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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
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Background
9 month old baby GA referred from Worcester Hospital
Problems: # Recurrent “stridor” for 3 months
# Pulmonary tuberculosis on treatment for 5 months
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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
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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
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TCH course
Clinically: Well grown child on 10th centile for weight.
Resp exam: Monophonic wheeze
Minimal stridor
No differential air entry
Other systems normal
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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
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CXR showing calcified node
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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
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Large gland herniating into the trachea with >90% occlusionLarge gland herniating into the trachea with >90% occlusion
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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
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Calcified gland eroding into trachea
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Surgery
Enucleation done Large amount of caseous material
removed Small tracheal defect closed
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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
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Before surgery Post surgery
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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
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Transferred back to Worcester to continue TB treatment
For follow-up in 1 months time
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Airway involvement in TB
Trachea and 2 main bronchi most affected.
Upper airway involvement rare in children
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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
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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
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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.
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Learning points
Differentiating stridor from monophonic wheeze
Stridor - Harsh, high-pitched inspiratory sound usually audible without a stethoscope
- Extrathoracic obstruction Monophonic wheeze – Intrathoracic
obstruction
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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
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Summary
Unusual presentation of endobronchial TB.
Potential for life-threatening complications.
Thus far the outcome has been favourable.
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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.