case presentation : tracheal obstruction by calcified tb gland in a child aneesa vanker, pierre...
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Case Presentation : Tracheal obstruction by calcified TB gland in a child
Aneesa Vanker, Pierre Goussard, Sharon Kling, JT Janson, B Barnard, M Connellan . Tygerberg Children`s Hospital.Department of Paediatrics and Cardiothoracic surgery .University of Stellenbosch
Background
9 month old baby GA referred from Worcester Hospital
Problems: # Recurrent “stridor” for 3 months
# Pulmonary tuberculosis on treatment for 5 months
TB diagnosis & Mx
TB diagnosed at 4 months of age based on - +ve tuberculin skin test
- CXR with suggestive features of TB
- No gastric washings done Commenced on TB Rx and was already
on continuation phase Rx Apparently “many” TB contacts
Stridor background
History of repeated admission to Caledon Hospital from 6 months of age with stridor.
Treated with nebulisations and sent home. Eventually at 9 months of age, referred to
Worcester Hospital for Ix of stridor. Noted on CXR to have ?mass in right main
bronchus area
TCH course
Clinically: Well grown child on 10th centile for weight.
Resp exam: Monophonic wheeze
Minimal stridor
No differential air entry
Other systems normal
Investigations
CXR – calcified lesion in area of right main bronchus – most likely lymph node
ENT consult – Not able to detect any abnormality
The next step - Bronchoscopy
CXR showing calcified node
Bronchoscopy
Large gland herniating into the trachea with >90% occlusion
Right main bronchus occluded by herniating gland
Areas of gland removed piecemeal at bronchoscopy (endoscopic enucleation)– still significant occlusion
BAL done and cultures sent
Large gland herniating into the trachea with >90% occlusionLarge gland herniating into the trachea with >90% occlusion
Further developments
Intubated post bronchoscopy to protect the airway
Transferred to PICU Urgent chest CT scan done
confirmed large gland of tuberculous nature herniating into trachea and right main bronchus
Calcified gland eroding into trachea
Surgery
Enucleation done Large amount of caseous material
removed Small tracheal defect closed
Post-surgery
Repeated bronchoscopy 1 hour after returning to PICU
Trachea now only 50% occluded (prev >90%), RMB still occluded
Changed to MDR TB Rx (INH, Rif, Oflox, Amik, Etham) + Steroids
Reason – no response to previous Rx, possible MDR TB
Extubated
Before surgery Post surgery
Further course
ZN stain positive for AFB on enucleated gland
Culture pending Clinically wheeze improved Repeat bronchoscopy 1 week post-
enucleation Trachea patent, no gland herniation, RMB only 50% occluded by herniating gland
Transferred back to Worcester to continue TB treatment
For follow-up in 1 months time
Airway involvement in TB
Trachea and 2 main bronchi most affected.
Upper airway involvement rare in children
Presentation
Enlarged glands can cause external compression of the airways.
May herniate into airways. Varying degrees of obstruction rarely
complete obstruction. Partial obstruction “ball-valve” effect – air
enters lung but trapped on expiration Complete obstruction lung or lobar
collapse
Assessment
CXR – 4 patterns of compression
1) airway narrowing
2) ball-valve effect
3) expansile pneumonia
4) lobar collapse Bronchoscopy – degree of obstruction, BAL,
endoscopic enucleation CT scan – Confirmation, assist in planning
further interventions
Management
TB treatment – standard 3 drug regime Corticosteroid – prednisone 2mg/kg for
1 month then weaned Evaluated for enucleation – life-
threatening obstruction, poor response to Rx and steroids.
Learning points
Differentiating stridor from monophonic wheeze
Stridor - Harsh, high-pitched inspiratory sound usually audible without a stethoscope
- Extrathoracic obstruction Monophonic wheeze – Intrathoracic
obstruction
Recurrent presentations of stridor/wheezing warrant further investigation
Although on CXR – gland look calcified, still needed further management
TB cultures are always important especially when the diagnosis is made
Summary
Unusual presentation of endobronchial TB.
Potential for life-threatening complications.
Thus far the outcome has been favourable.
Review of the literature
Endobronchial TB with gland herniation has been described: Airway involvement in pulmonary tuberculosis. Goussard P, Gie R Paediatr Respir Rev. 2007 Jun;8(2):118-23.
However, very little described on gland herniation into the trachea 2 articles :
Tuberculous cavitating node communicating with the trachea.Case report with radiographic and pathologic review.Palacios EJ, Tirman RM, White HJ.J Ark Med Soc. 1972 May;68(12):407-9.
Airway obstruction secondary to tuberculosis lymph nodeerosion into the trachea: drainage via bronchoscopy.Schwartz MS, Kahlstrom EJ, Hawkins DB.Otolaryngol Head Neck Surg. 1988 Dec;99(6):604-6.
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