(3): 300
[Pubmed]



 

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