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Case Report Ind. L Tub., 1992, 39, 47 SPREAD OF PULMONARY TUBERCULOSIS FOLLOWING BRONCHOSCOPY R.L. Agrawal 1 , Manju Agrawal 2 and D.K. Agrawal 3 (Received on 12.12.1990; Accepted on 14.5.1991) Summary. Fibreoptic bronchoscopy was performed in a suspected case of pulmonary tuberculosis. Radiological dissemination and sputum positivity for acid fast bacilli followed after two days of the procedure. Introduction Diagnosis of pulmonary tuberculosis is confirmed after sputum is found positive for acid fast bacilli either by direct smear or culture examination. Any pulmonary tuberculosis patient suspected on clinical and radiological grounds whose sputum is negative for acid fast bacilli, on repeated smear examination, poses a diagnostic problem, specially in an emergency situation. Fibreoptic bronchoscopy and bronchial washings are, then, very useful in making the diagnosis in such cases 1 ' 2 - Case Report J.S., 22 year old Indian male, presented in S.R.N. Hospital, Allahabad with recurrent 1. Assistant Professor, Tuberculosis and Respiratory Diseases; 2. Assistant Professor, Anaesthesiology; 3. Lecturer, Cardiology From M.L.N. Medical College, Allahabad. Correspondence: Dr. R.L. Agrawal, 27, Chah Chand, Allahabad-211. 003.
R.L. AGRAWAL ETAL 48 episodes of hemoptysis for two months. Clinical examination of chest revealed no abnormality. Haemogram was within normal limits except for raised ESR (47 mm); Mantoux test induration was 12 mm and sputum was repeatedly negative for acid fast bacilli on 3 direct smear and culture examinations. Skiagram chest showed no other abnormality except a small cavity in left middle zone (Fig. 1). Bronchial washing of the left upper lobe was done using 30 ml normal saline without wedging of instrument. The aspirated fluid was positive for acid fast bacilli by floatation smear method and culture. Post bronchoscopy, sputum smear was positive for acid fast bacilli. On the third day of bronchoscopy, patient had fever with chill and dyspnoea. On auscultation, there were rales in left lower chest. No organism could be isolated on smear and culture examination of blood. Skiagram chest showed multiple small nodular shadows in left middle and lower zone (Fig. 2). Patient showed good response with chemotherapy (Rifampicin, Isoniazid and Ethambutol) and skiagram chest after nine months showed closure of the cavity with residual fibrosis. Discussion In suspected patients of pulmonary tuberculosis where demonstration of acid fast bacilli by sputum smear and culture is not possible, bronchoscopy along with bronchial washing, tissue histology and post-bronchoscopy sputum smear examinations are important tools for confirmatory diagnosis 23 Complications following fibreoptic bronchoscopic procedure are relatively uncommon 4 ' 5 However, no significant spread of tuberculosis after this procedure has been reported 1 ' 2 - 6 In our patient, there was spread of pulmonary tuberculosis which became evident both on clinical and radiological examinations. Three such similar cases have been reported in the available literature 7 ' 8 - Reactivation of a tuberculous lesion following bronchography has also been described 9 - Spread of tuberculosis after bronchoscopy can be explained by (1) spillage of contaminated washing fluid from bronchoscope, (2) entrance of contaminated bronchoscope into a normal site, and (3) opening of bronchi adjacent to cavity lesion due to raised intrabronchial pressure leading to leakage of contents of the cavity. It is difficult to say which of the above factors contributed to the spread in our case. References 1. Sarkar, S.K., Shaarma C.S., Gupta, P.R. and Sharma, R.K. : Fibreoptic bronchoscopy in the diagnosis of pulmonary tuberculosis. Tubercle; 1980, 61, 97. 2. SO, S.Y, Lam, W.K. and Yu, D.Y.C. : Rapid diagnosis of suspected pulmonary tuberculosis by fibreoptic bronchoscopy. Tubercle; 1982, 63,195. 3. Wallace, J.M, Deutsch, A.L., Harrell, J.H. and Moser, K.M. : Bronchoscopy and transbronchial biopsies for evaluation of patients with suspected active tuberculosis. Am. J. Med.; 1981, 70,1189. 4. Credle, W.F, Smidd, J.F. and Elliot, R.C. : Complications of fibreoptic bronchoscopy. Am. Rev. Respir. Dis.; 1974, 109, 67. 5. Pereira, W., Kornat, D.M. and Snider, G.L.: A prospective study of complications following flexible fibreoptic bronchoscopy. Chest; 1978, 73, 813. 6. Jaiswal, A.K., Kulpati, D.D.S., Jain, J.K. and Singh M.M. : Role of bronchoscopy in the early diagnosis of suspected smear negative cases of pulmonary tuberculosis. Ind. J. Tub.; 1989, 36, 233. 7. Rimmer, J., Gibson, P. and Bryant, D.H. : Extension of pulmonary tuberculosis after fibreoptic bronchoscopy. Tubercle; 1988, 69, 57. 8. Sesma, P., Sanchez, E., Deben, F.M. and Sambade, D.S. : Tuberculous pneumonia, a complication of bronchoscopy. Rev. Clin. Espan.; 1984, 173, 185. 9. Jain, S.K. and Agarwal, R.L. : Reactivation of a tuberculous lesion following bronchoscopy. Tubercle; 1980, 61, 105.
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