Endobronchial Tuberculosis in Children: Dis Chest

Endobronchial Tuberculosis in Children
JOHN F. DALY, DAVID S. BROWN, EDITH M. LINCOLN and VIRGINIA N. WILKING Dis Chest 1952;22;380-398 DOI 10.1378/chest.22.4.380 The online version of this article, along with updated information and services can be found online on the World Wide Web at: http://chestjournal.chestpubs.org/content/22/4/380
CHEST is the official journal of the American College of Chest Physicians. It has been published monthly since 1935. Copyright 1952 by the American College of Chest Physicians, 3300 Dundee Road, Northbrook, IL 60062. All rights reserved. No part of this article or PDF may be reproduced or distributed without the prior written permission of the copyright holder. (http://chestjournal.chestpubs.org/site/misc/reprints.xhtml) ISSN:0096-0217
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Endobronchial
EDITH JOHN M.
Tuberculosis
in
BROWN, N.
Children*
M.D., WILKING, M.D.
F. DALY, M.D., DAVID S. LINCOLN, M.D. and VIRGINIA New York, New York
The symptoms endobronchial has been A Chest pital of tients suggested the 1) 2) 3) 4) 5) Since years, these A. I. ious
importance and signs lesions, discussed study
of
tuberculous of compression obstructive others.6 has been of information of films, primary clinical in incidence view: of
hilar of air pneumonitis undertaken
lymph passages and by the
nodes
in producing
causing
bronchiectasis Childrens Hoscourse those physical performed in this pasigns with group
by
co-operative Clinic and to obtain bronchial whose bronchial following To and To To x-ray To and To selves the this objectives. Clinical Incidence: forms of Ward 89 of 43 of Features: discover
Department further
Otolaryngology about the tuberculosis. behavior bronchoscopy bronchial methods disease through of bronchial
at Bellevue cause and In and was disease which by the
complications x-ray objectives the the course
obstruction,
to evaluate study the correlate and evaluate local. study and study will be
diagnostic of bronchial seen methods of effect in the
are available. repeated bron-
choscopy. what was clinical pictures. available the b) end results bronchoscope with systemic a) in them-
therapy-both lesions: distal only on our lung two
in their has been a progress
on the progress report
segment. and one-half to realize
efforts
Four
hundred during these (10
and were the two patients per cent
thirty-four seen and were of a for half examined entire the
patients first year
with time
varon the In
tuberculosis
Childrens that time, and in
study period. bronchoscopically group of patients
these
the
*From the Department of Otolaryngology of New York University PostGraduate Medical School and the Department of Pediatrics of New York University College of Medicine and from the Otolaryngology Service and the Chest Clinic of the Childrens Medical Service of Bellevue Hospital, New York City. Aided by the National Tuberculosis AssocIation, Parke, Davis and Company and the Division of Research Grants and Fellowships of the National Institutes of Health, U. S. Public Health Service. 380
Vol.
XXII
ENDOBRONCHIAL bronchial could staff of of of a be in that 90 the lesions established. suspecting tuberculous patients study truer this age endobronchial with There the total group Bronchial children. through with in Age: per per age the proved Table Bronchial cent cent group. from Stage had of hilar had of four primary and chronic in focus the of of I. tuberculosis children. the the The Tuberculosis: patients patients ages of to Forty-two months tuberculosis mediastinal pulmonary Of study bronchial was group found an seen period. estimate group. disease were
TUBERCULOSIS seen, As the bronchial bronchial for This of the the figure incidence presented seen in in study which disease disease first time (30 definite progressed, increased was during per of cent), this the adults,
381 tuberculous the found the acumen and in last probably disease form which in of It is 30 six
seen), etiology of the noteworthy per months represents children tuberculous is in and III. seen those shown IV. in 48.4 69.8 that ranged V. group ence patient the cent
One child frequently
associated II. Sex: both
cavitation. even distribution of children seen tuberculous was found 27.9 were tuberculosis was those were with the nine per white, were diagnosed seen under bronchial patients years. of the 43 on The In one the had early patients x-ray by remaining in the this presdiagnosed lymphadenopathy. tuberculosis. and the in time one the during three with cent of males during the and females study period in of as
in the Race:
to have tuberculosis Although period
bronchial disease. more commonly of only white more the years tuberculosis bronchial all 13.9 the per children, frequently study of children cent
non-white
younger
period age, were disease but in
five calcificationof bronchial
calcification the disease meninhis
was present parenchymal was losis, gitis discovered.
hilar region was present at patients had
Five
disseminated
miliary
tubercuof
as well as with miliary
primary disease dissemination
and during
tuberculous stages
TABLE
I
Children with
Disease
To tal
Group Per
Bronchial
Race
Number
Cent
Number
Per
Cent
Negro Puerto White Chinese TOTAL Rican
144 165 121 4 434
33.2 38.0 27.9 0.9

