Case Presentation : Tracheal obstruction by calcified TB gland in a child

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.