Long term management of people with post-tuberculosis lung disease

Abstract

Post-tuberculosis lung disease (PTLD) is emerging as a significant area of global interest. As the number of patients surviving tuberculosis (TB) increases, the subsequent long-term repercussions have drawn increased attention due to their profound clinical and socioeconomic impacts. A primary obstacle to its comprehensive study has been its marked heterogeneity. The disease presents a spectrum of clinical manifestations which encompass tracheobronchial stenosis, bronchiectasis, granulomas with fibrosis, cavitation with associated aspergillosis, chronic pleural diseases, and small airway diseases-all persistent consequences of PTLD. The spectrum of symptoms a patient may experience varies based on the severity of the initial infection and the efficacy of the treatment received. As a result, the long-term management of PTLD necessitates a detailed and specific approach, addressing each manifestation individually-a tailored strategy. In the immediate aftermath (0-12 months after anti-TB chemotherapy), there should be an emphasis on monitoring for relapse, tracheobronchial stenosis, and smoking cessation. Subsequent management should focus on addressing hemoptysis, managing infection including aspergillosis, and TB-associated chronic obstructive pulmonary disease or restrictive lung function. There remains a vast expanse of knowledge to be discovered in PTLD. This review emphasizes the pressing need for comprehensive, consolidated guidelines for management of patients with PTLD.

Keywords: Aspergillosis; Bronchiectasis; Chronic obstructive pulmonary disease; Tuberculosis.

Figure 1

Hallmark bronchoscopic features of endobronchial tuberculosis patients. (A) Actively caseating type with a whitish cheese-like material (arrow heads), edematous-hyperemic type with swollen and hyperemic mucosal features (solid arrow), (B) fibrostenotic type with narrowing of the bronchial lumen due to fibrosis, and (C) ulcerative type with mucus secretion collected.

Figure 2

The distribution of endobronchial tuberculosis. Right main, right main bronchus; Left main, left main bronchus; RUL, right upper lobe; RI, right intermedius; RML, right middle lobe; Upper, upper division of left upper lobe; Lingular, lingular division of left upper lobe; LUL, left upper lobe. Adapted from Shim [30].

Figure 3

Computed tomography scans of post-tuberculosis lung disease patients with various clinical and radiologic features. (A) Post-tuberculosis lung disease patient with bronchiectasis (arrows) and fibrotic changes, (B) post-tuberculosis lung disease patients with multiple granulomas, remaining small nodularity, and fibrotic changes with traction of pleural, and (C) totally destroyed left upper lung with surrounding pleural wall thickenings (arrows).

Figure 4

(A) A COPD patient with no history of TB and a 40 pack-year smoking history. CT imaging reveals signs of emphysema, bronchial wall thickening, and post-bronchodilator spirometry demonstrates an FEV1/FVC ratio of 0.46, FEV₁ at 58% (1.73 L) of the predicted value, TLC at 5.46 L (84%), and DLco at 13.2 (65%) mL/min/mmHg. (B) A PTLD patient with no smoking history. CT imaging displays TB sequelae predominantly in the right upper lobe with minimal involvement in the other lobes. Pulmonary function tests do not indicate any decline, with a post-bronchodilator spirometry showing an FEV₁/FVC ratio of 0.76, and FEV₁ at 93% (3.02 L). (C) A PTLD patient with no smoking history. CT imaging shows a completely destroyed left lung, calcified granulomas, and fibrotic scars in the right upper lobe with pulmonary function significantly diminished, with an FEV₁/FVC ratio of 0.55, FEV₁ at 25% (0.59 L), TLC at 60% (2.81 L), and DLco at 12.0 (68%) mL/min/mmHg. COPD, chronic obstructive pulmonary disease; TB, tuberculosis; CT, computed tomography; FEV₁, forced expiratory volume in one second; FVC, forced vital capacity; TLC, total lung capacity, DLco, diffusing capacity of the lungs for carbon monoxide; PTLD, pulmonary-TB lung disease.

Figure 5

Pair of the same section of computed tomography scans of a pulmonary tuberculosis patient at the commencement of antituberculosis treatment (A) and after 3 months of the treatment (B).

Figure 6

A PTLD patient with cavitation in the LUL presented with dyspnea, sputum, and cough. The recent CT scan revealed a newly observed mass-like lesion with an air crescent sign (A) in the previously empty cavitation seen on a CT scan 17 years ago (B), confirming newly developed Aspergillosis with suspected invasive aspergillosis. PTLD, pulmonary-TB lung disease; LUL, left upper lung; CT, computed tomography.

Figure 7

Flow chart of long-term management of people with post-tuberculosis lung disease. There is limited evidence to choose vaccination recommendation differently to individuals with PTLD from rest of CRD patients. TB, tuberculosis; CT, computed tomography; mMRC, modified medical research council dyspnea scale; CAT, chronic obstructive pulmonary disease assessment test; 6MWT, 6-minute walk test; SpO2, peripheral oxygen saturation; BMI, body mass index; TB-PCR, tuberculosis-polymerase chain reaction; AFB, acid-fast bacilli; COVID-19, coronavirus disease 2019; NTM, non-tuberculous mycobacterium; COPD, chronic obstructive pulmonary disease; LAMA, long-acting muscarinic antagonist; LABA, long-acting beta agonist; ICS, inhaled corticosteroids; IV, intravenous; CCPA, chronic cavitary pulmonary aspergillosis; CFPA, chronic fibrosing pulmonary aspergillosis; SAIA, subacute invasive aspergillosis.

Figure 8

Balloon dilation procedure on the annular cicatrical stenosis at the left main bronchus of an endobronchial tuberculosis patient after two years of antituberculosis chemotherapy (A) and chest X-rays before (B) and after the dilation procedure (C).