-
18 19 6
41.9 44.2 13.9

-
43
382 bronchial in 18 The of the signs the 43 to 25
DALY, disease. patients. and presenting patients. months, the patients frequent which were high had Physical that (1) pitched no the
BROWN, Definite symptoms
LINCOLN Ghon of other a mean of known the symptom
AND tubercies endobronchial of 2Q, tuberculous there interval tuberculous tuberculosis.
WILKING were tuberculosis infection was of an seven bronchial noted for cough an
Oct.,
1952
ultimately cornin of disease in cough. varying cough. inare Table The from and
seen
prized these one months made VI. II, lesion short, children VII. dicates the symptoms
evidence In the with diagnosis with
23 from was
of
interval
one-half
before in the Symptoms most
During were wheeze
Diagnostic was (2) bark pressure to
Period:As persistent specific
only a
apparently and
endobronchial Twelve
expiratory symptom Signs During physical
a paroxysmal
suggestive of the Diagnostic signs of bronchial
bronchial disease. Period: Table III tuberculosis
classic
TABLE
II of weeks Frequency 18 14 Instances Instances
Symptoms Persistent, Brassy Wheezing Fever Repeated Pertussis-j pneumonias ust prior to in the or dry cough for cough
in
Order
2 or more
paroxysmal
8 Instances 7 Instances past of bronchial tuberculosis 5 Instances 2 Instances
discovery
TABLE
Physical Diminished Dullness Persistent Rales Diminished Bronchial Deviation Hyper-resonance Tracheal Diminished Diminished shift tactile vocal Three fremitus fremitus patients thoracic breath motility sounds wheeze breath sounds
Signs
in
III Order
of
Frequency 36 31 12 Instances Instances Instances
9 Instances on respiration 6 Instances 5 Instances (cardiac dullness) 4 Instances 3 Instances 2 Instances 2 Instances 2 Instances presented no physical signs.
of mediastinum
Vol.
XXII
ENDOBRONCHIAL expected X-ray case on five shadows, Of diagnose fissures. were were and was the involved segment cases abnormal leaflets. from changes limitation involved diagnostic and study on in the right was was displayed elevation Fluoroscopy x-ray films associated and chest and with found the left left. side middle the involved in any case
TUBERCULOSIS of bronchial obstruction,
383 regardless
findings of the with largement homogeneous remaining parenchymal cause. VIII. one
Features During the with chronic pulmonary tuberculosis x-ray shadows showed other the of films. showed Thirty-seven emphysema than 37 with bronchial significant It in is the They in (14 right at or was in the involving
Diagnostic tuberculosis, hilar of lobes of the or an probable or 42
Period: Excluding the 42 mediastinal showed entire infiltrate segmental from of one these far on most and (12 in one more the the instances). this series. seven the of or lung segments
patients node enthe without of the it films
primary
dense, and
primary infection. was possible to alone of than 33 cases volved frequently lobe and Thirteen showed matic gained namic matic of the alter ination B. I. most separate use the abnormalities they in 26, interlobar
lobar or obstruction displacement
shadows, x-ray more radiographic frequently right frequently next
because
noteworthy right were 10. The upper least of depression useful in observing bronchial in from films. Disease: were one-half examined were the once lung noted
that
side most Every
in in-
lobe
instances),
deviation
mediastinum and of
diaphrag-
confirming impressions the intrathoracic dyobstruction. Diaphragshift and splinting no case did fluoroscopy careful physical exam-
displacement, mediastinal were noted, but gained x-ray of the patients two were procedures and
impressions of the Aspects
Bronchoscopic Procedure: during of
Eighty-nine the
examined year repeatedly, performed. only inspection experience, serious study
bronchosperiod. more with than the was Since 230
copically
these children bronchoscopic general
Satisfactory of a
bronchoscopy anesthetic was trauma
could be because
accomplished careful in be which this our no may type occurred,
necesbeen the two
sary. safe, However,
A method free of a to
developed, and has of caution and familiar prolonged intubation the ether a careful
which produced should
has complications. concerning distressing In
word of one
expressed
development problem children
spasm not of
apnea, with apnea
present a of anesthesia. which was
a period
success-
fully managed by of oxygen through The study required
with the cannula inspection
bronchoscope and of the scope. of the
delivery entire tracheo-
384 bronchial
DALY, tree and the
BROWN, an
LINCOLN accounting To few
AND of accomplish months not to
WILKING every to say would this nine quite make We segmental in
Oct.,
1952
division age, The bronscope to also the trauma
visible through ing unanesthetized would psychic choscopies convinced is in place the larynx, be physically trauma
bronchoscope. child of a impossible, of such and and a
a strugglyears of inaccurate. repeat are
procedure probably done crying by
undesirable that plus with
unobtainable. the accounts child
the struggling coughing resulting desirable to the cooperation (sodium rectally cent The
while for the
subglottic develop of
edema.
These
considerations and technique. his staff. of body have
made it highly In this we had Sodium turate) weight been spasm of the of A and was choscopy the important relaxation unanesthetized hour upper period. respiratory A in was surital used a
