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(Chest. 2000;117:385-392.)
© 2000 American College of Chest Physicians

Bronchoscopic Assessment of the Evolution of Endobronchial Tuberculosis*

Hee Soon Chung, MD, FCCP and Jae Ho Lee, MD

* From the Division of Pulmonology, Department of Internal Medicine, Seoul Municipal Boramae Hospital Affiliated to Seoul National University Hospital, Seoul, Korea. Supported in part by the Seoul Municipal Boramae Hospital.

Correspondence to: Hee Soon Chung, MD, FCCP, Department of Internal Medicine, Seoul Municipal Boramae Hospital, #395 Shindaebang-2-Dong, Dongjak-Gu, Seoul, 156–707, Korea; e-mail: hschung{at}brm.co.kr


   Abstract
TOP
 Abstract
Introduction
 Materials and Methods
 Results
 Discussion
 Conclusion
 References
 
Background: We previously classified forms of endobronchial tuberculosis (EBTB) into seven subtypes by bronchoscopic finding: actively caseating, edematous-hyperemic, fibrostenotic, tumorous, granular, ulcerative, and nonspecific bronchitic.

Study objective: To evaluate the value of this classification in predicting the therapeutic outcome of EBTB.

Design: A prospective study with serial bronchoscopy performed from the diagnosis of EBTB to the completion of antituberculosis chemotherapy.

Participants: Eighty-one patients with biopsy-proven EBTB.

Interventions: Fiberoptic bronchoscopy was done every month until there was no subsequent change in the endobronchial lesions, every 3 months thereafter, and at the end of treatment.

Results: Twenty-two of the 34 cases of actively caseating EBTB changed into the fibrostenotic type, and the other 12 healed without sequelae. Seven of the 11 cases of edematous-hyperemic EBTB changed into the fibrostenotic type, and the other 4 healed. Nine of the 11 cases of granular EBTB, 6 cases of nonspecific bronchitic EBTB, and 2 cases of ulcerative EBTB resolved completely. However, the other two cases of granular EBTB changed into the fibrostenotic type. Seven cases of fibrostenotic EBTB did not improve despite antituberculosis chemotherapy. These various changes in bronchoscopic findings occurred within 3 months of treatment. In 10 cases of tumorous EBTB, 7 progressed to the fibrostenotic type. In addition, new lesions appeared in two cases, and the size of the initial lesions increased in another two cases, even at 6 months after treatment.

Conclusions: The therapeutic outcome of each subtype of EBTB can be predicted by follow-up bronchoscopy during the initial 3 months of treatment, with the exception of the tumorous type. In tumorous EBTB, close and long-term follow-up is advisable because the evolution of the lesions during treatment is very complicated and bronchial stenosis may develop at a later time.

Key Words: bronchoscopic finding • bronchoscopy • endobronchial tuberculosis • evolution • subtype


   Introduction
TOP
 Abstract
 Introduction
Materials and Methods
 Results
 Discussion
 Conclusion
 References
 
The incidence of tuberculosis affecting respiratory organs including the trachea and bronchi has been greatly reduced, especially in the past 50 years.1 Nevertheless, endobronchial tuberculosis (EBTB) continues to be a health problem1 because of the following: (1) its diagnosis is frequently delayed because the decreased incidence itself diminishes the suspicion of tuberculosis2 ; (2) bronchostenosis may develop as a serious complication despite efficacious antituberculosis chemotherapy3 4 5 ; and (3) it is often misdiagnosed as bronchial asthma6 7 8 or lung cancer.9 10 11 Moreover, there has recently been an unprecedented resurgence of tuberculosis that is related to the HIV epidemic, multidrug-resistant strains, poverty and homelessness, immigration, and failures in the treatment system,12 13 14 and the HIV epidemic may be associated with a higher incidence of EBTB.11 15

The pathogenesis of EBTB is not yet fully established. However, sources of EBTB may include direct implantation of tubercle bacilli into the bronchus from an adjacent pulmonary parenchymal lesion, direct airway infiltration from an adjacent tuberculous mediastinal lymph node, erosion and protrusion of an intrathoracic tuberculous lymph node into the bronchus, hematogenous spread, and extension to the peribronchial region by lymphatic drainage.9 10 16 17 18

The clinical course of EBTB is variable because not only are there several possible pathogenetic mechanisms, but the interaction between the effect of mycobacteria, host immunity, and antituberculous drugs is complex, and any variation in these three factors may result in an altered course.19 Therefore, the forms of EBTB need to be classified into subtypes.

