ulcero-caseous tuberculous bronchitisthe lung tissue between the caseous bronchi is severely...

Thorax (1953), 8, 167.

ULCERO-CASEOUS TUBERCULOUS BRONCHITISA MEIHOD OF "SPREAD" IN PULMONARY TUBERCULOSIS

BY

J. W. CLEGGFrom the Brompton Hospital, London

(RECEIVED FOR PUBLICATION MAY 12, 1953)

One of the striking features of the surgicalpathology of pulmonary tuberculosis is thefrequent finding of epithelioid tubercles in thebronchial mucosa of otherwise normal bronchi.Fig. 1 is a typical example, and it is important to

reported as normal. Meissner (1945) drew atten-tion to these tubercles and pointed out thefrequency with which they could be found in areaswhere the bronchi and surrounding lung tissueappeared normal to the naked eye. The epitheliumis usually intact and caseation rare, two findingswhich led Meissner to conclude that thesetubercles were more likely to result from a spreadof the infection through the bronchial lymphaticsthan from the surface implantation of tuberclebacilli aspirated from an " open " focus. I havenever failed to find these mucosal tubercles inapparently normal areas remote from any macro-

Fig. I.-x 130

note that the epithelium over the tubercle isnormal. The segment of bronchus from whichthis section is taken was examined broncho-scopically immediately before the operation and

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J. W. CLEGG

scopic tuberculous lesion when a search has beenmade. It follows that such tubercles must be verycommon and the majority must heal without:giving rise to any significant lesion. On the otherhand, detailed examination of many surgicalspecimens resected from patients suffering frompulmonary tuberculosis has shown that foci ofcaseous tuberculous bronchitis frequently developat some distance from the main disease. Suchcaseous bronchi may not serve areas of tuber-culous pneumonia and the alveoli they serve maybe either normal or collapsed. It appears there-

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fore that new areas of disease are arising directlyin the bronchi.The first specimen is the left upper lobe from a

woman aged 28 years with a seven-year historyof pulmonary tuberculosis (Fig. 2). The surgicalresection was performed for the removal of the"cavitating" pear-shaped lesion in the posteriorsegment which communicated directly with thesegmental bronchus. The adjacent apical seg-ment is entirely free of any foci of tuberculouspneumonia, but did contain a number of twig-likebodies, one of which is indicated by the arrow in

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Fig. 2. These bodies are 5-8 mm.long and 2-4 mm. in diameter andare frequently branched. In thefixed specimen these bodies areeasily palpated and several morecan be felt below the cut surfaceof the specimen. A block of tis-sue from the apical segment con-taining one of these " twigs " wassubmitted to serial sectioning.One of the sections is seen inFig. 3. A small bronchus, cutlongitudinally, stretches across thesection to terminate just below thepleura. This bronchus is the siteof a severe ulcero-caseous bron-chitis, but remnants of bronchialepithelium (EP) and many bron-chial cartilages (C) are still easilymade out. The muscle, however,has disappeared, being replacedby caseous material which isslightly distending the lumen. Inaddition to the bronchus seenlongitudinally there are a numberof round lesions each with acaseous centre. The serial sectionsshowed conclusively that these areall bronchioles or small bronchiderived from the larger bronchus.In each case there is an ulcero-caseous tuberculous bronchitiswhich has destroyed the mucosafilling up the lumen with caseousmaterial. The considerable hyper-trophy of the adventitia gives theappearance of a round, caseous,encapsulated nodule which mayeasily be mistaken for a healedpneumonic lesion. No tuber-culous pneumonia was found inany of the serial sections cut fromthis block, and it is clear that adestructive ulcero-caseous tuber-culous bronchitis is developing inthis segment of bronchus before there is any pneu-monia in the lung tissue to which it is functionallyrelated. It will be noted that there is a tear (T) inthe section (Fig. 3). This is due to the fact that thenormal alveolar tissue is very easily torn from therigid diseased bronchus during the process of trim-ming a block for histological examination.The second specimen is the apical segment of

the left lower lobe resected from a male patient

Fig. 4.- 1

aged 20 years with a one-year history of pul-monary tuberculosis. The cut surface of thespecimen is shown in Fig. 4. There are multiplesmall round caseous foci, each surrounded bydark zones of collapsed lung tissue. In the centreof the pathological area the caseous foci are be-coming confluent. A block of tissue from justbelow the pleura, containing one of these roundedcaseous lesions, was taken, and a section is shown



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Fig. 5.-x 10

in Fig. 5. Once again there isa small bronchus seen longitu-dinally and several smallerbronchi cut at right angles. Inthis section, however, thedestructive process is moresevere, and recognizable bron-chial elements are much harderto find. Serial sections wereagain cut and showed that allthe bronchioles cut at rightangles were branches of thebronchus seen longitudinally,and no tuberculous pneumoniawas found in any section. Thislesion differs from the firstonly because it is slightly moreextensive and destructive, withthe result that the bronchialocclusion is now sufficientlysevere for collapse to be detect-able. Towards the bottom ofthe section there is a moderatedegree of alveolar collapsewith the result that the ulcer-ated bronchi are becomingapproximated.