a general anesthesia Doctor Rovenstine [1-methylbutyll dose per details bronchospasm by by of
5-allyl-5 in 1 gram solution. dangers to a tree for The of great degree accomplished containing children for to and many was test reaction region. those inspect relaxation
-2-thiobarbi50 pounds this and technique laryngeal
2 per
published.7 were controlled tracheo-bronchial
preliminary aerosolizing than to child the and to were child if the of agent.8 24 five
anesthesia 8 cc. months, years during orifices biopsies. struggling done had the in an anese.g., flexed satisfactory. and would anesthesia not any with bronchial pinching its arm the likewas be one a positive a acute was of of age bronall Such of an four
0.5 pontocaine solution 3.5 mm. bronchoscope, a 4 mm. The made also it instrument complete possible bronchi eliminated child. Bronchoscopy infection, simple childs pectoral same not As used.
a wetting younger from of two the carefully
obtain specimens the trauma due as not for 15 done the to If children if the or
laryngitis,
anesthesia
unsatisfactory. thesia was the the skin of the and If the leg on child the
effectiveness
painful stimulus, the child slowly was considered was too spasm the could When child for deep
side-anesthesia move, laryngeal child cried and anesthesia
did
lihood that was greater. considered done II. of the mantoux, tuberculosis 1) 2) 3) 4) Persistent Localized Brassy Persistent shadows because Criteria
annoying If the too of for it was was light the First felt
and bronchial or moved about, examination
develop
satisfactory
activity during bronchoscopy. Bronchoscopic Examination: was present in examination a that bronchoscopic wheeze. on x-ray even film. in the
following
findings indicated. respiratory emphysema cough. dry on x-ray cough,
film
inspection. absence of significant lung
Vol.
XXII
ENDOBRONCHIAL Sudden increase in the
TUBERCULOSIS x-ray shadow obstruction in a child examination. around of a or lobe near or
385 a prevpulmon-
5) 6) 7)
iously stable primary focus. An x-ray shadow suggesting ary segment. on positive x-ray is or gastrics physical Persistently findings
without
significant of the effectivenessof In third repeated addior from fourth the exam-
III. Criteria for bronchial lesion therapy. tion, lesions examination. procedure inations copies usually Appearance a) Bronchial Bronchial Bronchial Bronchial with b) Bronchial By By By By Although to determine subsided, quiescence mucosal granuloma caseous fibrous Repeated were With controlled were
Repeated important examinations frequently the psychic by a safe in from of this
Bronchoscopies: Visualization in evaluating the are not and general study. to on or fixation six therefore seen until physical anesthesia, Intervals months. Bronchoscopy by nodes: No. required. the trauma
possible varied
between
bronchos-
one Lesion
Initial
compression fixation fixation fixation mucosal
of 1 1 3
Cases
only and compression and compression inflammation
obstruction: inflammation material stricture in or patients permit the from ruptured node 24 11 1 1 has process watched outline a been has to the pattern of insufficient completely point of healing. through any proof
follow-up whether enough to
these not have observers
42 the
patients disease been to
gression which these The earliest stage of a bronchoscope was fixed or compressed irregularity to be mation mation able reaction first to extrabronchial of at the the site to the and was to the cases of of the of result edema. replaced a granular second caseous who the
lesions seem the disease mostly by mucosal the by
to follow in the course which could be recognized the but The next producing mucosal In from an During the 10 out this inflamed transition perforation wall of third the case actual bronchial A bronchus did not stage diffuse edema of 11 and
extra-bronchial; enlarged nodes, mucosa. third irritation stage
was display seemed and cases inflaminflamwe edematous from in showed
endobronchial In
granulation. mucosa.
were the of an two an
observe
progression stage, mass initially subsequent
we observed through displayed perforation.
compression
bronchus
386 unchanging eventual We of drain .2) In leaving bronchial patients, mucosal tributed tary in an
DALY, granular perforation. have observed granulation: extrabronchial patients, an two
BROWN, mucosa four 1)
LINCOLN for
AND four
WILKING months at from to
Oct.,
1952
the the perforate
site stage
of
his
subsequent One patient
developments was seen
mucosal
and sinus. clear, The in patients disinto solimucosa 10 place the to these were examined, typical patients in the three endo14 the
caseous mucosal lumina cleared normal became and plaques of be three granulomata.
mass through granulations were stenosed in an
a bronchial observed to scar. 3) six months In in coalescing took the in time addition 11 others first most Eleven of 10 irregularly
bronchial granulations leaving granulations mounds pedunculated average
by fibrotic average of mucosa. rising ultimately last development from 4)
bronchial exuberant, and This months granular. pedunculated
time
was first patients, found to we believe and most with an of have have was c) occurred lesion from imate the time toms treatment d) examined