We previously classified forms of EBTB into seven subtypes by bronchoscopic finding: actively caseating, edematous-hyperemic, fibrostenotic, tumorous, granular, ulcerative, and nonspecific bronchitic.2 However, it was not known whether the proposed classification had predictive value after treatment. Here, we show the value of this classification in predicting the outcome of EBTB after the treatment in a prospective clinical study.


   Materials and Methods
TOP
 Abstract
 Introduction
 Materials and Methods
Results
 Discussion
 Conclusion
 References
 
The diagnostic criteria of active EBTB were as follows: (1) certain endobronchial lesions existed on bronchoscopy, as illustrated in Figure 1 ; and (2) tuberculosis was proven by bronchoscopic biopsy of these lesions. Forms of EBTB were classified into seven subtypes by our own definitions: actively caseating, edematous-hyperemic, fibrostenotic, tumorous, granular, ulcerative, and nonspecific bronchitic (Fig 1) . If a certain case contained two or more subtypes of EBTB simultaneously, it was classified by the dominant form. Follow-up bronchoscopy was done every month until there was no subsequent change in endobronchial lesions, every 3 months thereafter, and at the end of treatment according to our protocol.



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  		Figure 1. Classification of EBTB by bronchoscopic finding. Top: A, actively caseating type; B, edematous-hyperemic type; C, fibrostenotic type; and D, tumorous type. Bottom: E, granular type; F, ulcerative type; and G, nonspecific bronchitic type. See Results section for the explanation of each type of EBTB.

 
One hundred fourteen patients were enrolled in this study, out of 1,938 patients with pulmonary tuberculosis from January 1992 to December 1997. EBTB was diagnosed in all patients by bronchoscopy at Seoul Municipal Boramae Hospital, a university-affiliated teaching hospital, and the study patients agreed to follow-up bronchoscopy. EBTB was treated with a combination of isoniazid, rifampicin, pyrazinamide, and streptomycin or ethambutol. The duration of treatment was generally 9 months but could be prolonged, considering the follow-up bronchoscopic findings. In actively caseating, edematous-hyperemic, fibrostenotic, and tumorous forms of EBTB that had varying degrees of bronchostenoses proximal to segmental bronchi, prednisolone, 1 mg/kg qd, was given during the initial month and gradually tapered off over 4 to 6 weeks.

Comparisons of the presence of bronchial stenosis before and after treatment were done using {chi}2 analysis and Fisher’s Exact Test. A p value of < 0.05 was considered statistically significant.


   Results
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
Discussion
 Conclusion
 References
 
Analyzing data from all of the 114 patients with EBTB, the peak incidence occurred in the third decade and the male-to-female ratio was 1:5.4. Sputum smear for acid-fast bacilli was positive in 57 of 107 patients (53.3%), and sputum culture for tuberculosis bacilli was positive in 67 of 91 patients (73.6%). Drug sensitivity tests were done in 46 cases, but a multidrug-resistant strain was not found. When forms of EBTB were classified into subtypes by initial bronchoscopic findings, the actively caseating type (49 cases; 43.0%) was the most common form. Edematous-hyperemic (16 cases; 14.0%), fibrostenotic (12 cases; 10.5%), tumorous (12 cases; 10.5%) and granular (13 cases; 11.4%) types were relatively common. However, nonspecific bronchitic (nine cases; 7.9%) and ulcerative (three cases; 2.7%) types occurred less frequently.

To assess the changes in bronchoscopic findings during treatment in each subtype of EBTB, we analyzed 81 cases, because 33 participants dropped out of the study and follow-up bronchoscopy could not be performed as scheduled in these cases.

Actively Caseating EBTB
Actively caseating lesions were diagnosed when the bronchial mucosa was swollen, hyperemic, and diffusely covered with whitish cheese-like material. This form was usually accompanied by luminal narrowing at diagnosis whether granulation tissue was present or not (Fig 1 , top, A).

Changes in the bronchoscopic findings of the 34 cases of actively caseating EBTB during treatment are summarized in Table 1 . Seven cases transformed into the fibrostenotic type via the edematous-hyper-emic type, and another 15 cases directly transformed into the fibrostenotic type, within 3 months of treatment. Therefore, 22 cases became fibrostenotic. Distinctively, 12 of these 22 cases, which showed granulation tissue on follow-up bronchoscopy, changed into the fibrostenotic type. The other 12 cases healed through the edematous-hyperemic, granular, or nonspecific bronchitic types without complication. Significant improvement of bronchial stenosis was shown after treatment in this type of EBTB only.


