Abstract Introduction Interventional bronchoscopy in pediatrics is challenging due to small airway caliber, limited pulmonary reserve, and scarce appropriately sized instrumentation. Expertise is often concentrated in high-volume centers, making complex airway interventions difficult elsewhere. Endobronchial tuberculosis (TB) in children is likely under-recognized, as bronchoscopy is not routinely performed, leading to missed diagnoses and long-term morbidity. Case A 3-year-old male was referred for bronchoscopy due to persistent symptoms and radiographic abnormalities despite treatment for pulmonary TB. He was exposed to an index case in October 2024 and initially had a negative interferon-gamma release assay (IGRA), equivocal tuberculin skin test, and negative stool mycobacterial PCR. A repeat IGRA on 12/17/24 was strongly positive, and treatment with rifampin, pyrazinamide, and isoniazid began on 12/20/24, continuing through 3/31/25. Despite therapy, he had persistent productive cough, intermittent fevers, and night sweats. A March 2025 chest radiograph showed right upper lobe (RUL) consolidation. Chest CT revealed RUL pneumonia without cavitation, calcified mediastinal lymph nodes, and right hilar adenopathy. A repeat CT on 8/12/25 showed partial improvement but identified an obstruction in the anterior segment of the RUL. Flexible bronchoscopy on 8/14/25 revealed an obstructing endobronchial lesion in the RUL anterior segment. Given the patient’s small airway, a size 2 laryngeal mask airway (7 mm ID) was used to accommodate a 4.2-mm bronchoscope with a 2-mm working channel (Olympus BF-P190), as a standard endotracheal tube would not allow instrumentation. The lesion was sprayed with epinephrine 1:100,000 and 1% lidocaine, then debulked using a 1.8-mm flexible forceps (Boston Scientific Radial Jaw 4). Removal yielded copious purulent secretions prompting intraoperative antibiotics and brief post-procedure observation (24h). The procedure was well tolerated with minimal bleeding and no complications. Pathology showed bronchial lymphoid tissue with chronic granulomatous inflammation and multifocal calcification; acid-fast bacilli stain, MTB PCR, and cultures were negative. Discussion This case underscores the diagnostic and therapeutic value of interventional bronchoscopy in pediatric endobronchial TB. Procedural adaptations may be necessary due to equipment limitations in young children. The apparent lack of response to TB therapy was likely due to post-obstructive pneumonia from mucus stasis and possible bacterial co-infection. Failure to identify endobronchial TB can result in airway obstruction, pulmonary abscess, and bronchial stenosis. Early bronchoscopy in persistent pediatric TB cases and broader access to pediatric-specific bronchoscopic tools may improve therapeutic outcomes. This abstract is funded by: None
Goncalves et al. (Fri,) studied this question.