Endobronchial tuberculosis simulating bronchial asthma.

A 23 years old female medical student presented to the Aga Khan Hospital with three months history of cough; sputum and weight loss. Physical examination at that time revealed bilateral wheeze and PEFR was reduced to 60% of predictive value. Chest X-ray PA and lateral views were normal. A diagnosis of bronchial asthma was made and patient was started on inhaled B2 agonist. Her cough slightly improved, however, she continued to loose weight and developed fever. She was admitted in the hospital for further investigations. There was nothing significant in the past medical history. She also denied any family history of tuberculosis. On examination she looked ill, her weight was 40 kg and temperature of 37.4°C. There was no lymphadenopathy. Abdominal, cardiovascular and central nervous system examinations were within normal limits. Her chest examination revealed wheeze more marked on the left mid zone. Rest of the chest examination was normal. Investigations showed Hb 11.6 g/dl, WBC 11.9x1o9/L, with 72% neutrophil, ESR was 32 mm after first hour. Renal and liver function tests were normal. Sputum smear for acid fast bacilli (AFB) was negative. Fibre optic bronchoscopy under local anaesthesia showed that left math stem and apical segment of left lower lobe were severely inflamed with mucosa covered by whitish necrotic material. Rest of the bronchial tree was normal. Bronchial lavage was done and biopsy obtained. Examination of bronchial lavage (from apical segment) showed presence of AFB culture report later confirmed mycobacterium tuberculosis. Biopsy of bronchial mucosa showed presence of chronic granulomatous inflammation. Patient was started on anti-tuberculous treatment and at six weeks follow-up was asymptomatic and physical examination was normal. She had gained 4kg of weight. During 6 months of treatment patient remained well.