Tracheobronchial Tuberculosis With Lymph Node Fistula:Report Of Four Cases And Review Of The Literature

Objective : In order to explore the clinical features and treatment of tracheobronchial tuberculosis with lymph node fistula(type VI TBTB),and to improve the understanding of tracheobronchial tuberculosis with lymph node fistula(type VI TBTB).Method:4 cases of tracheobronchial tuberculosis with lymph node fistula(type VI TBTB)were diagnosed,combined with the literature data,the clinical features,laboratory examination,instrument examination data,diagnosis and treatment process were analyzed retrospectively.Results:(1)Case report in our hospital:This paper reports 4 cases,3males and 1 female,aged from 27 to 51 years old,with an average age of 38.5years.The time from the onset of the disease to our hospital ranged from 2weeks to 4 years.The clinical manifestations included cough and sputum in 3cases,fever in 2 cases,hemoptysis in 2 cases,cervical lymph node enlargement in 2 cases,inguinal lymph node enlargement in 2 cases,tuberculosis poisoning in 1 case,chest pain in 1 case,shortness of breath in 1 case and abdominal pain in 1 case.Auxiliary examination: sputum smear acid-fast staining(+)in 1 case,tuberculosis antibody(+)in 1 case,PPD test was strongly positive in 1 case,erythrocyte sedimentation rate increased in 3 cases,blood lactate dehydrogenase increased in 2 cases.Chest CT showed signs of enlargement and compression of mediastinal or paratracheal lymph nodes in 3 cases,patchy inflammatory changes in the lung in 3 cases,and emphysema in 1 case.Fiberoptic bronchoscopy showed varying degrees of stenosis of the trachea or bronchial lumen in 3 cases,showing congestion and edema in the compressed airway,uneven mucosa,protruding growth of the tumor,attachment of necrotic abscess on the surface.2 cases had black carbon deposition in the airway lumen,leaving fistula healing scar.All of the 4 cases were confirmed by pathological biopsy to be in accordance with the diagnosis of tuberculosis.Among the 4 cases,there were 3 cases of clinical active stage(1 case in the early stage of rupture,2 cases in the stage of rupture)and 1 case in clinical stable stage(in the late stage of rupture).There were 2 cases of systemic drug anti-tuberculosis combined with fiberoptic bronchoscope interventional therapy,1 case of only drug anti-tuberculosis,3 cases of improvement and 1 case of loss of follow-up.(2)Literature review results: the literature was searched from the four major databases at home and abroad,pubmed,China knowledge Network,Wanfang and VIP.From the establishment of each database to April 2020,a total of 1080 cases were collected and sorted out.There was no significant difference in the ratio of male to female.The age of onset ranged from 7 months to 85 years,with an average age of 37.62 ±5.43 years.The most common symptoms are cough and sputum,fever,chest tightness,dyspnea,wheezing,night sweats,hemoptysis,chest pain and so on.Most of the imaging findings were mediastinal hilar lymph node enlargement,atelectasis,patchy exudation / ground glass shadow,obstructive pneumonia,hilar lymph node calcification,tracheobronchial deformation or displacement,tuberculous pleurisy and so on.In some cases,multiple imaging findings coexisted.The imaging findings of a very small number of cases were not abnormal 3.3%(19/543).Coexistence with pulmonary tuberculosis accounted for only 48.7%(267/548),and chest CT enhancement accounted for only 14.55%(79/543).Fiberoptic bronchoscopy showed that most of the cases were in the stage of rupture,accounting for 91.2%(601/667).Case analysis showed that the distribution of fistula in the right bronchus accounted for 43.81%(492/1123),which was more than that in the left bronchus(accounted for 38.38%,431/1123).The distribution of fistula mainly occurred in the bilateral main bronchi,and the right main bronchus accounted for 19.15%(215/1123).The left main bronchus accounted for 13.27%(149/1123),followed by the proper branch of the left upper lobe 12.91%(145/1123)and the right upper lobe bronchus.Carina,right intermediate branch and large trachea are also common sites.On the basis of systemic anti-tuberculosis,the total number of cases treated by fiberoptic bronchoscopy was 870,with an effective rate of92.75%.In terms of specific treatment methods,fiberoptic bronchoscope cryosurgery + drug dripping treatment group and fiberoptic bronchoscope cryosurgery + forceps operation + drug dripping treatment group had better curative effects,with an effective rate of more than 97%,which was higher than that of fiberbronchoscope forceps operation+ drug dripping treatment group,and the effective rate of this group was 84.31%.The effective rate of fibrobronchoscope cryosurgery + forceps operation + high frequency thermal ablation+ dripping drug treatment group was 96.93%,and the effective rate of fiberoptic bronchoscope cryosurgery + forceps operation+ high frequency thermal ablation + dripping drug + Oral corticosteroid treatment group was the lowest,only 84.31%.Conclusion:1.Type Ⅵ TBTB is a kind of special bronchial tuberculosis formed by the collapse of mediastinal or hilar paratracheal lymph nodes into the trachea or bronchi,which belongs to the type Ⅵ of tracheobronchial tuberculosis.It is relatively rare in clinic,and the proportion of male and female is about the same,which often occurs in young people,and it is also reported in children.2.The onset of Type Ⅵ TBTB is hidden,and its clinical manifestation is not specific.It is often found in the stage of rupture,and it is easy to be misdiagnosed as bronchial tumor.The disease can be associated with primary or secondary pulmonary tuberculosis,or it can exist alone.Imaging diagnosis needs to observe the correlation between airway lesions and lymph nodes.It is recommended to choose chest CT enhancement or CT multi-dimensional image reconstruction as an auxiliary examination tool for this disease.3.The bronchoscopic findings of Type Ⅵ TBTB are characteristic and of great diagnostic significance.Fiberoptic bronchoscopy showed that the fistula was mostly distributed in the bilateral main bronchi,followed by the proper branch of the left upper lobe and the right upper lobe bronchus,and the overall fistula distribution was slightly more in the right bronchus.4.Systemic anti-tuberculosis drug chemotherapy is the basis for the treatment of this disease,and fiberoptic bronchoscope interventional therapy is the key.The overall prognosis of the disease is relatively good.