1. An unusual endobronchial Tumour S. A. Saleemi

2. A 28 years old Sudanese office worker A 28 years old Sudanese office worker smoker, married with 2 children smoker, married with 2 children four weeks history of dry cough and occasional hemoptysis. four weeks history of dry cough and occasional hemoptysis. Good appetite, no weight loss Good appetite, no weight loss No chest pain, no shortness of breath No chest pain, no shortness of breath No history of recent travel No history of recent travel No past history of respiratory illness No past history of respiratory illness Not on any medications Not on any medications CASE HISTORY

3. Past medical history Past medical history Kaposi Sarcoma of both lower limbs treated with chemotherapy and radiation therapy 3 years ago. Kaposi Sarcoma of both lower limbs treated with chemotherapy and radiation therapy 3 years ago. His HIV screening was negative on several occasions. His HIV screening was negative on several occasions.

4. Clinical examination: Afebrile, P80/min regular, BP 110/70, RR 20/min SpO2 96% on RA No pallor, no jaundice, No cervical lymphadenopathy No pallor, no jaundice, No cervical lymphadenopathy Trachea central, Chest clear, no added sounds CVS: unremarkable Abdomen: NAD CNS: no abnormal signs Legs: No calf swelling. Residual changes on his lower limbs after phototherapy and radiotherapy.

5. investigations investigations FBC and differential - Normal values FBC and differential - Normal values ESR 35 ESR 35 Renal profile- normal Renal profile- normal Liver profile- normal Liver profile- normal Bone profile – normal Bone profile – normal Sputum culture - normal Sputum culture - normal Sputum for Acid Fast stain (AFB)- negative Sputum for Acid Fast stain (AFB)- negative Recent spirometry- normal Recent spirometry- normal ECG - normal ECG - normal

6. Chest X-ray DR. Saleemi

7. Bronchoscopy Bronchoscopy

9. Bronchial washing Bronchial washing Biopsy of both lesions Biopsy of both lesions

10. Bronchial wash Negative for malignant cells, Negative for malignant cells, Culture Negative Culture Negative AFB stain Negative AFB stain Negative

11. Biopsy Biopsy Caseating granuloma Caseating granuloma

12. The patient was started on anti tuberculosis treatment comprising of four drugs Isoniazid, Rifampicin, pyrazinamide and Ethambutol. The patient was started on anti tuberculosis treatment comprising of four drugs Isoniazid, Rifampicin, pyrazinamide and Ethambutol. Later on Bactec AFB culture of bronchial wash came back as positive for Mycobacterium tuberculosis, Later on Bactec AFB culture of bronchial wash came back as positive for Mycobacterium tuberculosis, Final sensitivity result showed pan-sensitive mycobacterium tuberculsis Final sensitivity result showed pan-sensitive mycobacterium tuberculsis

13. Follow-up after six weeks showed resolution of cough symptom and significant clearing of lung infiltrates on repeat chest X-ray. Follow-up after six weeks showed resolution of cough symptom and significant clearing of lung infiltrates on repeat chest X-ray. A repeat bronchoscopy was not offered in view of significant clinical and radiological improvement A repeat bronchoscopy was not offered in view of significant clinical and radiological improvement

16. Endobronchial tuberculosis is usually a complication of primary pulmonary tuberculosis mostly occurring in children, but can occur in adults. The incidence of endobronchial TB is higher in females. is usually a complication of primary pulmonary tuberculosis mostly occurring in children, but can occur in adults. The incidence of endobronchial TB is higher in females. 1.Ip MS; So SY; Lam WK; Mok CK. Endobronchial tuberculosis revisited. Chest 1986 May; 89(5):72-30

17. Commonest form of endobronchial TB Commonest form of endobronchial TB is mucosal erosions. is mucosal erosions. Submucosal lymph node involvement Submucosal lymph node involvement can lead to endobronchial ulceration, granulation tissue, polypoid or ulcerous lesions and local infiltration causing bronchial stenosis. can lead to endobronchial ulceration, granulation tissue, polypoid or ulcerous lesions and local infiltration causing bronchial stenosis. 1- Matthews JI; Matarese SL; Carpenter JL. Endobronchial tuberculosis simulating lung cancer. Chest 1984 Oct; 86(4):642-4 2- Altin S; Cikrikcioglu S; Morgul M; Kosaf F; Ozyurt H. 50 Endobronchial tuberculosis cases based on bronchoscopic diagnosis. Respiration 1997; 64(2): 162-4.

18. Erosion of mediastinal lymph nodes into main bronchus has also been reported Erosion of mediastinal lymph nodes into main bronchus has also been reported Endobronchial Tb presenting as mass lesion simulating lung cancer is rare and only a few case reports are in the literature. Endobronchial Tb presenting as mass lesion simulating lung cancer is rare and only a few case reports are in the literature. Guleria R, Gupta R, Panda JN. Endobronchial tuberculosis simulating lung cancer. Indian J Chest Dis Allied Sci 1997 Oct-Dec; 39(4): 251-4.

19. Cough is the most frequent symptom occurring in almost 97% of cases. Cough is the most frequent symptom occurring in almost 97% of cases. The most serious complication of endobronchial TB is bronchial stenosis The most serious complication of endobronchial TB is bronchial stenosis

20. Early diagnosis and treatment is essential in preventing the disabling complication of bronchial stenosis which can lead to morbidity and even mortality due to secondary complications. Early diagnosis and treatment is essential in preventing the disabling complication of bronchial stenosis which can lead to morbidity and even mortality due to secondary complications. Lee JH, Chung HS. Bronchoscopic, radiologic and pulmonary function evaluation of endobronchial tuberculosis. Respirology Dec 2000,5(4) 411-7

21. Several treatment options have been tried to prevent bronchial stenosis including Isoniazid inhalation and systemic steroids but results are not promising. Several treatment options have been tried to prevent bronchial stenosis including Isoniazid inhalation and systemic steroids but results are not promising.

22. Role of corticosteroids therapy in preventing complications in endobronchial tuberculosis is controversial. Role of corticosteroids therapy in preventing complications in endobronchial tuberculosis is controversial. Study from South Korea has shown no influence on the outcome of endobronchial tuberculosis by addition of corticosteroids in a prospective trial. Study from South Korea has shown no influence on the outcome of endobronchial tuberculosis by addition of corticosteroids in a prospective trial. Park IW, Choi BW, Hue SH. Prospective study of corticosteroid as an adjunct in the treatment of Endobronchial tuberculosis in adults. Respirology 1997 Dec; 2(4) 275-81.

23. Most authors stress the need for early bornchoscopy to diagnose the condition so that anti tuberculosis treatment is started on time to prevent serious complications of endobronchial tuberculosis. Most authors stress the need for early bornchoscopy to diagnose the condition so that anti tuberculosis treatment is started on time to prevent serious complications of endobronchial tuberculosis. 1- Cherian MJ, Dahniya MH, al-Marzouk N, Osmanagich E, Abul A, Haider A. Australias Radiol 1998 Primary pulmonary tuberculosis presenting as mass lesions and simulating tumours in children. Australas Radiol 1998 Nov; 42(4):309-12 2- Chung HS; Lee JH. Bronchoscopic assessment of the evolution of Endobronchial tuberculosis. Chest.Feb2000, 117(2) 385-92

24. Thank you