기관지 결핵 Endobronchial Tuberculosis (EBTB) Disease Review 기관지 결핵 Endobronchial Tuberculosis (EBTB) 호흡기 내과 4년차 유정선

Clinical features High prevalence in young people Male : female = 1 : 4~5 High infectivity Simulating bronchial asthma Difficult to diagnosis Bronchoscopic appearances can be similar to those of a tumor Can be mistaken for malignancy EBTB can lead to collapse of a lobe Complication : Bronchostenosis (->dyspnea) Cough, shortness of breath and wheezing

Diagnosis History taking, P/E, ROS Wheezing or stridor, severe cough, hemoptysis Bronchoscopy Sputum culture AFB stain(+) CXR Nomal

Pathogenesis Not yet fully established Direct implantation of tubercle bacilli Direct airway infiltration Erosion and protrusion of intrathoracic tuberculous LN Hematogenous spread Extension to peribronchial region by lymphatic drainage 아직 원인이 명확하지는 않으나 주변 폐 실질의 감염으로부터 기관지로의 결핵균의 직접 착상 주변 종격부 림프절로부터 기도로 결핵균 침윤 결핵에 감염된 흉곽 내 림프절이 기도벽을 미란시키고 뚫고 나오는 경우 결핵균의 혈행성 전파 기도 주변의 림프계로부터의 유입 등이 주요 발병기전으로 알려져 있다

Clinical course Variable Several possible pathogenetic mechanisms Interaction between effect of mycobacteria, host immunity & antituberculous drugs is complex Three factors result in altered course Forms of EBTB need to classified into subtypes

Classification of EBTB by bronchoscopic finding CHEST 2000: 117: 385

A. Actively Caseating EBTB CHEST 2000: 117: 385

A. Actively Caseating EBTB bronchial mucosa : swollen, hyperemic & diffusely covered with whitish cheese-like material luminal narrowing ± granulation tissue Poor prognosis 2/3 : changed into fibrostenotic type 1/3 : healed without complication 부어있고 충혈되어있고 하얀 cheese 확산되게 퍼져있음 이로인해 Lumen이 좁아져 있고 granulation tissue는 있는경우도 없는경우 도 있습니다. 예후는 2/3가 fibrostenotic type CHEST 2000: 117: 385 J Korean Med Assoc 2006: 49(9): 799~805

B. Edematous-Hyperemic EBTB CHEST 2000: 117: 385

B. Edematous-Hyperemic EBTB Bronchial lumen : narrowed due to severe mucosal swelling ± caseous material & fibrous contracture found Poor prognosis fibrostenotic type within 2 - 3 months after treatment complete obstruction of bronchial lumen CHEST 2000: 117: 385 J Korean Med Assoc 2006: 49(9): 799~805

C. Fibrostenotic EBTB CHEST 2000: 117: 385

C. Fibrostenotic EBTB Narrowing of bronchial lumen + fibrosis Crushed waterdrop shape not circularly involve normal mucosa was partly spared Dense fibrosis Biopsy from inflamed mucosa at periphery of lesion 으스러진 물방울 모양 CHEST 2000: 117: 385 J Korean Med Assoc 2006: 49(9): 799~805

D. Tumorous EBTB CHEST 2000: 117: 385

D. Tumorous EBTB Endobronchial mass Surface : covered with caseous material & nearly totally occluded bronchial lumen Mistaken for lung cancer Prognosis : most grave & unpredictable 예후는 예측하기 곤란하지만 그냥 두면 70% 이상에서 기 도협착이 발생하므로 치료경과 중 6개월 이상 기관지경검사 를 추시할 필요가 있으며 기도협착을 최소화하기 위해선 약 물치료와 함께 조기에 기관지 내 중재적 치료가 중요하다 CHEST 2000: 117: 385 J Korean Med Assoc 2006: 49(9): 799~805

Enlargement of peribronchial & mediastinal LN CHEST 2000: 117: 385 CT : Tumerous EBTB Enlargement of peribronchial & mediastinal LN

E. Granular EBTB CHEST 2000: 117: 385

E. Granular EBTB scattered grains of boiled rice severe inflammatory change CHEST 2000: 117: 385 J Korean Med Assoc 2006: 49(9): 799~805

F. Ulcerative EBTB CHEST 2000: 117: 385

F. Ulcerative EBTB Bronchial ulcer Similar to that of peptic ulcer Good prognosis : so excellent CHEST 2000: 117: 385 J Korean Med Assoc 2006: 49(9): 799~805

G. Nonspecific Bronchitic EBTB CHEST 2000: 117: 385

G. Nonspecific Bronchitic EBTB Mild mucosal swelling & hyperemia Proven by bronchoscopic biopsy of lesions Good prognosis CHEST 2000: 117: 385 J Korean Med Assoc 2006: 49(9): 799~805

Observed healing process ( ) Presumptive natural course ( ) CHEST 2000: 117: 385

Bronchoscopy (Case)

Actively Caseating EBTB

Edematous-Hyperemic EBTB

Fibrostenotic EBTB

(2007.10.17) Rt. RUL ant. Segmental branch를 완전히 막고 있는 mass가 관찰됨. “inflammatory mass” (2008.02.25) RUL ant. 에 Decreased mass. 기관지내경을 막고 있지 않음. Tumorous EBTB

(2007.10.17) Rt. RUL ant. Segmental branch를 완전히 막고 있는 mass가 관찰됨. “inflammatory mass” (2008.02.25) RUL ant. 에 Decreased mass. 기관지내경을 막고 있지 않음. Granular EBTB

Ulcerative EBTB

Treatment Pulmonary Tbc.와 동일한 약물 요법(2HREZ+4HRE) Steroid (to prevent bronchostenosis) Balloon catheter (to dilate bronchus) Bronchoplasty

Conclusion Therapeutic outcome of each subtype (except tumorous type) : predicted by follow-up bronchoscopy during initial 2 to 3 months of treatment Tumorous EBTB : aggressive therapy Bronchoscopic approach : mandatory for prompt diagnosis of EBTB & prevention of further bronchostenosis