Abstract Introduction Tuberculosis (TB) can compromise airways from severe lymphadenopathy or obstructive endobronchial tuberculosis (EBTB) lesions. While rifampin, isoniazid, pyrazinamide, and ethambutol (RIPE) therapy is a mainstay of TB treatment, adjunctive therapies like steroids or endobronchial lesion resection may be necessary. We present a rare case of an infant with disseminated TB who has benefitted from long-term steroids for severe bilateral airway obstruction from lymphadenopathy and endoluminal bronchus intermedius mass despite appropriate RIPE therapy. Case Presentation A 9-month-old female presented to clinic with a 3-month history of cough. She had received steroids, albuterol, and multiple courses of antibiotics for community acquired pneumonia. Clinic exam was notable for moderate respiratory distress, broncho-dilator responsive wheezing, and hypoxemia. CT chest showed conglomerate calcified mediastinal and hilar lymphadenopathy and diffuse bilateral pulmonary nodules, as well as calcified foci in the liver and spleen. Confirmatory diagnosis of TB was from bronchoalveolar lavage (BAL) mycobacterium TB PCR as QuantiFERON test was indeterminate and gastric aspirates were negative. Bronchoscopy revealed compression of the distal trachea, bilateral mainstem bronchi, and an obstructing caseous lesion in the bronchus intermedius. Bronchoscopy was complicated by acute respiratory failure due to severe bronchospasm requiring an epinephrine drip, intubation, and mechanical ventilation. Given clinical instability, excision of the obstructive EBTB lesion was not pursued. Systemic steroids were initiated in conjunction with RIPE given her severe airway compression. She had significant clinical improvement and was extubated and weaned to room air; thus, steroids were discontinued after a 5-day course. However, due to recurrence of wheezing and respiratory distress after discontinuation of steroids; she was discharged home on a longer 1-month steroid taper, while continuing RIPE therapy. She was seen in pulmonary clinic the day prior to completion of the planned taper but was noted to have deep retractions. Steroids were extended for an additional month and a repeat airway exam with coordinated flexible and rigid bronchoscopy was performed. Discussion Disseminated TB with EBTB in infants can cause complications such as airway compression and obstruction from endobronchial lesions. In those with severe respiratory symptoms, systemic steroids can provide benefit. Guidelines on steroid dosage and duration are limited. Ultimately, in the case of an endobronchial obstruction, rigid bronchoscopy for resection may provide more benefit than supportive therapies with potential decreased risk of bronchiectasis and airway stenosis. This abstract is funded by: None
Mackin et al. (Fri,) studied this question.