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  		Table 1. Changes in Bronchoscopic Findings of 34 Actively Caseating EBTBs During Treatment*

 
Edematous-Hyperemic EBTB
In edematous-hyperemic EBTB, the bronchial lumen was always narrowed due to severe mucosal swelling with surrounding hyperemia. However, there was neither caseous material nor fibrous contracture found at diagnosis (Fig 1 , top, B).

The prognosis of our cases of edematous-hyper-emic EBTB was not good because 7 of the 11 cases became fibrostenotic in type within 2 to 3 months after treatment, and 2 of these 7 cases showed complete obstruction of the bronchial lumen. The other four cases changed into the nonspecific bronchitic type at 1 or 2 months after treatment and healed within 3 months of treatment (Table 2 ).


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  		Table 2. Changes in Bronchoscopic Findings of 11 Edematous-Hyperemic EBTBs During Treatment*

 
Fibrostenotic EBTB
Patients with fibrostenotic EBTB presented with a marked narrowing of the bronchial lumen with fibrosis. Usually, the endobronchial tuberculous lesion did not circularly involve the bronchial mucosa and the normal mucosa was partly spared. Therefore, the stenotic bronchial lumen became a crushed waterdrop shape, as shown in Figure 1 , top, C. In some cases, the bronchial lumen was completely occluded. It was not easy to obtain biopsy specimens because of dense fibrosis, but active tuberculosis could be diagnosed with bronchoscopic biopsy from the inflamed mucosa at the periphery of the lesion.

All seven cases remained in a fibrostenotic state in spite of drug therapy. In addition, three endobronchial lesions showed progressive fibrostenosis and resulted in complete obstruction of the bronchial lumen at 2 or 3 months after treatment.

Tumorous EBTB
Tumorous EBTB was characterized by an endobronchial mass whose surface was often covered with caseous material and nearly totally occluded the bronchial lumen (Fig 1 , top, D). This form of EBTB was frequently mistaken for lung cancer because of its bronchoscopic appearance and the fact that CT findings mimicked lung cancer (Fig 2 ).



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  		Figure 2. CT showing enlargement of peribronchial and mediastinal lymph nodes (arrow) in tumorous EBTB. Endobronchial mass was the visible tip of the enlarged lymph node, and its major portion was located outside the bronchus.

 
Ten cases were analyzed. The evolution of tumorous EBTB was very complicated and unpredictable. Seven cases changed into fibrostenotic type at the end of treatment, six of which did within 3 months. In these seven cases, three progressed to complete obstruction of the bronchial lumen with fibrosis within the initial month and another two showed anthracofibrosis at 2 or 3 months after treatment. In addition, new tumorous lesions appeared in another segmental bronchus at 5 or 6 months after treatment in two of these seven cases. These new lesions turned into the fibrostenotic type at the end of treatment. Another 2 of the 10 cases exhibited impending obstruction of the left main bronchus by a regrowing mass at 6 months after treatment. These were successfully removed by bronchoscopic electrocautery. Anthracotic pigmentation was observed in one of these two cauterized cases. The other one case eventually healed (Table 3 ). Therefore, the prognosis of tumorous EBTB was found to be most grave and unpredictable.


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  		Table 3. Changes in Bronchoscopic Findings of 10 Tumorous EBTBs During Treatment*

 
Granular EBTB
Granular EBTB appeared like scattered grains of boiled rice, and the underlying bronchial mucosa showed severe inflammatory change (Fig 1 , bottom, E).

Two cases transformed into the edematous-hyperemic type at 1 month after treatment and showed fibrostenosis of the bronchial lumen at 2 months after treatment. Another three cases transformed into the edematous-hyperemic type at 1 month after treatment but healed without endobronchial sequelae at 3 or 4 months after treatment. The other six cases healed within 3 months of treatment (Table 4 ).


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  		Table 4. Changes in Bronchoscopic Findings of 11 Granular EBTBs During Treatment*

 
Ulcerative EBTB
The appearance of the bronchial ulcer in ulcerative EBTB was very similar to that of peptic ulcer (Fig 1 , bottom, F), and both of the cases were completely resolved within 3 months of treatment.

Nonspecific Bronchitic EBTB
In nonspecific bronchitic EBTB, only mild mucosal swelling and/or hyperemia were seen on bronchoscopy (Fig 1 , bottom, G). However, tuberculosis was proven by bronchoscopic biopsy of these lesions.

The prognosis was so excellent that all the six cases were healed within 2 months of treatment.


