Sixty three years old, female case who has been followed for three years with the diagnosis of anthracofibrosis admitted to our hospital with the complaints of cough, fever and dyspnea. She has been living in rural part of the city and had indoor cooking/heating smoke exposure history for at least forty years.
Complete blood count was performed with Cell-Dyn 3700 analyzer (Abbott, USA). This blood examination revealed elevated WBC count of 20.600/microL, hemoglobin concentration of 13.1 g/dl, hematocrit level of 42.1 and platelet count of 501.000/microL. Sputum examination for acid-fast bacilli (AFB) was negative and CRP was 98.9 mg/dl. Erythrocyte sedimentation rate was 64 mm/ hour.
The posterior anterior chest graphy showed consolidation area in right paracardiac region. The high resolution thorax spiral computed tomography (HRCT) obtained on admission revealed consolidation area and atelectasis in right middle lobe (Figure 1). Flexible bronchoscopy (FOB) application was planned to the patient. FOB examination revealed hypervascularisation, hyperemia, deformed bronchial trees and these findings were similar to previous FOB findings. Previous FOB examination has been done to examine middle lobe atelectasis. However, white necrotic lesions were observed in orifice of the middle lobe and at entry of main right bronchus and intermediate bronchus differently from previous bronchoscopic examination (Figure 2, 4). Biopsy from necrotic lesions and bronchus lavage were performed. Histological and cytological findings of material were benign. Microscopic findings of biopsy revealed infection that consists of concentrated lymphoplasmocytes, regular cartilage, and a few polymorph nuclear leucocytes. No AFB was performed on the biopsy specimen. AFB was negative in bronchus lavage; however, mycobacterial cultivation was positive revealing mycobacterium tuberculosis and sensitive to all major tuberculosis agents.
Tuberculosis treatment was initiated with isoniazid with a daily dose of 300 mg, rifampicin 600 mg, ethambutol 1500 mg, pyrazinamide1500 mg and these doses were planned to be continued for further 6 months. Clinical remission started after two weeks of the treatment period. Control sputum samples were obtained and control culture analysis was performed at the end of two months therapy. Both of these were negative for AFB. We observed significant clinical and radiological remission at the end of three months of this treatment period. Control FOB examination performed in the sixth month of the therapy demonstrated that the white colored necrotic lesions disappeared completely and significant improvement was observed (Figure 3 and Figure 5, respectively).