A Case of Laryngeal Tuberculosis, Endobronchial Tuberculosis and Pulmonary Tuberculosis Coexistent in an Immunocompetent Host

Abstract

Historically associated with poor prognosis seen in advanced disease, laryngeal tuberculosis (LTB) now represents only 1% of all cases of tuberculosis (TB). The incidence of LTB has decreased drastically with the introduction of anti-tubercular drugs. LTB can be primary or secondary to pulmonary tuberculosis. LTB can mimic laryngeal cancer. We present a case of primary laryngeal TB with descending tracheobronchial spread in an immunocompetent 71-year-old female who developed progressive dysphonia over several months with unintentional weight loss and non-productive cough. Non-contrast enhanced computed tomography (CT) revealed clustering of subcentimeter stellate nodules in the right upper lung field with an enlarging ground-glass opacity in the right lower lung but did not show structural abnormalities within the neck. Positron emission tomography (PET) showed pathologic fluorodeoxyglucose (FDG) uptake within the larynx and trachea with extension into the left mainstream bronchus as well as the proximal left upper and lower lobe bronchi. Diffuse standardized uptake value (SUV) was greatest in the larynx (20.5). Polymerase chain reaction (PCR) on bronchoscope sputum specimen confirmed Mycobacterium tuberculosis. Findings were consistent with primary laryngeal TB with endobronchial extension. She was started on a four-drug regimen comprising of isoniazid, rifampin, ethambutol, and pyrazinamide with a good response. Her close contacts were treated as well. This case highlights the unusual spread of primary laryngeal TB in an immunocompetent host. Early diagnosis can limit adverse complications and unnecessary exposure to healthcare workers. To our knowledge, this is the first case of primary LTB with proximal spread to the tracheobronchial and pulmonary tuberculosis.

Keywords: endobronchial tuberculosis; laryngeal tuberculosis; tuberculosis.

Figure 1. Non-contrast computed tomography of the chest, axial view, showing a new ground-glass opacity of the right lower lung field (red circle).

Figure 2. Non-contrast computed tomography of the chest, axial view, showing worsening pleural-based opacity with branching opacification within the inferior segment of the right lung (red circle).

Figure 3. Positron emission tomography (PET) scan showing pathologic fluorodeoxyglucose (FDG) uptake within the larynx and trachea with extension into the left mainstream bronchus as well as the proximal left upper and lower lobe bronchi. The involvement of bilateral cervical chain lymph nodes was also noted. Diffuse standardized uptake value (SUV) was greatest in the larynx (20.5) (red circle).

Figure 4. Bronchoscope imaging showing edematous supraglottic mucosa with normal vocal cords.

Figure 5. Bronchoscope imaging showing ulcerative lesion on the first carina.

Figure 6. Bronchoscope imaging showing narrowing of the segmental bronchus and hyperemic lesions seen on the mucosa.