Kunal Shekhar, Shah Ashok
Department of Pulmonary Medicine, Vallabhbhai Patel Chest Institute, University of Delhi, Delhi, India.
Department of Pulmonary Medicine, Vallabhbhai Patel Chest Institute, University of Delhi, Delhi, India.
Indian J Tuberc. 2017 Jan;64(1):5-9. doi: 10.1016/j.ijtb.2016.10.003. Epub 2016 Dec 15.
Bronchial anthracofibrosis (BAF), diagnosed bronchoscopically, is a clinical entity which is now beginning to emerge from obscurity. This is commonly encountered in elderly females with history of long-standing exposure to biomass fuel smoke in poorly ventilated kitchens. As awareness of BAF has increased in recent times, distinct clinicoradiological and bronchoscopic features of the disease have emerged. Diagnosis is achieved by visualisation of bluish-black mucosal hyperpigmentation along with narrowing/distortion of the affected bronchus on fibreoptic bronchoscopy (FOB). BAF was first recognised nearly a decade ago in India, when a 65-year-old female who presented with a middle lobe syndrome (MLS) was diagnosed with concomitant pulmonary tuberculosis and BAF. Pulmonary tuberculosis, seen in up to one-third of patients with BAF, is now considered to be an associated condition rather than a causative agent, as was initially postulated.
Respiratory symptomatics with a history of biomass fuel smoke exposure underwent high-resolution computed tomography (HRCT) of chest as well as FOB to establish a diagnosis of BAF. In patients who were diagnosed with BAF, an association with tuberculosis was also sought for.
Of the 31 patients diagnosed with BAF in one unit, four had an associated diagnosis of tuberculosis. Cough was the most common presenting symptom seen in all four patients. Imaging revealed consolidation in 3/4 subjects, nodular lesions in one and in another one multifocal narrowing on HRCT, a feature characteristic of BAF. One patient had a diagnosis of MLS. FOB, in all four subjects, visualised anthracotic pigmentation along with narrowing/distortion of the affected bronchi with the left upper lobe bronchus being most commonly affected. Stains and cultures of the bronchial aspirate for Mycobacterium tuberculosis were positive in all four patients while GeneXpert performed in three was positive in all. Rifampicin resistance was not detected. One patient had an actively caseating form of endobronchial tuberculosis as evidenced by oedematous, hyperemic mucosa along with whitish cheese-like material affecting the right middle lobe as was seen on FOB.
Once a diagnosis of tuberculosis is established in a patient with long-standing exposure to biomass fuel smoke, invasive procedure required for the diagnosis of BAF is usually not considered and the diagnosis would remain confined to pulmonary tuberculosis. This study highlights the need to recognise BAF and to exclude pulmonary tuberculosis in such patients.
支气管炭末纤维化（BAF）通过支气管镜检查确诊，是一种目前才开始从隐匿状态中显现出来的临床病症。这在长期暴露于通风不良厨房中生物质燃料烟雾的老年女性中较为常见。近年来，随着对BAF认识的提高，该疾病独特的临床放射学和支气管镜特征逐渐显现。通过纤维支气管镜检查（FOB）观察到受影响支气管的蓝黑色黏膜色素沉着以及狭窄/变形来确诊BAF。BAF近十年前在印度首次被认识，当时一名出现中叶综合征（MLS）的65岁女性被诊断为合并肺结核和BAF。在高达三分之一的BAF患者中可见的肺结核，现在被认为是一种相关病症，而非最初假设的致病因素。
有生物质燃料烟雾暴露史的有呼吸道症状者接受胸部高分辨率计算机断层扫描（HRCT）以及FOB以确诊BAF。对于诊断为BAF的患者，还探寻其与肺结核的关联。
在一个单位确诊的31例BAF患者中，4例同时诊断为肺结核。咳嗽是所有4例患者最常见的首发症状。影像学显示3/4的受试者有实变，1例有结节性病变，另1例在HRCT上有多灶性狭窄，这是BAF的特征性表现。1例患者诊断为MLS。在所有4例受试者中，FOB均观察到炭末色素沉着以及受影响支气管的狭窄/变形，最常受累的是左上叶支气管。所有4例患者支气管吸出物的结核分枝杆菌染色和培养均为阳性，3例行GeneXpert检测的均为阳性。未检测到利福平耐药。1例患者有活动性干酪样支气管内结核，如FOB所见，表现为水肿、充血的黏膜以及累及右中叶的白色奶酪样物质。
一旦在长期暴露于生物质燃料烟雾的患者中确诊肺结核，通常不会考虑进行诊断BAF所需的侵入性检查，诊断将局限于肺结核。本研究强调了在此类患者中认识BAF并排除肺结核的必要性。