   Discussion
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
Conclusion
 References
 
We and our colleagues had retrospectively analyzed the bronchoscopic findings of 166 cases of EBTB diagnosed at Seoul National University Hospital, Seoul, Korea. In 1991, we suggested a seven-subtype classification of forms of EBTB based on bronchoscopic features: actively caseating, stenotic without fibrosis, stenotic with fibrosis, tumorous, granular, ulcerative, and nonspecific bronchitic.2 This classification was partially reported at the Sixth World Congress for Bronchology.20 However, the terms "stenotic without fibrosis" and "stenotic with fibrosis" were renamed "edematous-hyperemic" and "fibrostenotic," respectively, because gross bronchoscopic findings cannot reflect the presence of fibrosis. Therefore, in this study, we classified forms of EBTB into seven subtypes by bronchoscopic finding: actively caseating, edematous-hyperemic, fibrostenotic, tumorous, granular, ulcerative, and nonspecific bronchitic. Each subtype of EBTB has its own characteristic appearance, as illustrated in Figure 1 . Four of the subtypes–actively caseating, edematous-hyperemic, fibrostenotic, and tumorous EBTB–show varying degrees of luminal narrowing of the bronchus, while the other three subtypes–granular, ulcerative, and nonspecific bronchitic EBTB–do not.

In this study, EBTB showed a marked preponderance in female patients, consistent with other reports from Korea2 17 and Japan.21 22 However, the reason why EBTB is common in female patients is not clear. One of the possible reasons may be because the implantation of organisms from infected sputum occurs easily in female subjects, especially those in their teens and twenties, since they do not expectorate sputum well because of their sociocultural and cosmetic backgrounds. The incidence of EBTB in pulmonary tuberculosis was 5.88% (114 cases of EBTB/1,938 patients with pulmonary TB). However, it should be considered that the actual incidence is higher than this frequency because bronchoscopy was not routinely performed in all of the patients with tuberculosis.

We think that our classification of EBTB is closely related to the extent of disease progression. Pathologically, the initial lesion, which presents as simple erythema and edema of the mucosa with lymphocytic infiltration of the submucosa,1 23 corresponds to nonspecific bronchitic EBTB. This lesion is followed by submucosal tubercle formation that produces the erythema and granularity seen at bronchoscopy,16 and partial bronchial stenosis caused by considerable congestion and edema of the mucosa.23 These are granular and edematous-hyperemic type, respectively, according to our classification. At this point, development of caseous necrosis with formation of tuberculous granuloma can be found at the mucosal surface.23 This constitutes actively caseating EBTB. When the inflammation erupts through mucosa, an ulcer is seen that may be covered by caseous material.16 At this point, the disease is considered to be of the ulcerative type. Finally, the bronchial mucosal ulcer evolves into hyperplastic inflammatory polyps, and the endobronchial tuberculous lesion heals by fibrostenosis.10 24 In this process, the lesion has moved through either the tumorous or fibrostenotic type. In addition, tumorous EBTB can also develop through another pathway in which an intrathoracic tuberculous lymph node erodes and protrudes into the bronchus.1 11 In our experience, this mechanism is the principal one in tumorous EBTB, because CT usually reveals an endobronchial mass and enlarged lymph nodes adjacent to the bronchus, as illustrated in Figure 2 , and anthracotic pigment is frequently seen on biopsy specimens.10 25 Interestingly, EBTB in patients with HIV infection shows bronchoscopic and CT findings similar to ours.11 15 26 27

In the present study, 62 cases with actively caseating, edematous-hyperemic, fibrostenotic, and tumorous EBTB showed luminal narrowing of the bronchus at diagnosis. This number significantly decreased to 43 cases by the end of treatment. This result was consistent with other reports.15 18 19 However, it is noteworthy that drug therapy had no impact on the prevention of bronchostenosis22 in 43 of these cases. Among 19 cases with granular, ulcertive, and nonspecific bronchitic EBTB that did not show luminal narrowing of the bronchus at diagnosis, 17 cases healed without bronchostenosis, although the other 2 cases of granular type did show bronchial stenosis after treatment. Thus, the evolution of EBTB seems to be crudely determined by initial bronchoscopic findings that reflect the extent of the progress of the disease.

