Exposure to Mycobacterium tuberculosis during Flexible Bronchoscopy in Patients with Unexpected Pulmonary Tuberculosis

Abstract

ObjectiveRecent guidelines recommend the use by healthcare personnel of a fit-tested N95 particulate respirator or higher-grade respiratory precaution in a patient undergoing bronchoscopy when pulmonary tuberculosis (PTB) is suspected. However, PTB may be unexpectedly diagnosed in this setting and therefore not evaluated, resulting in the unexpected exposure to Mycobacterium tuberculosis (MTB) of healthcare workers in the bronchoscopy suite. Here, we examined the incidence of unexpected exposure to MTB during flexible bronchoscopy and determined the exposure-related factors.MethodsBetween 2011 and 2013, a retrospective study was conducted to evaluate unexpected diagnoses of PTB in the bronchoscopy suite. During the study period, 1650 consecutive patients for whom previous CT scans were available and who underwent bronchoscopy for respiratory disease other than PTB were included. The results of bronchial washing, bronchoalveolar lavage, and post-bronchoscopic sputum were reviewed.ResultsPTB was unexpectedly diagnosed in 76 patients (4.6%). The presence of anthracofibrosis [odds ratio (OR), 3.878; 95% confidence interval (CI), 1.291–11.650; P = 0.016), bronchiectasis (OR, 1.974; 95% CI, 1.095–3.557; P = 0.024), or atelectasis (OR, 1.740; 95% CI, 1.010–2.903; P = 0.046) as seen on chest CT scan was independently associated with unexpected PTB. Patients with both anthracofibrosis and atelectasis were at much higher risk of unexpected PTB (OR, 4.606; 95% CI, 1.383–15.342; P = 0.013).ConclusionsThe risk of MTB exposure by healthcare personnel in the bronchoscopy suite due to patients with undiagnosed PTB has been underestimated. Therefore, in geographic regions with an intermediate PTB prevalence, such as South Korea (97/100,000 persons per year), higher-grade respiratory precaution, such as a fit-tested N95 particulate respirator, should be considered to prevent occupational exposure to MTB during routine bronchoscopy, especially in patients with CT-confirmed anthracofibrosis, bronchiectasis, or atelectasis.

Guidelines for diagnostic flexible bronchoscopy in adults: Joint Indian Chest Society/National College of chest physicians (I)/Indian association for bronchology recommendations

“…[14] It has also been reported that 4.6% of patients without an initial suspicion of TB had an unexpected diagnosis of TB after bronchoscopy, thereby demonstrating the risk of healthcare exposure to Mycobacterium in otherwise unsuspected cases in countries with intermediate TB incidence, and potential utility of N95 or better respirators for infection control. [15]…”

Unexpected Diagnosis of Pulmonary Tuberculosis During Bronchoscopy Using Radial Probe Endobronchial Ultrasound

“…In previous studies on bronchoscopy using radial probe EBUS [9][10][11][12][13][14][15], although most of the study patients were diagnosed with malignant disease, 3.9-11.0% of patients were eventually diagnosed with pulmonary tuberculosis, rates that are similar to that found in this study (Table 6). During conventional bronchoscopy, the probability of unexpected diagnosis of pulmonary tuberculosis is known to range from 0.3% to 1.3% in low pulmonary tuberculosis prevalence regions, and 3.7% to 9.1% in intermediate or high prevalence regions [2]. Our results suggest that the risk of healthcare personnel being exposed to Mycobacterium tuberculosis during bronchoscopy using radial probe EBUS has been underestimated, with it being as high as that on conventional bronchoscopy.…”

“…However, in some patients, pulmonary tuberculosis is unexpectedly diagnosed from bronchoscopy samples when the patient was not initially thought to be suffering from tuberculosis. 2 Previous studies reported that healthcare workers in the Republic of Korea, which is an intermediate tuberculosis prevalence region (59/100 000 persons per year, 2019), have at least a 4-6% chance of inadvertent exposure to Mycobacterium tuberculosis during conventional bronchoscopy [2][3][4].…”

Pulmonary infections mimicking malignancy on bronchoscopy: A retrospective single‐center study in Japan

“…The rate of incidence of newly notified TB cases in Japan was 12.3 per 100 000 population in 2018, 3 and therefore, Japan is categorized as an intermediate TB‐burden country similar to South Korea. Na et al reported that 76 of 1650 patients were unexpectedly diagnosed with TB after undergoing bronchoscopy for suspected nontuberculous pulmonary diseases between 2011 and 2013 at Pusan National University Hospital 4 . Therefore, TB can result in the inadvertent exposure of healthcare workers to TB during diagnostic evaluation, especially during invasive diagnostic procedures such as bronchoscopy.…”