罕见病例:1例有肺结核病史的右上肺叶支气管闭塞

病例汇报

The patient presented as a 34-year-old female with a remote history of pulmonary tuberculosis, which was treated, resulting in the resolution of symptoms. 

The patient presented with increased coughing and sputum production, and the sputum test demonstrated Mycobacterium avium complex. 

Antimicrobial treatment was initiated and several months later, after improvement of symptoms, the patient underwent a CT chest examination. 

The test demonstrated a narrowed right main bronchus with occluded or absent right upper lobe bronchus (Figure 1). 

There was complete right upper lobe atelectasis. No focal airspace disease was present at the time of the CT examination (Figure 2). 

Further evaluation with bronchoscopy was advised.

Bronchial washings were negative for mycobacteria or other suspicious organisms.

病例讨论：

In the case of our patient, the presence of normal imaging that predated the first tuberculosis infection would have been more confirmatory to more definitively delineate a cause for the obstructed or missing right upper lobe bronchus. 

这个病例，在第一次肺结核感染之前，影像学表现正常，可以更明确右上肺叶支气管梗阻或缺失的原因。

Given the absence of associated mass or mechanical obstruction evident upon bronchoscopy, a congenital/developmental cause could be an additional consideration. However, the typical pattern of disease for congenital/developmental entities differs from what is found in this case. 

考虑到支气管镜检查没有明显的肿块或机械性梗阻，先天性或发育性原因可能是另一个考虑因素。

However, the typical pattern of disease for congenital/developmental entities differs from what is found in this case.

For example,bronchial atresia is a rare developmental anomaly that usually results in a segmental or subsegmental bronchus that lacks communication with the central airway, in which distal alveoli are usually aerated by collateral pathways resulting in a hyperlucent lung field. 

Bronchial aplasia is associated with a lack of a bronchus and its corresponding lung tissue. 

The fact that our patient had collapsed right upper lung tissue,but absent right upper lobe bronchus, both bronchial atresia and bronchial aplasia seem unlikely.

事实上，这个病例右上肺组织塌陷了，但无右上肺叶支气管，支气管闭锁和支气管发育不全的可能性不大。

EBTB is relatively common in patients with pulmonary tuberculosis, and many patients with EBTB develop bronchostenosis. 

Given our patient’s history of tuberculosis, a known acquired cause of bronchostenosis,EBTB seems to be the likely cause of the bronchostenosis.

EBTB在肺结核患者中较为常见，许多EBTB患者发展为支气管狭窄。

鉴于这个病例有肺结核病史，肺结核是已被认知的引起支气管狭窄的后天原因，EBTB似乎是支气管狭窄的可能原因。

疾病概述

气管支气管内膜结核（EBTB）定界为气管支气管树存在微生物学和组织病理学依据的结核菌感染，是由于结核杆菌侵袭气管支气管粘膜、粘膜下层或进一步深入损坏弹力纤维网和肌层，最终瘢痕愈合导致气管支气管狭窄。

通常不是一个独立的疾病，为肺结核的一部分，属于呼吸器官结核的范畴。

起病可为急性、隐匿性或首次抗结核治疗后迟发，本病的病程和预后变异较大，可以是完全无症状到严重的支气管狭窄伴肺不张和支气管扩张。

 病理机制

病变从支气管溃疡到息肉，最后疤痕狭窄形成的演变，是smithk等经过一系列的纤维支气管镜检查研究而得出。

导致EBTB的原因机制不清楚。

诊断标准

EBTB诊断不易，由于早期诊断是防止严重瘢痕狭窄的关键，因此临床上高度警惕EBTB至关重要。

诊断流程

Wilson在1945年依据临床和放射线提出结核病人支气管镜检查标准，其中有三条仍适用：

相关阅读：

参考文献：

1.Jenson M, Forshee W A, Padilla R M, et al. (January 15, 2021) Endobronchial Tuberculosis and Bronchostenosis: A Rare Case of Bronchial Occlusion in a Patient With History of Tuberculosis. Cureus 13(1): e12717. DOI 10.7759/cureus.12717

2.中华医学会结核病学分会.气管支气管结核诊断和治疗指南（试行）.中华结核和呼吸杂志.2012年8月第35卷第8期3.中华人民共和国国家卫生和计划生育委员会.结核病分类.2017-11-09发布/2018-05-01实施4.况九龙 段凤英.气管支气管内膜结核.实用临床医学.2005年第6卷第1期