Tuberculosis: tracheal involvement

Radiol Bras. 2016 Nov/Dez;49(6):406–413 410 http://dx.doi.org/10.1590/0100-3984.2015.0165 mass to an intravascular mass or even a solitary pulmonary nodule. In the case reported here, the patient was young, had no comorbidities, and presented with a voluminous mass in the right intrathoracic right region, the initial diagnostic suspicion pointing to sarcoma. In accordance with the literature, the analysis of clinical data and CT images obtained can only suggest primary sarcoma of the thorax as one of the differential diagnoses; the differentiation between sarcoma subtypes is only possible through pathological examination of the biopsy sample. Carlos Henrique Simões de Oliveira Waszczynskyi, Marcos Duarte Guimarães, Luiz Felipe Sias Franco, Bruno Hochhegger, Edson Marchiori


Dear Editor,
A previously healthy 22-year-old female sought medical attention, complaining of productive cough and hoarseness. She reported no other respiratory or constitutional symptoms. Physical examination revealed discrete stridor. For diagnostic clarification, computed tomography (CT) of the chest was performed The CT scan showed grouped, branching centrilobular opacities, with the "tree-in-bud" aspect, suggesting distal bronchiolar filling. The trachea and left main bronchus presented irregular internal contours, with nodular thickening of the walls (Figure 1), together with a discrete increase in the density of the mediastinal fat adjacent to those changes. Sputum examination was conducted and was positive for tuberculosis, confirming the clinical and radiological suspicion of tracheobronchial tuberculosis. Specific treatment was started and resulted in resolution of the findings.
In patients with tuberculosis, tracheal involvement is relatively uncommon, occurring in only 4% of those with the endobronchial form of the disease (1)(2)(3) . Tracheobronchial tuberculosis mainly affects younger, female patients, its incidence peaking in the third decade of life. The disease can affect the greater part of the trachea, also affecting the bronchi, or it can affect just a small segment of the trachea or of one bronchus (4,5) . The clinical presentation can be insidious, simulating bronchogenic carcinoma, or acute, with a profile similar to that of asthma, foreign body aspiration, or pneumonia. In most cases, patients with tracheobronchial tuberculosis present a productive cough, hemoptysis, chest pain, generalized weakness, fever, dyspnea and bronchorrhea (1,3) . In cases that Tuberculosis: tracheal involvement are more severe, there can be acute tracheal obstruction (6) . The main complications are fibrotic scarring and tracheobronchial stenosis, an accurate diagnosis and early treatment being crucial (6) . http://dx.doi.org/10.1590/0100-3984.2015.0200 The differential diagnoses include other diseases affecting the trachea, not only those presenting localized involvementsuch as primary tracheal neoplasms, injuries of traumatic origin, and some infectious diseases-but also those presenting diffuse involvement-amyloidosis, tracheobronchopathia osteochondroplastica, relapsing polychondritis, laryngotracheobronchial papillomatosis, tracheobronchomegaly, neurofibromatosis, Wegener's granulomatosis, lymphoma, and paracoccidioidomycosis (5,(7)(8)(9)(10)(11)(12) .
Imaging studies have become increasingly important in the evaluation of chest diseases, as recently noted in the radiology literature of Brazil (13)(14)(15)(16)(17)(18)(19) . In the study of the trachea, imaging studies comprise X-rays and, primarily, CT of the chest, which can show irregular, circumferential narrowing of the lumen, with or without mediastinitis. In fibrotic disease, the lumen is smoother and the wall is not thickened. Lymphadenopathy is generally associated with active tuberculosis (4,6) .
Bronchoscopy can reveal inflamed mucosa, submucosal granuloma or polyp, ulceration, hypertrophy, or cicatricial stenosis; histologically, tracheobronchial tuberculosis can be identified the presence of giant cell granuloma and caseous necrosis (1) . Although the gold standard for the diagnosis of tracheobronchial tuberculosis is the finding of granulomas in the tracheal/bronchial mucosa, a diagnosis based on imaging findings and sputum positivity is accepted and enables immediate treatment (2) .
Making a diagnosis of tracheobronchial tuberculosis requires suspicion, and it is necessary to correlate the clinical manifestations with the radiological findings. Early diagnosis and treatment can avert the complications of the disease.

Dear Editor,
A 26-year-old male presented with complaints of cough and fever for a few days. He reported having followed a weight loss program for the last four months, having lost 20 kg. He reported no comorbidities.
Chest X-ray showed pulmonary consolidation in the left lung. A complete blood count showed leukocytosis and a lymphocyte count at the lower limit of normality. Subsequent X-rays, during antibiotic therapy, showed an increase in the consolidation. Computed tomography of the chest showed left lung consolidation with air bronchogram and a partially rounded hilar opacity, both containing areas of hypointense signals ( Figure 1A), raising the hypothesis of an infectious or neoplastic process. Because he developed mental confusion, seizures, and postural instability, the patient was submitted to magnetic resonance imaging (MRI) of the brain, which showed multiple intraparenchymal cystic lesions ( Figure 1B), with no enhancement and minimal edema at the borders.
Pathological examination of a biopsy sample obtained from the pulmonary consolidation revealed fungal infection with characteristics of deep cryptococcal mycosis. Staining with mucicarmine showed a mucin-positive capsule. The serology was negative for HIV, as well as for hepatitis B and C. Treatment was started with fluconazole, alternated with amphotericin B. During hospitalization, the general status of the patient became unstable and he was submitted to tracheostomy, subsequently developing tracheal candidiasis. After clinical improvement, he was discharged to outpatient follow-up, with home therapy and attention to an appropriate diet.
Five weeks after discharge, the patient was readmitted to the hospital with worsening neurological status. Another MRI of the brain showed the development of marked, progressive perilesional vasogenic edema ( Figure 1C) and significant enhancement of Immune reconstitution inflammatory syndrome, with pulmonary and neurological cryptococcosis, in an HIV-negative patient