noted to who displayed have lesions that the frequently
Since, granulomata,
of this type when pedunculated granuloma found form of this have gone months such than being within mass Lesions: which Arrest of lesions. a year two in removed was the on from
they were is the disease. to the complete time
endobronchial average time the polyp at persisted recurred One by a of in was two left Duration and the for
polyps of seven two site more recurred similar the after of
clearing visualization of in the base which during lesion the
patients
developed These four
fibrotic patients
stricture and the out
bronchus
pedunculated masses through on coughed endobronchial
mechanically months
bronchoscope. bronchoscopic
the
examination. an average first observed, and one-half of between these the in used. of microscopically. the Lesions: All six In of six these cases specimens granulomata showed were tuberand for Ziehlfrom on each period with to 32 lesions, actual case of 8.4 months from the range of duration months. In evaluating it is well appearance to and also to of produce that keep the time the extending the approxmind and and forms that the of
duration interval it developed is
in lesion signs
proportions
sufficient
symp-
unknown were
varying
Pathology
culous granulation caseation necrosis. 26 months showed only Neelsen a sinus section one of stain. through and tubercie these A
tissue with One such extensive biopsies specimen a bronchial bacilli
Langhans giant cells, tubercies mass, which had been present calcification. It is noteworthy that acid cheesy showed cultured fast organisms on material obtained caseation from It. necrosis
showed of the wall were
Vol.
XXII
ENDOBRONCHIAL of of 42 their had the positive course. were positive had at least of the Lesions: In Lesions: Nineteen
TUBERCULOSIS Thirty-four from were culture or more different had several two had from lesions the of gastric found and all positive lesions to the patients washings have but one gastrics.
387 in somebronchial of obseparate (always bronchi recurred. these
e) this time
Bacteriology series during
cultures on one Fifty-two
secretions which had previously f) served lesions pedunculated into the On tree IV. ren: about tuberculosis information Bronchiectasis obstruction been found the lobes which x-ray lung and the not yet persistent obstructed fever suggest has clinical out of lacking. patients It is tion bus of focus, seen to initial of Late Continued the can gives these Location
were
in this group; simultaneously. major granulomata) stem lesions Manifestations
nine patients addition, which bronchi.
or more lesions lobar which
migrated Four had in Table be any IV. in will
examination,
the is seen of of made some be a
distribution Endobronchial bronchial with definite frequent
tracheo-bronchial in before in but of the Childconclusions primary our present bronchial have in patients over to this In but this antibiotics possibility 14 patients six entirely of these the previously with and infectibn have already
Tuberculosis necessary involvement accuracy, consequence Five by coughs, of pulmonary readily although studies.
observations complications be may in have were shadows, areas and which of explored
impressions. children bronchograms Eighteen rales
these patients. bronchiectasis proved previously productive episodes respond lipiodol bronchiectasis, with obstructed.
leukocytosis, diagnosis been
evidence for the 42 studied It is planned the to have before of interest the lung two
bronchiectasis is clinical to study note been obtain is that
is equivocal, evidence for lipiodol completed. of the found to 12
in only possibility on who all 42 had the
studies patients the have
obstructubercu-
segment
which
contained
primary
bronchiectasis in
TABLE Location
Right Instances
VI of Lesions
Left Instances
Upper lobe bronchus Middle lobe bronchus Main bronchus Lower lobe bronchus Lower lobeApical Seg. bronchus TOTAL
10 10 9 5 3 37
Main bronchus Upper lobe bronchus Lower lobe bronchus Lower lobeDors. Seg. broncbus
11 2 1 1 15
388 same chiectasis likely. had by V. 39 The obstruction absorption Treatment: children or to therapy. shorter study lobe,
DALY, eight and in remaining
BROWN, have only strong two five was and
LINCOLN clinical is the with manifest these to of or no
AND
WILKING evidence pointing of
Oct.,
1952
to
bron-
possibility definite five
bronchiectasis unrather of than brondiet; strepp05used 0.5 dose for
parenchymal primaries by emphysema have no evidence bed and specific
which collapse In addition this group acid There than was 42
chiectasis. in rest in 42 had alone promizole. the control and days, was acid of effect group. when an adequate therapy with conjunction of 36 No these seperate drug was dihydroless than sufficient the it with was courses
tomycin para-aminosalicylic sible of courses streptomycin grams; to produce
dihydrostreptomycin bronchoscopically
or In of
in 34
streptomycin or never amounts and over,
was used, para-aminosalicybic blood levels
it
in daily doses, was used in per cent
3 mgm.
and
TABLE Type of Treatment and
V Course of Disease
Disease worse within 3 months after start of treatment
Improvement 3 months after start of treatment
No improvement within 3 months after start of treatment
SM0rDHSM DHSM SM and salicylic Para-aminoacid