The earlier stages of caseoustuberculous bronchitis areeasily overlooked in- histo-logical sections when only thesmaller bronchi and bron-chioles are involved, especiallyif these are seen only in cross-section. Fig. 6 is from anotherspecimen and the block oftissue is over two inches fromany recognizable tuberculouslesion. Indeed the area ap-peared normal to the nakedeye but felt " shotty." Thereare a number of small round,oval, or irregular lesions pre-sent, each consisting of acaseous central zone sur-rounded by a capsule of fibroustissue. At first sight thesemight be mistaken for smallpneumonic foci, but in factthey are all bronchioles orsmall bronchi. To prove thisit may be necessary to cut anumber of sections to find sur-viving islands of bronchialepithelium or cartilage, and

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ULCERO-CASEOUS TUBERCULOUS BRONCHITIS

often the most helpful method is to stain for elastictissue, as this will frequently outline the positionof the bronchial wall and artery long after thespecialized tissues have disappeared.The lesions so far described are small, with only

a short segment of the bronchial tree involved.Such ulcerated bronchi are far too small to berecognized in the chest radiograph. When theentire bronchial tree of a segment or subsegmentis involved the degree of collapse is much moresevere. Clearly the caseous bronchi will then beseparated from each other only by very narrowbands of collapsed lung tissue and the histologicalpicture becomes more complicated. At this stageit will require only a very slight extension of theulcero-caseous process through the collapsed lungtissue for the caseous and expanded bronchi tofuse and become confluent. Such a caseous massmay be termed a bronchial cold abscess and belarge enough to cast a shadow in the chest radio-graph.

SOLITARY BRONCHIAL COLD ABSCESSThe next group of specimens illustrate the histo-

logical features of the pathogenesis of a bronchialcold abscess. Fig. 7 shows the cut surface of theright upper lobe from a woman aged 17 years witha two-year history of pulmonary tuberculosis.The apical segment is collapsed, but the anteriorand posterior segments are fully expanded. Inthe collapsed area there are many round caseousfoci each measuring 2-3 mm. in diameter sur-rounded by rims of collapsed lung tissue. In thecentre these caseous areas are becoming confluentand a block of tissue from the edge of this area(A) was taken for histological examination.Fig. 8 is a section from this block, and five smallbronchi (Br.) filled with caseous material are in-cluded in the section. In all these bronchi thereis extensive destruction of the bronchial mucosa,but all contain sufficient bronchial remnants toestablish their identity as bronchi. The intervening

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J. W. CLEGG

Fig. 7.- x IIlung tissue is collapsed and in some fields showsslight alveolar thickening. There is well-markedlymphoid hyperplasia in the collapsed lung tissue,but there is a complete absence of tuberculouspneumonia. The condition of the alveoli isentirely the mechanical result of the bronchialocclusion. The three larger bronchi, towards thebottom of the section, are enlarged as a result ofthe caseous bronchitis and approximated as a

result of the collapse. Clearly only a very slightextension of the'ulceration will result in the fusionof these three caseous bronchi into a single bron-chial cold abscess. At the left of the section thenormal alveoli belonging to a neighbouring andunaffected bronchopulmonary segment make a

striking contrast with the collapsed alveoli of theaffected segment.

Fig. 9 shows both the medial and lateral viewsof the left lower lobe from a woman aged 45years with a one-year history of pulmonary tuber-culosis. Resection was performed on account ofthe large cavity in the apical segment. The cutsurface of the hilar aspect of the lobe is studdedwith small round caseous foci which at a casualglance might be mistaken for foci of aspirationbronchopneumonic tuberculosis. Examination witha hand lens, however, reveals that each caseousnodule is actually a small Pronchus distended withcaseous material. A block of tissue extending

right across the sub-apical segment (marked in thefigure) was taken for section, and a portion isshown in Fig. 10. The figure shows a taperingband of caseous material which branches at B. Themany remaining bronchial cartilages (C) are theonly surviving remnants of the former bronchialwall, but the position of these cartilages leaves nodoubt that this branching tube of caseous materialoccupies both the lumen and mucosa of abronchus which has been destroyed in an ulcero-caseous process. All the other rounded foci inthis section, each of which has a caseous centre,can be recognized as a bronchus if serial sectionsare cut. The lung tissue between the caseousbronchi is severely collapsed, the alveolar wallsare thickened and frequently lined with cuboidalcells, and there is marked lymphoid hyperplasia.There are no tuberculous lesions in this collapsedtissue. Indeed the changes in the lung tissue areindistinguishable from the changes seen in anyother form of collapse due. to bronchial occlusion,as, for example, in bronchial adenoma -or car-cinoma. It is very clear that had not operationterminated the process these caseous bronchiwould soon have fused into a complex broncho-genic cold abscess.A further stage in the formation of a broncho-

genic cold abscess is seen in the next specimen.This is the apical segment of the left upper lobe

