Lee J H, Chung H S
Department of Internal Medicine, Seoul National University College of Medicine, Seoul Municipal Boramae Hospital, Korea.
Respirology. 2000 Dec;5(4):411-7.
Endobronchial tuberculosis (EBTB) causes problems in both making a diagnosis and following up the endobronchial lesion, because the lesion is not evident in simple chest radiograph. Frequently, the diagnosis and follow up of EBTB lesion during treatment mainly depend on bronchoscopy. Chest computed tomography (CT) and pulmonary function test (PFT) have also been used in evaluating EBTB and differentiating it from the other diseases. Primary purpose of the present study was to observe the change of EBTB lesion during treatment and determine the optimal time and the indication of follow-up bronchoscopy. We also evaluate the usefulness of chest CT and PFT in EBTB.
Eighty-one biopsy-proven EBTB patients were enrolled from 1992 to 1997. Endobronchial tuberculosis was classified into seven subtypes: actively caseating, fibrostenotic, oedematous-hyperaemic, tumorous, ulcerative, granular, and non-specific bronchitic type according to bronchoscopic features by Chung's Classification. The change of bronchoscopic findings during treatment in each subtype of EBTB was evaluated prospectively. Follow-up bronchoscopy was done each month until there was no subsequent change in endobronchiat lesion, and every 3 months thereafter, and at the end of treatment. Chest CT and PFT were performed in 26 and 68 patients respectively, at initial bronchoscopy.
Twenty-two of the 34 cases of actively caseating EBTB changed into the fibrostenotic type, and the other 12 healed without sequelae. Seven of the 11 cases of oedematous-hyperaemic EBTB changed into the fibrostenotic type, and the other four healed. Nine of the 11 cases of granular EBTB, six cases of non-specific bronchitic EBTB, and two cases of ulcerative EBTB resolved completely. However, the other two cases of granular EBTB changed into the fibrostenotic type. Seven cases of fibrostenotic EBTB did not improve despite antituberculosis chemotherapy. These various changes in bronchoscopic findings occurred within 3 months of treatment. In 10 cases of tumorous EBTB, seven progressed to the fibrostenotic type. In addition, new lesions appeared in two cases, and the size of the initial lesions increased in another two cases, even at 6 months after treatment. On chest CT findings of 26 EBTB patients, the length of bronchial involvement was measured from 10 to 55 mm. Bronchial stricture was noticed in 25 cases and the range of narrowing was from total occlusion to near normal, and there was wide variation in bronchial stricture even within same subtype of EBTB. The dominant feature of PFT in EBTB at the diagnosis was restrictive pattern.
The therapeutic outcome of each subtype of EBTB can be predicted by follow-up bronchoscopy during the initial 3 months, with the exception of the tumorous type. In tumorous EBTB, the evolution of the lesions during treatment is very complicated, and bronchial stenosis may develop at a later time. Chest CT was useful in measuring the length of involved bronchus and degree of stricture in EBTB. PFT may be useful in differential diagnosis and follow up of EBTB.
支气管内膜结核（EBTB）在诊断和支气管内病变的随访方面均存在问题，因为在普通胸部X线片中病变并不明显。通常，EBTB病变在治疗期间的诊断和随访主要依赖于支气管镜检查。胸部计算机断层扫描（CT）和肺功能测试（PFT）也已用于评估EBTB并将其与其他疾病相鉴别。本研究的主要目的是观察EBTB病变在治疗期间的变化，确定随访支气管镜检查的最佳时间和指征。我们还评估了胸部CT和PFT在EBTB中的应用价值。
1992年至1997年纳入81例经活检证实的EBTB患者。根据钟氏分类法，依据支气管镜特征将支气管内膜结核分为七种亚型：活动性干酪型、纤维狭窄型、水肿充血型、肿瘤型、溃疡型、颗粒型和非特异性支气管炎型。对EBTB各亚型治疗期间支气管镜检查结果的变化进行前瞻性评估。每月进行一次随访支气管镜检查，直至支气管内病变不再有后续变化，此后每3个月检查一次，并在治疗结束时进行检查。分别对26例和68例患者在初次支气管镜检查时进行胸部CT和PFT检查。
34例活动性干酪型EBTB患者中有22例转变为纤维狭窄型，其余12例愈合且无后遗症。11例水肿充血型EBTB患者中有7例转变为纤维狭窄型，其余4例愈合。11例颗粒型EBTB患者中有9例、非特异性支气管炎型EBTB患者中有6例以及溃疡型EBTB患者中有2例完全缓解。然而，另外2例颗粒型EBTB转变为纤维狭窄型。7例纤维狭窄型EBTB患者尽管接受了抗结核化疗仍未改善。支气管镜检查结果的这些不同变化发生在治疗的3个月内。10例肿瘤型EBTB患者中，7例进展为纤维狭窄型。此外，即使在治疗6个月后，仍有2例出现新病变，另2例初始病变的大小增加。在26例EBTB患者的胸部CT检查结果中，支气管受累长度为10至55毫米。25例发现支气管狭窄，狭窄范围从完全闭塞到接近正常，即使在同一亚型的EBTB中，支气管狭窄也存在很大差异。EBTB诊断时PFT的主要特征为限制性模式。
除肿瘤型外，在最初3个月内通过随访支气管镜检查可预测EBTB各亚型的治疗结果。在肿瘤型EBTB中，治疗期间病变的演变非常复杂，且后期可能会出现支气管狭窄。胸部CT有助于测量EBTB中受累支气管的长度和狭窄程度。PFT可能有助于EBTB的鉴别诊断和随访。
