Pulmonary vocal syndrome due to Endobronchial Tuberculosis reported
A case of a 30-year-old lady who was diagnosed with pulmonary vocal syndrome due to endobronchial tuberculosis (TB) was reported in the Journal of Association of Physicians of India (JAPI).
Tuberculosis is a life-threatening disease which involves various organs, presenting with a wide variety of clinical manifestation. Endobronchial tuberculosis (EBTB) or tracheobronchial TB is a special form of TB and is defined as a tuberculous infection of the tracheobronchial tree with microbial and histopathological evidence. This form of TB is difficult to diagnose because the lesion is not evident in the chest radiograph frequently and thus delaying treatment.
Suhas HS, and colleagues from TNMC and BYL Nair Hospital, Mumbai, reported a case of a 30-year-old lady who was presented with symptoms of three months duration of intermittent fever, cough, and hoarseness of voice. There was no history of preceding viral illness, vocal cord abuse, paroxysmal nocturnal dyspnoea or rheumatic heart disease. Her general physical and systemic examination was within normal limits.
Chest radiograph showed left upper lobe fibrosis. Sputum examination did not reveal acid-fast bacilli. High-resolution computerized tomography (CT) of thorax showed fibrosis in left upper lobe and lingula with the absence of any other intrathoracic lesion or enlarged mediastinal lymph nodes. Fibreoptic bronchoscopy revealed left vocal cord palsy along with an additional finding of scarring of the trachea at the distal end with the stenosis of left mainstem bronchus. Bronchial washing gene Xpert detected Mycobacterium Tuberculosis thus confirming the diagnosis of endobronchial tuberculosis.
The authors stated that hoarseness of voice is a frequently encountered symptom seen due to structural or functional involvement of larynx or secondary to involvement of recurrent laryngeal nerve. Common causes include iatrogenic such as following thyroid surgeries (41%), idiopathic causes (33%) and well-defined causes (25%)1 such as lung malignancy, thyroid malignancy, oesophageal malignancy, cardiac causes such as Ortner's syndrome and chronic benign inflammatory conditions such as tuberculosis.
In this case, earlier hoarseness of voice after ruling out malignancy of the lung was largely attributed to cardiovascular causes such as mitral stenosis, left atrial enlargement or pulmonary hypertension. This entity was known as Ortner's syndrome. The involvement of left recurrent laryngeal nerve is more common when compared to the right as it arches around the arch of the aorta and has a substantial intrathoracic course.
Such an entity is more often encountered in association with bronchogenic carcinoma. However, authors also suspected association with chronic benign inflammatory conditions such as tuberculosis.
Based on the diagnostic data the authors concluded that our patient was a case of pulmonary vocal syndrome secondary to endobronchial tuberculosis. To the best of our knowledge pulmonary vocal syndrome attributable to primary endobronchial tuberculosis has not been reported earlier. Hence endobronchial tuberculosis should be considered as a differential diagnosis in cases presenting with vocal cord palsy after ruling out other etiologies in the correct clinical context.
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