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of a patient aged 27 years with a 10-year historyof pulmonary tuberculosis (Fig. 11). The segmentis cut across to demonstrate that the three mainbranches of the segmental bronchus are expandedby a severe ulcero-caseous process. In the freshspecimen the expanded bronchi were completelyfilled with caseous material, but the central areaswere semi-fluid and washed away in the course ofpreparing the specimen; thus the appearance ofcavitation is an artefact. The bronchus on the leftis the most severely ulcerated and the bronchus onthe right the least affected. A block of tissue fromthe tip of the bronchus on the right (marked in A 'R-:Fig. 11) was taken for section and is seen in Fig.12. Over about two-thirds of the surface of thebronchus is still covered with epithelium, but else-where there is caseous ulceration. In some placesthis epithelium is normal, but at some points it isof the simple cuboidal type. The caseous ulcershave undermined the epithelium. The adjacentlung tissue is collapsed around the caseousbronchus and it is evidently merely a matter oftime before the ulcerating process extends throughthe collapsed lung tissue to fuse with a similarprocess extending from the neighbouring bron-chus.

Fig. 13 is a low-power magnification (x 2) ofa section through the pear-shaped "cavitating'lesion seen in the posterior segment of the upperlobe seen in Fig. 2. Clearly this is comparable tothe previous case except for the fact that the ulcer-ating bronchi have now fused with caseousdestruction of the intervening collapsed lungtissue. The ulcerating bronchi have retained com-munication with the segmental bronchus. The r

resulting bronchial abscess has undergone partialliquefaction with the formation of a " cavity."Once the process of ulcero-caseous bronchitis is

established in a lung it is clear that it may pro-duce a variety of differing types of picture. Forexample, it might produce multiple nodular lesionswidely separated from each other in a lobe or eventhe whole lung. Alternatively it might give riseto a progressive ulcero-caseous bronchitis in-volving a whole lobe or lung with the productionof an extensive caseous bronchiectasis. Further-more, as in all forms of tuberculosis, the processmay become quiescent or even heal. It is a matterof observation that all these possibilities fre-quently occur. It is proposed to consider both themultiple disseminated form of ulcero-caseousbronchitis and also the process of healing in thispaper. Ulcero-caseous tuberculous bronchiec-tasis, however, is a complicated subject and will Fig. 8. x6be the subject of another communication.

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@t};4f,3k(^ $ i +; tuberculous pneumonia. Fig. 18^0'ts,>5}*i;'&it'<;i}7-l, o t 'J . 'shows the middle basic broncnlus of

the same lower lobe. The middlebasic bronchus terminates abruptly}st: ,.' t;j ,1> 3 ,j ;ctOf ,tSina small calcified cold abscessabout an inch proximal to its nor-

e * Ni > .... + jEi P .....mal end. This is a small caseous¾ f# iijo < }^;ieS'*_ t + s bronchial abscess which has become

almost completely calcified (A). Thecentral portion of this abscess is still

Fte*a{')~4,; ,7w*'4.>^..S eJgcaseous,but there is a complete egg-shell of calcification around thej44 ^fi J....'caseouscentre. A small branch

0104 . . ,,...,bronchus (B) branching from themid-basic bronchus also contains asmall caseous bronchial abscess (C).In dissecting this bronchus, tightbut still incomplete strictures bothabove and below the caseous abscesswere cut. Here again the lesion wasbecoming sealed off the main bron-chial tree by the development ofstenosis at the margins of the caseous

r bronchial segment. Further dissec-tion of this specimen revealed theextensive bronchial cold abscess

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Fig.17.-x.8truction of the bronchial mucosa, but at the distalend of the abscess the bronchial epithelium canagain be seen. At this point there. is -a smallbronchus branching off .the main stem and hereagain the bronchial mucosa is destroyed and afibrous stenosis is developing. Clearly there is a

7

marked tendency to localize this destructive tuber-culous bronchitis and seal it off by means offibrous strictures both above and below the lengthwhich has been transformed into an abscess.Further dissection of the specimen revealed mtil-tiple bronchial cold abscesses but no areas of Fig. 16.-x I