To assess the evolution of EBTB in detail, the changes in the bronchoscopic findings during the treatment of each subtype of EBTB needed to be analyzed. In 34 cases of actively caseating EBTB, 22 moved on to become fibrostenotic despite the treatment. The 12 of these cases that showed granulation tissue on follow-up bronchoscopy changed into dense fibrosis. However, the other 12 cases healed with the same treatment. Seven of the 11 cases of edematous-hyperemic EBTB converted into the fibrostenotic type, but the other 4 healed. Four of the seven cases of fibrostenotic EBTB showed no change, and the other three showed complete obstruction of the bronchial lumen with dense fibrosis. Nine of the 11 cases of granular EBTB healed, but 2 changed into the fibrostenotic type. All of the ulcerative (two cases) and nonspecific bronchitic EBTB (six cases) healed. These various changes in bronchoscopic findings occurred within 3 months of treatment, even if they followed different courses to their final subtypes. Therefore, the therapeutic outcomes of these six subtypes of EBTB can be predicted when follow-up bronchoscopy is performed every month for the first 2 to 3 months of treatment. In addition, marked stenosis is inevitable despite efficacious chemotherapy once fibrostenotic EBTB develops, or if extensive granulation tissue appears.10 However, it can be alleviated by aggressive intervention therapy.4 20 28 29 30

It was very difficult to analyze the evolution of tumorous EBTB because it showed diverse progress and unexpected changes. However, the opinions of Shulutko and coworkers1 were extremely valuable to our understanding of the evolution of tumorous EBTB. In bronchoglandular tuberculosis, which is equivalent to our tumorous EBTB, bronchoglandular fistulas occur when the necrotic foci of the tuberculous lymph node rupture into the bronchial lumen, and the lymph node contents are extruded. During this stage, bronchial stenosis is often temporary. The bronchoglandular fistula usually heals, leaving a thin tender scar that neither deforms the wall nor narrows the lumen of the bronchus, if endobronchial treatment (removal of caseous masses and granulations, cauterization of the fistulous opening, and peribronchial blockades) is performed. But, if scarring of the bronchoglandular fistula continues, the bronchial lumen may be left narrowed by persistent cicatricial stenosis or can even be completely obliterated. Most cicatricial stenoses of EBTB appear to be sequelae of tumorous bronchadenitis, and sometimes more lymphoglandular fistulas arise near the first one. When we applied their opinions to our results, we realize that the unexpected changes in the present study were actually unexpected, but probable. In addition, in order to maintain bronchial patency, the early diagnosis and efficacious treatment including interventional modalities6 10 31 is very important in tumorous EBTB. Also, our results fit in with their assertion that tumorous EBTB has a unique pathogenetic mechanism and shows a grave prognosis regarding bronchostenosis32 if it is not treated aggressively.

In summation, we suggest a scheme for the presumptive natural course of endobronchial tuberculous lesions (Fig 3 , dashed arrow), which we deduced by observing the healing process (Fig 3 , solid arrow). The desired end result of EBTB is healing without significant sequelae, and the other conflicting end is fibrostenosis. All subtypes of EBTB are situated between these two ends and can transform into another subtypes during treatment. But, there is a critical point between these two ends, which is mainly determined by the extent of disease progression18 and closely related to formation of granulation tissue.1 10 Bronchial stenosis is inevitable3 33 if the disease progresses beyond this critical point. Therefore, prompt diagnosis and efficacious treatment are of paramount importance in EBTB in order to minimize the resultant bronchial stenosis.5 To alleviate bronchostenosis that has already developed, aggressive therapeutic modalities such as electrocautery,31 stent insertion,29 or laser therapy28 should be considered before dense fibrosis continues or complete obstruction of the bronchus occurs.



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  		Figure 3. This scheme summarizes the observed healing process (solid arrow) and the presumptive natural course (dashed arrow) of endobronchial tuberculous lesions.

 

   Conclusion
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 Conclusion
References
 
When forms of EBTB are classified into seven subtypes (actively caseating, edematous-hyperemic, fibrostenotic, tumorous, granular, ulcerative, and nonspecific bronchitic), the therapeutic outcome of each subtype, except the tumorous type, can be predicted by follow-up bronchoscopy during the initial 2 to 3 months of treatment. However, in tumorous EBTB, close and long-term follow-up is advisable because the evolution of the lesions during treatment is very complicated and bronchial stenosis may develop at a later time. It is essential that aggressive therapy be performed before the disease progresses too far and bronchostenosis seems to be inevitable. Therefore, the bronchoscopic approach is mandatory, not only for the prompt diagnosis of EBTB, but also for the prevention of further bronchostenosis.


   Acknowledgements
 
We are grateful to Mss Young Sook Cha and Mi Sook Kwon for their secretarial assistance.


   Footnotes
 
Abbreviation: EBTB = endobronchial tuberculosis

Received for publication February 22, 1999. Accepted for publication September 9, 1999.


   References
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 Conclusion
 References
 

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