Endobronchial Tuberculosis Presenting as Right Middle Lobe Syndrome: Clinical Characteristics and Bronchoscopic Findings in 22 Cases

Abstract

PurposeEndobronchial tuberculosis (EBTB) presenting as right middle lobe syndrome (RMLS) is an uncommon clinical condition. We investigated the clinical characteristics in patients with EBTB presenting as RMLS.Patients and MethodsWe retrospectively reviewed the records of 22 patients with EBTB presenting as RMLS who were diagnosed at our hospital from 2003 to 2006.ResultsIts occurrence was more common in females than males (F, 18; M, 4). The mean age was 70.3 ± 8.5 years, and 17 patients were above the age of 65 years. Cough with sputum was the most common manifestation and 2 patients were asymptomatic. In bronchoscopic analysis, the most common finding was edematous-type EBTB, which was found in 15 patients, followed by actively caseating type in 6 and tumorous type in 1. Acid-fast bacilli (AFB) staining for bronchial washing fluid was positive in only 5 patients: 1 with edematous type and 4 with actively caseating type. Bronchoscopic biopsy showed chronic granulomatous inflammation in 16 patients. Follow-up chest X-ray after treatment showed complete disappearance of the lesion in 2 patients, more than 50% improvement in 5, less than 50% improvement in 5, and no change of lesion in 4.ConclusionEdematous-type EBTB was the most common type of EBTB presenting as RMLS, and it usually occurred in elderly patients. Culturing for mycobacterium and histologic examination by bronchoscopy are necessary for proper diagnosis in these patients.

Middle Lobe Syndrome: A Review of Clinicopathological Features, Diagnosis and Treatment

“…Low-dose macrolide therapy can be used, particularly if bronchiectasis is present [35]. Consideration must also be given to unusual infections (atypical mycobacteria, fungi) that may require specific antimicrobial agents [11,12,14]. The use of nebulized antibiotics has not been studied in MLS.…”

“…The most common cause of extrinsic compression of the right middle lobe bronchus is enlargement of the peribronchial lymph nodes [4]. This can be due to granulomatous infections such as histoplasmosis that cause adenopathy, but other fungal infections and typical and atypical mycobacterial infections are also well-described etiologies of obstructive MLS [3,10,11,12,13,14]. Furthermore, adenopathy due to sarcoidosis or lymph node metastases has also been described in obstructive MLS [3].…”

“…Antibiotic treatment is often continued for several weeks or months, as recurrences are common [19]. If available, antibiotics are chosen based on microbial culture or sensitivity results from bronchoalveolar lavage fluid or sputum [11,12,13,27]. Otherwise, broad-spectrum antibiotics are used, covering streptococci (including Streptococcus pneumoniae ), Haemophilus influenzae, Moraxella catarrhalis and even Pseudomonas aeruginosa in difficult cases [3].…”

Endobronchial tuberculosis mimicking lymphoma

“…Foreign body aspiration is another situation that should be considered in the differential diagnosis of ET (3)(4)(5)(6)11). A patient with asthmatic symptoms, hilar lymph node enlargement and parenchymal infiltration on Thorax CT was biopsied from endobronchial nodular appearance similar to our finding which revealed ET (2).…”

“…Several reports declared that ET manifests as different presentations. Parenchymal infiltration, especially patchy alveolar type was the most prevalent radiologic finding whereas it can mimic malignancy with partial segmental collapse appearance or right middle lobe syndrome (1,(3)(4)(5)(6).…”