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Fig. 19.-x l

in the bronchus to the apical segment(Fig. 19). There were no foci of tuberculouspneumonia in this lower lobe. Clearly this is anexample of disseminated tuberculous bronchitiswith multip'e bronchial abscess formation inwhich some of the lesions are " healing."Another example is seen in Fig. 20, which shows

the cut surface of the apical segment of the upperlobe resected from a woman aged 26 with a five-year history of pulmonary tuberculosis. The seg-mental bronchus is exposed and appears normaluntil it bifurcates just below the pleura. Imme-diately beyond this bifurcation each branchexpands into a small calcified cold abscess. Theselesions are completely calcified and undoubtedlyrepresent the "healed " stage of a caseous bron-chial co'd abscess.

DISCUSSIONThe purpose of this paper is to show how

ulcero-caseous tuberculous bronchitis develops inisolated small bronchial segments as the initialtuberculous lesion in areas of lung tissue whichwere previously normal. It has been shown thatthese bronchial lesions frequently precede thedevelopment of tuberculous pneumonia in the

178

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alveolar tissue to which they are functionallyrelated. In cases where ulcero-Laseous bronchitisis progressive, and tuberculous pneumonia doesnot develop, the alveolar tissue becomes collapsed.One important consequence of the pulmonarycollapse is the drawing together of the caseous,dilated bronchi like a ripening bunch of grapes.Progressive ulceration of the diseased bronchi willthen rapidly lead to fusion of the individualbronchi and the production of a caseous masswhich may be termed a bronchial cold abscess.As the ulcero-caseous bronchitis ultimately in-volves total destruction of the bronchial wall, it isfrequently very difficult, or even impossible in afully developed caseous lesion, to determine if itarose from an area of tuberculous pneumonia oras a result of extensive ulcero-caseous bronchitis.If a number of blocks and many sections areexamined patience is usually rewarded by findingsuch bronchial remnants as cartilage, mucousgland, or epithelium where the lesion is a conse-quence of ulcero-caseous bronchitis. In the truepneumonic lesions sections stained for elastictissue will frequently outline the remnants ofalveolar walls, destroyed in the expanded state,whereas in the bronchogenic cold abscess similarsections will often clearly show the remnants ofthe former bronchial wall and bronchial arteryand collapsed alveoli. These difficulties are attheir greatest in post-mortem material where thereis usually a widespread destruction of the lung.In surgical material the destruction is usually farless extensive and pneumonic lesions can usuallybe differentiated fairly easily from the bronchialtypes of the disease.

Detailed examination of many surgical speci-mens has shown that progressive tuberculousbronchitis, often progressing from the peripheryof the lung towards the hilum, is a very importantmechanism in the development of pulmonarytuberculosis. As has already been pointed out, thistype of tuberculosis is inevitably complicated bymechanical consequences. Clearly the severity ofthe mechanical complications will depend more

upon the site of the bronchial lesion than uponits extent. Thus, ulcero-caseous bronchitis withstenosis close to a lobar or main bronchus maylead to total collapse and destruction of a wholelobe or even a lung distal to the point of stenosis.The amount of lung tissue lost and disabilitysuffered by the patient may be entirely dispro-portionate to the extent of the tuberculous lesion.It is my experience that tuberculous bronchitisoccurring in bronchi ranging from the small sub-pleural type to the lobar and main bronchus arecommonplace. In the larger bronchi, however,the picture is usually complicated by the develop-ment of extensive tuberculous bronchiectasis, andthis will be examined in a subsequent communica-tion.

SUMMARYUlcero-caseous tuberculous bronchitis of all the

segments of the bronchial tree may arise as theinitial lesion in the " spread " of pulmonary tuber-culosis to areas of the lung which were previouslyhealthy.

If such a focus of ulcero-caseous bronchitisextends, it will be complicated by collapse of thealveolar tissue to which it is functionally related.Where collapse has occurred a further extension

of the ulcerative process leads to confluence of thecaseous bronchi with the formation of a bronchialcold abscess.

Bronchial cold abscesses may be single, givingrise to solitary caseous foci, or multiple, givingrise to disseminated caseous foci.The process may heal either by fibrosis or calci-

fication. Either process leads to bronchial stenosis.

I would like to thank the physicians and surgeonsof the Brompton Hospital for allowing me to use thecases contained in this paper. I would also like tothank Mr. D. F. Kemp, of the Photographic Depart-ment of the Institute of Diseases of the Chest, for thephotographs and histological preparations.

REFERENCEMeissner, W. A. (1945). Dis. Chest, 11, 18.

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ulcero-caseous tuberculous bronchitisthe lung tissue between the caseous bronchi is severely...

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