6 1 3 5 2 3 1 1 2 1 1 3 2
.
1 1 3 4 1 1 2
DHSM and Para-aminosalicylic acid SM and Promizobe and Promizole
DHSM
SM, Para-amino-salicylic acid, Promizole Para-amino-salicybic acid alone Forceps Dilatation AgNO3 Suction Each the unit local recorded therapeutic removal
indicates one measure.
course
of chemotherapy not treated; five
or were
one not
trial
of
Three patients bronchoscopically
in the group of 42 were during their treatment.
observed
Vol.
XXII
ENDOBRONCHIAL was cent. to regulated the patient to with
TUBERCULOSIS produce chronic blood levels between disease
389 1 and where
of
promizole
3 mgm. per In contrast streptomycin and widespread three weeks, showed ment, duced in and but Table the in the
pulmonary the
produced the
complete inflammation of best result within 90 reduction Details in of who the various improved, the groups types days
clearing of the bronchial obtained in in of after the the degree and make
shallow ulcers mucosa within the 20 patients who beginning of of obstruction and results duration comparison impossible, abbe to make some are of treatproshown therapy of the
improvement was moderate by the V. small of cases lesion. Variation size the
treatment amount treated, of we have
effectiveness
chemotherapy been
_.
Figure Figure
1:
Early
with
endobronchial
of ulceration medial
tuberculosis
wall fistula of and
of
left
right
main
upper
lobe
bronchus.
3:
2: Tuberculoma
bronchus.-Figure ofmain bronchus. left
Compression
formation
Figure
4: Stenosis
of left
main
bronchus
above
opening
of left
upper
lobe.
390 observations chemotherapy. dihydrostreptomycin noted these mucosa, mucosa, wall in All two of with the these in the
DALY, about Twenty
BROWN, the were type courses
LINCOLN of of appearance lesion
AND
WILKING which with which might improvement the lesion.
Oct.,
1952
respond or was In 13 of
to
therapy of
streptomycin
given, treatment lesion was was
during
the lesion in three in two edema
bronchoscopic before the there and
was simple inflammation and compression of the overlying
granulation of the edema of the of the bronchial and of There there Nine three only, visualized. chloromycetin were distal to of the of lesion difficult obstructive infections establishing a effect such was could by of these infections. not not obvious conbe respiratory inflammathe bewas of mucosa granuboma. months
visible
inflammation lesions became
pre-treatment lesions
were pedunculated less within three
ginning were no the consisted tion used lesions in these control measures The sidered used
of streptomycin 14 courses of and so of and edema sulfa was present children. series, it in reducing use effectively. of local Use is heavy of when treated lesions
or dihydrostreptomycin similar treatment progression were bronchial evidence and Because in the there to of granulation the of tissue mucosa aureomycin suppuration presence was the pedunculated
treatment. given in which lesion and in were and of no in two three. granulomata,
improvement
Penicillin, frequently
compounds,
way
impossible the incidence therapy directed application silver nitrate
evaluate and severity to of was the made
feasible.
Topical of
antibiotics
FIGURE
Figure 5, Case 1:(a)
5a
FIGURE 1948 showing 4th to 8th interpreted 1950 showing incomplete
5b widening of mediasposterior ribs. Irregular as possible bronchogenic narrowing of bronchus fillingmiddle of lobe
X-ray of February 16, tinum to right, diffuse clouding from clouding adjacent to right heart shadow spread.-(b) Bronchogram of March 13, to right middle lobe and distortion and bronchi.
Vol.
XXII
ENDOBRONCHIAL problems movement removal of aspirator. Illustrative inherent of bronchi. pedunculated
TUBERCULOSIS in small Most granulomas scopes, successful by forceps, small
391 bronchi has been scope and the
mechanical respiratory surgical tip or
Case
Records
Rican fever showed revealed boy was admitted and a positive patch homogeneous shadow in only hyperemia of in test.
Case
February A wheeze
1: E.C.,
1948 was
an 11 because present
left the
tubercle
upper tracheo
lobe bronchial
bacilli.
month old Puerto of brassy cough, and x-ray film (Figure 5a). Bronchoscopy
tree;
and
culture
mild
of
respiratory
bronchial
distress
aspiration
continued.
positive
Repeat
for
Cough
FIGURE
6a
FIGURE
6b
FIGURE
Figure 6, Case 2:(a)
6c
FIGURE
6d
X-ray of September 1, 1949 showing marked rounded enlargement in region of righthilum.-(b) X-ray of October 19, 1949 showing widening of mediastinum to right and homogeneous clouding from 7th to 9th right posterior ribs.-(c) X-ray of January 4, 1950 showing new shadow similar to x-ray of October 19, 1949 but sharply demarcated above. Mediastinum still enlarged to right. Lateral view (d) shows clouding localized In right middle lobe; shadow in retrocardiac space interpreted as residual involvement of anterior basilar segment of right lower lobe.
392
DALY,
BROWN,
LINCOLN
AND
WILKING
Oct.,
1952
I.I
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l
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Vol.
XXII
ENDOBRONCHIAL
TUBERCULOSIS
granulation Patient in July tissue treated showed
393
on the for 42 compression medial days with
bronchoscopy in May showed extensive wall of the right middle lobe bronchus. 0.5 gm. streptomycin daily. Bronchoscopy
of right main orifice of right

