Hemoptysis is the predominant symptom of tuberculosis and is considered as important clue toward evaluation of tuberculosis and treatment accordingly, especially in high burden countries like India where disease is endemic. 8-25% cases of pulmonary tuberculosis are having hemoptysis during course of their illness. Unexplained hemoptysis with normal chest radiograph needs further evaluation including CT thorax and bronchoscopy. Bronchoscopy would be ideal choice for confirming diagnosis and to localize exact site of bleeding as well. In this case report, we describe a case of a young male who presented with cough and intermittant hemoptysis. During fiberoptic video-bronchoscopy we noted exophytic endobronchial growth in right main stem bronchus. Histopathological evaluation suggests mucoepidermoid carcinoma (MEC) of salivary gland type originating from main stem bronchus right side. PAS and mucicarmine staining differentiated MEC from Adenocarcinoma in our case.
Lower lung field tuberculosis (LLF TB) is an atypical presentation of tuberculosis (TB). LLF TB is common, and a proportionate number of non-resolving pneumonia cases are diagnosed to have pulmonary TB.
Materials and Methods
The prospective observational study was conducted during June 2013 to December 2015 in the Department of Pulmonary Medicine, MIMSR Medical College, Latur, India; the objective of the study is clinical, microbiological, and radiological presentation of LLF TB and the comparison of yield of conventional diagnostic techniques and bronchoscopy-guided modalities in LLF TB. Additional important objective of the study is to find LLF TB in patients with nonresolving pneumonia (NRP). A total of 2,600 patients with pulmonary TB were included in the study after inclusion and exclusion criteria. Ethical clearance was taken from the ethical committee of the institutional review board. Consent was taken from the patients before inclusion in the study. Statistical analysis was done using chi-square test.
In the present study, 300 (11.53%) cases of LLF TB of total 2600 pulmonary tuberculosis were included, females constitutes 66.66% (200/300) with mean age of 58.4 ± 11.8 years and males constitutes 33.34% (100/300) with mean age of 56.8 ± 10.6 years. Constitutional symptoms were observed as cough in 93% cases, fever in 83% cases, shortness of breath in 72% cases, anorexia in 91% cases, and weight loss in 84% cases. Radiological assessment of study cases documented the involvement of right lower zone in 84% cases and left lower zone in only 16% cases. In the studied LLF TB cases, 57 cases (20.66%) were diagnosed by routine sputum microscopic examination for acid fast bacilli (AFB) and 80 cases (28%) were diagnosed by induced sputum microscopic examination for AFB. In the study of 170 LLF TB cases, head-to-head comparison between conventional diagnostic techniques (sputum microscopy and Induced sputum microscopy for AFB) made diagnosis in 60 cases, while bronchoscopy-guided sampling techniques (BAL for AFB and BAL for Gene Xpert MTB/RIF) made diagnosis in 155 cases (91.17%) (P < 0.00001). Comorbid conditions such as human immunodeficiency virus (HIV) coinfection in 36 cases (12.00%), Diabetes mellitus in 64 cases (21.33%), and chronic kidney disease (CKD) in 22 cases (7.33%) were observed. Comorbidities were observed in 41.67% of the studied cases and found very significant assessment to have successful treatment outcome (P < 0.00001). In the study of 300 LLF TB cases, 60 cases were having NRP pattern. In LLF TB cases with NRP pattern, bronchoscopy-guided bronchial wash microscopy for AFB made diagnosis in 18 cases (42%), while bronchoscopy-guided BAL for Gene Xpert MTB/RIF made diagnosis in 58 cases (96.66%) (P < 0.00001).
LLF TB is usually underdiagnosed because of diverse clinical and radiological presentation, less diagnostic yield of conventional diagnostic modalities, and these modalities used routinely and universally. Bronchoscopy-guided diagnostic techniques are superior, sensitive, and reliable to confirm LLF TB. Gene Xpert MTB/RIF in bronchial wash samples is found to be best diagnostic modality in evaluating LLF TB and should be used routinely to have successful treatment outcome. A proportionate number of NRP cases are having LLF TB and a high index of suspicion is a must while evaluating these cases.
A 25-year-old male patient received high-dose intravenous steroids for life-threatening anaphylaxis because of bee sting only for 4 days resulted in reactivation of latent tuberculosis infection (LTBI). Clinical presentation is acute form of progressive pulmonary tuberculosis with pleural efusion that can be misdiagnosed as a community-acquired pneumonia. High index of suspicion with adequate evaluation is must in all cases to have satisfactory treatment outcome. Bronchoscopy is crucial in evaluation with histopathology expertise is must while managing such cases.
Background: Human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome can affect the natural course of tuberculosis (TB) and pose diagnostic difficulties and may negatively affect the treatment due to frequent drug interactions in the advanced state of disease. Targeted tuberculin skin testing (TST) for latent tuberculosis infection (LTBI) identifies persons at high risk for TB who would benefit by treatment of LTBI, if detected. Materials and Methods: A prospective observational study conducted at the Department of Pulmonary Medicine and Department of Internal Medicine, MIMSR Medical College, Latur, India from November 2012 to October 2013 included all HIV-positive patients attending the outdoor department. A total of 100 HIV-positive patients subjected to TST were studied. The clinical presentation, CD4 count and tuberculin test result were studied. Chi-square test was applied to know the test of significance. Results: In this study of 100 patients, 48 were male, 52 were female and the male to female ratio was 0.92:1, with majority of the cases in the age group of 31-40 years. The mean age of the patients was 35.89 years. The most common mode of transmission of HIV infection was heterosexual in 93 patients (93%), blood transfusion in four patients (4%) and injections in three patients (3%). Of the 100 patients studied, 56 patients were TST negative (56%), whereas 44 patients were TST positive (44%). Of the 100 patients studied, 48 patients had a CD4 count of <200 cells/mm3; of these 48 patients, 37 patients were TST negative and 11 patients were TST positive. Conclusion: TST reactivity varied directly and that of anergy inversely with absolute CD4 counts. TST should be correlated with CD4 count as indurations to protein purified derivative depend on CD4 count. TST in asymptomatic HIV cases, irrespective of CD4 count, would definitely guide regarding decision of chemoprophylaxis in LTBI. The role of TST in the decision to start chemoprophylaxis in LTBI should be considered cautiously in India, as the prevalence of both HIV and TB is high.