An 8-year-old girl from a remote Aboriginal community approximately 2500 km from Brisbane was transferred to our hospital for management of a bronchial lesion. She had received 7-days of intravenous amoxicillin prior to transfer. She had a 4-year history of daily wet and sometimes productive cough, which was worse on exertion. There was no history of exertional dyspnoea, haemoptysis or weight loss. She also had a history of recurrent admissions for pneumonia at the local hospital (3 in the past 6 months). In the child's community, two adults were recently diagnosed with active pulmonary tuberculosis.
On arrival, the child was thin (weight 5th percentile, height 25th), appeared well and had a wet cough, reduced air entry over the right side and inspiratory crepitations. Spirometry values were invalid as she could not adequately perform maximum expiratory manoeuvres. Chest x-ray (CXR) showed right upper lobe (RUL) collapse, tram-tracks signs and increased peribronchial and interstitial markings of the right lower lobe. These CXR changes were documented at least 4-months ago (figures 1 and 2). Chest high resolution computerised tomography (CT) scan revealed RUL collapse and severe cystic bronchiectasis and cylindrical bronchiectasis of the right middle and lower lobes (figures 3 and 4). Sputum cultures grew Moraxella catarrhalis, and the microscopy was negative for acid-fast bacilli. Mantoux tests (M. tuberculum, M. Avium) were negative, sweat test and immunological workup were normal. Flexible bronchoscopy revealed a large lesion at the carina (Figure 5). Rigid bronchoscopy was then immediately performed during which the lesion was only partially removed piecemeal because of the presumed diagnosis of tuberculosis and length of time required to remove the bulk of the lesion (2-hours). Given the significant tuberculosis contact, anti-tuberculous medications were commenced and later ceased when cultures and Quantiferon test were negative. Histology showed a subepithelial neoplasm comprising glandular and solid areas with no evidence of significant mitotic activity or atypia, consistent with a low-grade muco-epidermoid carcinoma (MEC). Cytogenetic investigation on the tumour was not performed. Chest and abdomen CT scans revealed no metastases. Bronchoscopy was repeated and the remaining small lesions were biopsied. Right upper lobectomy and lymph node sampling was then performed and histological examination of the operative specimen demonstrated a small amount of residual tumour (with clear resection margins) and bronchiectasis. No metastases were found in the sampled lymph nodes. Postoperative progress was uneventful and the child was discharged 9-days later and was cough free. When reviewed 4 months post-discharge, she remained cough free and a repeat flexible bronchoscopy then confirmed the absence of any bronchial lesion or secretions.
Representative high resolution CT chest slices demonstrating collapse and severe bronchiectasis of the right upper lobe.