A 30-year-old, earlier completely healthy woman addressed to laryngologist complaining of persistent dysphonia lasting for about 12 months. Vocal function tended to worsen in the evening, no provocative or relieving factors as well as no systemic symptoms were mentioned. Prior medical history was unremarkable. Stroboscopy of the vocal cords was performed showing granuloma on the right vocal cord, causing decreased movement and diminished mucous wave in the 2nd and 3rd third of the right vocal cord (Fig. 1). The patient was diagnosed with chronic hyperplastic laryngitis and recommended to undergo surgical treatment with histological evaluation of the mass.
Microscopic view during the surgery suggested the need of rapid intraoperative histological examination. The answer came: granulation tissue. Hyperplastic tissues of the right vocal cord were removed with CO2 laser and sent for further detailed histological examination. Suspecting tuberculosis, initial anteroposterior chest X-ray was made showing nodules on the apex of the left lung. The patient was referred to the pulmonologist. As there were no clinical signs of pulmonary disease, CT scan and fibrobronchoscopy with bronchoalveolar lavage and BACTEC were done to differentiate between focal pulmonary tuberculosis and cancer. Fibrobronchoscopy demonstrated obturated subsegmential B1-2c bronchus: diameter was narrowed by mucous outgrowths (similar to granulative tissue), covered with whitish necrotic substance. Final histopathologic diagnosis came one week after the surgery: chronic granulomatous - necrotic laryngitis (might be of tubercular origin). Two pulmonary CT scans made with 1, 5 month interval showed negative dynamics - some of the nodules on the apex of the left lung were enlarged and new ones had appeared (Fig. 2).
No tuberculosis mycobacterium bacillus was found in bronchoalveolar lavage. In order to rule out Wegener's granulomatosis, autoimmune markers were taken - all of them negative. Bronchoalveolar lavage was repeated, and samples taken for Xpert MTB/Rif genetic test. Tuberculosis mycobacterium resistant to rifampicin was found. Esophagogastroduodenoscopy was performed to rule out associated gastrointestinal involvement - no macroscopic signs of gastrointestinal tuberculosis were detected. Final diagnosis was made: infiltrative pulmonary and laryngeal tuberculosis, a new case. The patient was admitted to the hospital and a combination of medications (Ethambutol 1,6g, Cycloserine 0,75g, Prothionamide 0,75g, Moxifloxacin 0,4g for 708 days; Para-Aminosalicylic acid 8,0g for 259 days and Capreomycin 1,0g for 202 days) was prescribed for the next two years.
Four months after the surgery, during a visit to the laryngologist, stroboscopy demonstrated normal vocal cord movement, reduced mucous wave in the 2nd and 3rd third of the right vocal cord and no pathologic masses on the right vocal cord (Fig 3).
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Informed consent has been obtained from all individuals included in this study.