tuberculous sion; brassy choscopy in chus due to
bronchus upper lobe

granulation cough December granulation in June
and tuberculous granulation bronchus; bronchoscopy in
tissue September
involving showed
Bronbron1949.
Bronchoscopy of right
showed tasis Case poliomyelitis. interpreted
tissue as before, but no evidence of comprescontinued with persistence of x-ray shadow. showed narrowing of lumen of right main tissue. Symptoms disappeared by February 1949 showed no granulation tissue, but stenosis
upper
lobe
of middle a five
bronchus.
right lobe. year middle
Bronchogram
lobe bronchus
(Figure
and
5b),
minimal
July
1950
bronchiec-
stricture of right
2: R.H.,
old
Negro
boy and X-ray
admitted chest film x-ray of
August film Oct.
31,
1949
with 6a) (Figure
Tuberculin as primary
was positive tuberculosis.
(Figure 19, 1949
6b) showed shadow in right lower lung field which decreased in size by November 14, 1949, but could still be seen on x-ray film of December 9, 1949. Bronchoscopy of December 1, 1949 showed anterior and middle basal segmental bronchi of right lower lobe obstructed with edematous tissue with purulent exudate coming from lateral segmental bronchus. X-ray film of January 4, 1950 (Figure 6c and 6d) showed new area of clouding in right middle lobe. Bronchoscopy showed a polyp arising in the right lower lobe bronchus; thickening of mucosa around orifice of right middle lobe bronchus. Dihydrostreptomycin 0.5 gm. and paraaminosalicylic acid given daily from January 21, 1950 through March 7, 1950 and para-aminosalicylic acid continued until July 5, 1950. Rapid shrinking of x-ray shadow in right middle lobe last seen in lateral view on February 1, 1950. Bronchoscopies in February and March showed decrease in size of granuloma in right lower lobe bronchus, but definite granulation tissue partially occluding right middle lobe orifice. Bronchoscopy on June 8, 1950 showed hyperemia of right middle lobe bronchus. Only slight thickening of right middle lobe orifice noted on follow-up bronchoscopy March 22. 1951.
Case 3: R.B., a 10 month old Negro boy admitted March 2, 1950 with a five month history of cough and enlarged cervical nodes. Brassy cough and wheeze on admission which persisted. X-ray film (Figure la) showed shift of medlastinum to right, emphysema on left and enlarged left root shadow. Bronchoscopy April 6, 1950 showed indentation of lateral tracheal wall above carina on left with normal mucosa. X-ray films of April 10, 1950 (Figures 7b and 7c) showed a shadow of left lower lobe collapse on oblique view not seen on posterior anterior view. A brassy cough persisted. At the end of May the child became acutely ill with fever. X-ray film of May 31, 1950 (Figure 7d) showed shadow in left upper lobe interpreted as bronchogenic spread. Streptomycin 1.0 gm. and promizole daily begun June 2, 1950. Bronchoscopy June 8, 1950 showed
extension lateral of wall of caseous left main material bronchus through a apparently mass due of granulation to rupture of tissue on a tuber-
culous node with clinical condition, 17, 1950. Steady

unchanged on
fistula formation para-aminosalicylic clinical improvement

June 29, 1950, on
into acid
August
the was July

10,
bronchus. Because of added to therapy June and August. Bronchoscopy

1950 showed large
poor
polypoid
394
DALY,
BROWN,
LINCOLN
AND
WILKING
Oct.,
1952
ir
5 5
US5
0 bD
5 o
5) C-
i0
a
5)
55)5)
. .-.
ri
05)
c
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XXII
ENDOBRONCHIAL mass occluding left
TUBERCULOSIS main bronchus, but moving
395 to and fro
granulating
with respiration; 60 per cent of this was removed with forceps. By end of August x-ray film showed marked clearing of left upper lobe and mediastinum in normal position and absence of emphysema on left. Bronchoscopies at monthly intervals showed steady improvement, however, new granuloma was noted on the medial wall of the left middle bronchus on September 1950 7, with some edema of the right main bronchus. Further improvement on x-ray film and bronchoscopy from October to February 1951, with complete clearing of left upper lobe lesion. Follow-up bronchoscopy February 1, 1951 showed polypoid mass of granulation tissue on medial wall of left main bronchus with a small amount of granulation tissue in left upper lobe bronchus. X-ray film of February 21, 1951 (Figure 7e is clear except for slight deviation of mediastinum to left and bilateral apical shadows continuous with mediastinum. SUMMARY
The associated their
endoscopic with importance case the
findings primary in children associated to endobronchial no was symptom therapy common diagnosis with
in
a and
series
of are
cases presented
of
endobronchitis to emphasize
tuberculosis endobronchial reinfection therapy. was
prognosis. disease In associated evidence of were pulmonary the with the observed. tuberculosis remaining primary effective use 42
Forty-three The one responded cases, pulmonary of streptomycin The most where
with
promptly tuberculosis,
streptomycin disease definite obtained.
suggesting paroxsymal one-fourth no symptoms of
endobronchial or
disease character. More than tuberculous sounds physical of the
was persistent Wheezing one-quarter involvement over a signs. patients. X-ray ows tive new A
was of of
cough, sometimes a complaint in the the cases bronchi. pulmonic wheeze had
brassy in the cases. breath common one-third
suggesting
localized persistent
Dullness and diminished area were the most was heard in about
films emphysema.
of lobes
37
of or
the segments
42
patients and the
showed other
homogeneous five showed
shadobstruc-
involving
Bronchoscopy technique for Criteria tuberculosis around gesting sistently significant A pattern
could of were
be anesthesia
done in wheeze,
safely with children sudden
and surital with focus, emphysema
repeatedly and Increase an local in x-ray or a in disease a primary
because pontocaine. pulmonary x-ray shadow report child asso-
of
bronchoscopy cough,
shadows of sugper-
a previously obstruction positive findings of the
stable primary or obstructive cultures on from x-ray pathogenesis gastric film of
washings or physical
without
examination.
endobronchial
396
DALY,
DROWN,
LINCOLN
AND emerges
WILKING as without a and of develop by more. bronchogram result mucosal the
Oct.,
1952
ciated with bronchoscopies; ment may wall stenosis of the 42 may precede may of a cases
primary bronchial precede ulceration follow; bronchus. has and
tuberculosis compression disease. and caseous already is suspected RESUMEN
of
repeated involve-
endobronchial
Edema erosion may proved
inflammation bronchial and in ultimately five
granulation; polyps been
Bronchiectasis
in
18
Los quitis su varon. El Cuarenta
hallazgos asociada
endobrOnquicos a tuberculosis en y tres diagnOstico ni#{241}oscon con a
en y
una
serie se
de presentan
casos
endobronpara se obseeresen prila estrepenfatizar
primaria, pronOstico. enfermedad
importancia
endobronquial pulmonar de
caso
asociado prontamente la afecciOn no hubo
tuberculosis
reinfecciOn,
pondiO los que maria, tomicina. El fu#{233} la La un nes una en

