Endobronchial Tuberculosis (EBTB)

Definition & Pathogenesis

Endobronchial tuberculosis is tuberculosis infection of the tracheobronchial tree with granulomatous inflammation and subsequent fibrosis of the bronchi.

• Primary infection occurs through lymphatic spread from infected mediastinal nodes
• Secondary infection through direct implantation from infected sputum
• Affects bronchial mucosa, submucosa, and cartilage

Key Characteristics

• More common in children than adults
• High risk of bronchial stenosis (60-95% of cases)
• Often missed due to normal chest X-ray in early stages

Common Symptoms

• Persistent dry cough (>3 weeks)
• Wheezing (localized or generalized)
• Decreased breath sounds
• Fever and night sweats
• Weight loss or failure to thrive
• Hemoptysis (rare in children)

Physical Examination

• Decreased chest movement on affected side
• Localized wheeze or rhonchi
• Signs of volume loss in affected lobe
• Lymphadenopathy (cervical, supraclavicular)

Diagnostic Approach

Essential Investigations

• Bronchoscopy (gold standard)
  • Direct visualization of lesions
  • Biopsy for histopathology
  • Bronchial washing for AFB and culture
• Imaging
  • Chest X-ray
  • CT chest with contrast
  • Virtual bronchoscopy
• Microbiological Tests
  • Sputum AFB (3 samples)
  • GeneXpert MTB/RIF
  • Culture and drug sensitivity

Bronchoscopic Classifications (Chung's)

1. Actively caseating
2. Edematous-hyperemic
3. Fibrostenotic
4. Tumorous
5. Granular
6. Ulcerative
7. Nonspecific bronchitic

Treatment Protocol

Medical Management

• Standard ATT regimen
  • 2HRZE + 4HR (minimum 6 months)
  • Consider extended therapy (9-12 months) in severe cases
• Adjunctive Therapy
  • Corticosteroids (controversial)
    • Prednisolone 1-2 mg/kg/day
    • Duration: 4-8 weeks with tapering
  • Bronchodilators for wheeze

Interventional Procedures

• Balloon dilatation for stenosis
• Bronchial stenting in selected cases
• Surgical intervention for persistent stenosis

Major Complications

• Bronchial stenosis (most common)
  • Can occur despite adequate ATT
  • Risk highest in fibrostenotic type
• Bronchiectasis
• Atelectasis
• Post-obstructive pneumonia
• Lung collapse
• Hemoptysis

Monitoring

• Regular bronchoscopy during treatment
• Pulmonary function tests
• Follow-up imaging
• Long-term respiratory monitoring