Letter to the Editor
Endobronchial Tuberculosis Simulating Lung Cancer
Tuberculosis endobronquial como simulador de cáncer de pulmón
Julen Cadiñanos Loidi, Daniel Abad Pérez
, Rosa de Miguel Buckley
Corresponding author
Servicio de Medicina Interna, Hospital Universitario de la Princesa, Madrid, Spain
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array:4 [ "nombre" => "Daniel" "apellidos" => "Abad Pérez" "email" => array:1 [ 0 => "danielabadperez@hotmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 2 => array:2 [ "nombre" => "Rosa" "apellidos" => "de Miguel Buckley" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Medicina Interna, Hospital Universitario de la Princesa, Madrid, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Tuberculosis endobronquial como simulador de cáncer de pulmón" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1358 "Ancho" => 1301 "Tamanyo" => 236735 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Bronchoscopy and CT images before treatment.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Tuberculosis (TB) still has an annual incidence in Spain of 18.2/100,000 inhabitants.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> We report a case of endobronchial tuberculosis with lymph node and skin involvement, an unusual form in our setting.</p><p id="par0010" class="elsevierStylePara elsevierViewall">A 45-year-old woman who had been resident in India until 8 months previously, presented with clinical symptoms for the last 3 months of daily fever (up to 38<span class="elsevierStyleHsp" style=""></span>°C), anorexia, weight loss, dry cough, and dyspnea that did not improve after 7 days of treatment with amoxicillin–clavulanic acid. She had good general health upon examination, the only remarkable finding being two mobile, rubbery subcutaneous nodules sized 1<span class="elsevierStyleHsp" style=""></span>cm in the left upper quadrant that were slightly painful but with no signs of inflammation, and a similar one in the left hand. Blood tests revealed anemia, leukocytosis and thrombocytosis. Chest radiography showed a mass in the anterior mediastinum described in the computed tomography (CT) report as “mass in the left upper lobe and ipsilateral hilar region, with anterior mediastinal infiltration causing stenosis of the bronchial lumen; ipsilateral subcarinal and paratracheal lymphadenopathies, accompanied by multiple independent nodules in the left lung, pleural implants, and subcutaneous abdominal nodules”. Bronchoscopy revealed inflamed mucosa with implants of tumor-like appearance and left bronchial stenosis. Malignancy was ruled out after biopsy, but both bronchial biopsies and one of the abdominal nodes showed non-necrotizing granulomas. Cultures were initially negative, but then multi-susceptible <span class="elsevierStyleItalic">Mycobacterium tuberculosis</span> grew in sputum. Accordingly, the patient was diagnosed with disseminated TB with tumor-type endobronchial and skin involvement. The patient improved rapidly with TB therapy and corticosteroids. Bronchoscopy was normal at 6 months, while the CT showed only residual thickening of soft tissues (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Endobronchial TB occurs in 5%–40% of active pulmonary TB, although it is underdiagnosed.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3</span></a> The cause is implantation directly from an adjacent cavity, a focus of tuberculosis or a mediastinal lymph node, or by bloodborne or lymphatic spread.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,4</span></a> Symptoms include cough (71%–100%), fever (50%), weight loss (30%), hemoptysis (18%–25%), dyspnea, chest pain and anorexia.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,4,5</span></a> Both the duration of symptoms and the disease progression are variable and can range from complete resolution to the appearance of bronchiectasis, bronchial obstruction or atelectasis. The most useful microbiological test is bronchoalveolar lavage, which outperforms sputum.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2–5</span></a> X-ray may show alveolar infiltrates (35%–43%), nodules (25%), cavitated lesions (12%), pleural effusion (9%) or hilar thickening (7%), but it may be normal in 10%–20% of cases.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3</span></a> CT is useful for assessment of disease extension, degree of bronchial obstruction and progress, and may replace bronchoscopy during follow-up,<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> although it is the imaging study of choice during diagnosis.