A
la estreptomicina. endobronquial se definida
En asociO de de que
los otros 42 casos, a la tuberculosis fuese efectiva
evidencia
sintoma tos
m#{225}s com#{252}n sugerente persistente, fu#{233} un los

casos
enfermedad y cuarto
que
endobronquial, sonora. de los fisicos casos.

el com-
veces
paroxistica en un
sibilancia cuarto de fueron area un

los
sintoma
no tenian
M#{225}s de m#{225}s comusobre
sintomas
sugirleran
promiso
tuberculoso obscuridad limitada tercio,

rayos X a cinco broncoscopia
de del
se lObulos
los y pulmOn.
bronquios. ruidos Un de
o segmentos
Los respiratorios silbido los enfermos.
signos disminuidos persistente

homogeneas
fu#{233} percibido
en areas entre 42,
aproximadamente,
encontraron
manchas de
correspondientes y otros La
37
enfermos
mostraban pudo
enfisema hacerse
obstructivo. segura y repetidamente, y pantocalna mediante local.
una El
nueva criterio
t#{233}cnica de para la
anestesia, broncoscopia
con surital en los
nifios
con
tuberculosis un de
primaria, fu#{233} decidido por la presencia de repetino aumento de una mancha a lOs foco primario antes estable, un aspecto obstrucciOn contenido gos de significantes Como berculosis resultado de primaria; lapatogenia o enfiesema a los de la rayos repetidas enfermedad compresiOn obstructivo, positivo X o a! examen broncoscopias, o un g#{225}strico persistentemente
tos, silbidos bronqulales, rayos X, alrededor de a los rayos X sugiriendo informe un emerge asociada sin invasiOn fisico. un patrOn con de tula mude cultivos hallazen ni#{241}oin s
endobronquial bronquial
vol.
XXII
ENDOBRONCHIAL pu#{233}de preceder a la
TUBERCULOSIS ulceraciOn y a la del el
397 granulaciOn; puede y desarrollarse p0bronquio. broncograma en
cosa seguir lipos La 5 de
despu#{233}s la erosiOn de la pared caseosos. Por #{252}ltimo vendr#{225} la bronquiectasia 42 casos y se se ha demostrado en RESUME 18 sospecha
bronquial estenosis ya m#{225}s. por
Les une au Ils
auteurs rapportent s#{233}rie dobservations de de vue observe primo-infection. du
leurs datteintes Ils et trois diagnostic
constatations endoscopiques bronchiques associ#{233}es insistent du enfants pronostic. atteints de sur leur
dans a la
tuberculose point ont
importance localisations sajoutait
quarante
bronchiques. fut rapidement deux avec montra Le chique un quart des quart suspecter et ment Chez homogenes, malades et Les de Les chique, dun evoquant Iexistence triques les La infection pression la peut localisation peuvent en mation la
Lunique cas trait#{233}grace pour
auquel un type la streptomycine. latteinte lutilisation qui lexistence aucun de larbre les un tiers fit
de reinfection Dans les quarantebronchique de la suspecter paroxystique. dun wheezing. symptOme bronchique. dans plus environ une frequents. des
autres cas une tuberculose aucune symptOme fut des la malades latteinte cas, le toux
lesquels primarie, certalne. habitue!
#{233}taitassoci#{233}e streptomycine ne latteinte Dans Plus dun pouvant faire Lobscurit#{233} zone pulmonaire Un malades. autres sifflebron-
efficacit#{233} plus o constata persistante,
parfoisa type
ne pr#{233}sentaient tuberculeuse du les fut bruit signes percu respiratoire physiques chez
diminution persistant 37 des
localis#{233}e furent
42 malades, occupant les avaient des signes purent repetee, de tuberculeuse
les radiographies montr#{233}rent lobes ou les segments. demphys#{232}me obstructif. leurs nouvelle chez la des ou un stable, ombres bronchoscopies technique les toux, enfants le une
des ombres Les cinq sans ennuls, danesth#{233}sie. atteints
auteurs facon indications
pratiquer grace a leur la bronchoscopie furent soudain jusqualors positives de latteinte grace sans aux atteinte les
de bron-
primo-infection foyer une
sifflement autour ombre obstructif, les tubages pouvant primopeut linflam-
laccrolssement primarie obstruction
radiologiques
radiologique ou bien gas-
emphys#{232}me
de cultures malgr#{233} labsence pathogenle se dessine tuberculeuse bronchique de
persistantes sur constatations radiologiques bronchique bronchoscopies de ulcerations de la parol la
expliquer. associ#{233}e a la muqueuse Loed#{232}me et et les bronchique. r#{233}p#{233}t#{233}es. La compreceder
endo-bronchique. ulceration
pr#{233}ceder
granulations. II Ii peut se
r#{233}sulter une
398 d#{233}velopper st#{233}nose de Lexistence dans autres. cinq
DALY, des la des de
BROWN, masses
LINCOLN tumorales a cas,
AND
WILKING et
Oct.,
1952
cas#{233}euses
finalement
une
bronche. bronchiectasies quarante-deux
ete prouv#{233}e par bronchographie et a ete suspect#{233}e dans dix-huit
REFERENCES 1 Macpherson, A. M. and Lutwyche, V. U.: Collapse of the Lung Associated with Primary Tuberculous Lesions, Thorax, 5:1, 1950. 2 Richards, W. F.: Bronchial Obstruction In Primary Pulmonary Tuberculosis, Proc. R. Soc. Med., 37:589, 1944. 3 Jones, E. M., Rafferty, T. N. and Willis, H. S.: Primary Tuberculosis Complicated by Bronchial Tuberculosis with Atelectasis (Epituberculosls), Am. Rev. Tuberc., 46:382, 1942. 4 Hutchlnson, J. E.: The Pathogenesis of Epituberculosis In Children, with a Note on Obstructive Emphysema, Glasgow Med. J.,30:271, 1949. 5 Roberts, J.C. and Blair, L. G.: Bronchiectasis In Primary Tuberculosis Associated with Segmental Collapse, Lancet, 258:386, 1950. 6 Jones, E. M., Peck, W. M. and Willis, H. S.: Bronchiectasis Following Primary Tuberculosis, Am. J. Dis. ChIld., 72:296, 1946. 7 Helrich, M., Daly, J. F. and Rovenstine, E. A.: Anesthetic Management of Infants and Children During Endoscopy, Ped., 6:625, 1950. 8 Miller, J. B., Mann, F. and Abramson, H. A.: A Method for Topical Anesthesia by Nebullzation of Local Anesthetics, Dis. 01 Chest, 16: 408, 1949.
Endobronchial Tuberculosis in Children JOHN F. DALY, DAVID S. BROWN, EDITH M. LINCOLN and VIRGINIA N. WILKING Dis Chest 1952;22; 380-398 DOI 10.1378/chest.22.4.380 This information is current as of May 12, 2010
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Endobronchial Tuberculosis in Children

importance and signs lesions, discussed study

hilar of air pneumonitis undertaken

lymph passages and by the

at Bellevue cause and In and was disease which by the

complications x-ray objectives the the course

diagnostic of bronchial seen methods of effect in the

are available. repeated bron-

therapy-both lesions: distal only on our lung two

in their has been a progress

on the progress report

segment. and one-half to realize

hundred during these (10

and were the two patients per cent

thirty-four seen and were of a for half examined entire the

patients first year

Childrens that time, and in

study period. bronchoscopically group of patients

One child frequently

associated II. Sex: both

to have tuberculosis Although period

period age, were disease but in

five calcificationof bronchial

calcification the disease meninhis

was present parenchymal was losis, gitis discovered.

hilar region was present at patients had

as well as with miliary

primary disease dissemination

Negro Puerto White Chinese TOTAL Rican

144 165 121 4 434

33.2 38.0 27.9 0.9

41.9 44.2 13.9

382 bronchial in 18 The of the signs the 43 to 25

BROWN, Definite symptoms

LINCOLN Ghon of other a mean of known the symptom

AND tubercies endobronchial of 2Q, tuberculous there interval tuberculous tuberculosis.

evidence In the with diagnosis with

before in the Symptoms most

During were wheeze

Diagnostic was (2) bark pressure to

Period:As persistent specific

expiratory symptom Signs During physical

suggestive of the Diagnostic signs of bronchial

bronchial disease. Period: Table III tuberculosis

II of weeks Frequency 18 14 Instances Instances

8 Instances 7 Instances past of bronchial tuberculosis 5 Instances 2 Instances

Frequency 36 31 12 Instances Instances Instances

TUBERCULOSIS of bronchial obstruction,

Diagnostic tuberculosis, hilar of lobes of the or an probable or 42

patients node enthe without of the it films

lobar or obstruction displacement

shadows, x-ray more radiographic frequently right frequently next

side most Every

impressions of the Aspects

Bronchoscopic Procedure: during of

examined year repeatedly, performed. only inspection experience, serious study

bronchosperiod. more with than the was Since 230

these children bronchoscopic general

bronchoscopy anesthetic was trauma

accomplished careful in be which this our no may type occurred,

necesbeen the two

sary. safe, However,

which produced should