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Chung and Lee classify TB into seven subtypes<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a>: caseating (12%–43%), edematous-hyperemic (14%–44%), fibrostenotic (6%–10.5%), tumoral (10.5%–30%),<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3–5</span></a> granular, ulcerative, and nonspecific bronchitis type. The first four have a poorer prognosis, because of associated bronchial stenosis.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> These types seem to represent different stages of the same disease, starting with granulomas and submucosal inflammatory lesions that progress to masses, fibrosis and airway stenosis.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,5</span></a> The tumoral subtype has endobronchial masses, with a hemorrhagic surface and a necrotic outer layer, simulating squamous carcinoma. Risk factors for residual bronchial stenosis are age over 45 years, fibrostenotic type, and late diagnosis.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,5</span></a> Treatment includes endoscopic dilation, mechanical resection, or stenting combined with corticosteroids. The latter seems to be effective in the early stages and the caseating/tumoral forms,<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> so for this reason they were used in our patient, who achieved total recovery.</p><p id="par0025" class="elsevierStylePara elsevierViewall">In the presence of fever and endobronchial lesions or pulmonary mass, consideration of TB at diagnosis is mandatory, especially in immigrants during the early years after arrival.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Cadiñanos Loidi J, Abad Pérez D, de Miguel Buckley R. Tuberculosis endobronquial como simulador de cáncer de pulmón. Arch Bronconeumol. 2014;50:126–127.</p>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1358 "Ancho" => 1301 "Tamanyo" => 236735 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Bronchoscopy and CT images before treatment.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "Informe sobre la situación de la tuberculosis. Red Nacional de Vigilancia Epidemiológica. España, 2007. Centro Nacional de Epidemiología. 18 de marzo de 2009. 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Chung" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Int J Tuberc Lung Dis" "fecha" => "2007" "volumen" => "11" "paginaInicial" => "57" "paginaFinal" => "62" ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/15792129/0000005000000003/v1_201403120155/S157921291400041X/v1_201403120155/en/main.assets" "Apartado" => array:4 [ "identificador" => "14576" "tipo" => "SECCION" "es" => array:2 [ "titulo" => "Letters to the editor" "idiomaDefecto" => true ] "idiomaDefecto" => "es" ] "PDF" => "https://static.elsevier.es/multimedia/15792129/0000005000000003/v1_201403120155/S157921291400041X/v1_201403120155/en/main.pdf?idApp=UINPBA00003Z&text.app=https://archbronconeumol.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S157921291400041X?idApp=UINPBA00003Z" ]
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| 2018 October | 51 | 27 | 78 |
| 2018 September | 30 | 7 | 37 |
| 2018 May | 18 | 0 | 18 |
| 2018 April | 49 | 4 | 53 |
| 2018 March | 22 | 4 | 26 |
| 2018 February | 35 | 6 | 41 |
| 2018 January | 32 | 9 | 41 |
| 2017 December | 47 | 7 | 54 |
| 2017 November | 41 | 4 | 45 |
| 2017 October | 27 | 11 | 38 |
| 2017 September | 32 | 5 | 37 |
| 2017 August | 50 | 9 | 59 |
| 2017 July | 49 | 10 | 59 |
| 2017 June | 56 | 15 | 71 |
| 2017 May | 49 | 4 | 53 |
| 2017 April | 46 | 7 | 53 |
| 2017 March | 44 | 5 | 49 |
| 2017 February | 30 | 5 | 35 |
| 2017 January | 34 | 3 | 37 |
| 2016 December | 29 | 8 | 37 |
| 2016 November | 53 | 15 | 68 |
| 2016 October | 54 | 26 | 80 |
| 2016 September | 45 | 17 | 62 |
| 2016 August | 43 | 7 | 50 |
| 2016 July | 26 | 13 | 39 |
| 2016 March | 2 | 0 | 2 |
| 2016 February | 2 | 0 | 2 |
| 2015 December | 3 | 0 | 3 |
| 2015 October | 59 | 3 | 62 |
| 2015 September | 41 | 11 | 52 |
| 2015 August | 47 | 12 | 59 |
| 2015 July | 44 | 6 | 50 |
| 2015 June | 41 | 10 | 51 |
| 2015 May | 43 | 16 | 59 |
| 2015 April | 30 | 9 | 39 |
| 2015 March | 51 | 6 | 57 |
| 2015 February | 40 | 10 | 50 |
| 2015 January | 38 | 3 | 41 |
| 2014 December | 43 | 9 | 52 |
| 2014 November | 34 | 9 | 43 |
| 2014 October | 61 | 15 | 76 |
| 2014 September | 39 | 15 | 54 |
| 2014 August | 40 | 15 | 55 |
| 2014 July | 39 | 10 | 49 |
| 2014 June | 38 | 15 | 53 |
| 2014 May | 2 | 0 | 2 |
| 2014 April | 0 | 1 | 1 |
Show all
