I read with interest the article entitled “An unusual cause of bronchial obstruction,” published in April 2012 issue of Lung India. The case was that of mediastinal lymph node TB which ruptured into left main bronchus and caused occlusion with monophonic wheeze. Fiberoptic bronchoscopy confirmed this finding and patient was treated with ATT and supplemental steroids. It is an interesting case and I would like to congratulate the authors for sharing their experience with others. I have some doubts regarding the present case and would like to highlight some points to the authors:
The diagnosis of mediastinal lymphadenitis was made on the basis of chest X-ray or CT scan. As there was involvement of left main bronchus, which stations of lymph nodes were involved? It will be helpful to us if authors would be able to provide us details about the lymph node stations.
I assume that the patient did not have any complaint of dyspnea prior to ATT, and so there was no baseline spirometry. Authors have reported flow–volume loop showing findings of large airway obstruction (flattening of inspiratory loop); but in the post-treatment spirometry showing complete recovery, the inspiratory loop is conspicuously missing. It would have been better if the authors had provided complete flow-volume loop for post-treatment spirometry also.
The bronchoscopy image shows two openings, and if we go by the universally accepted appearance of bronchoscopy, it does not appear to be carina. In this case, where was the occlusion? Left lower lobe basal segments. Would authors like to clarify at what level the images were taken?
If there was complete occlusion of left main bronchus as said by the authors, there is no comment from them regarding the collapse of left lung/lobes. Was any collapse of left lung/lobes present or not?
1. Liju A, Sharma N, Milburn H. An unusual cause of bronchial obstruction Lung India. 2012;29:182–4
2. Koppen W, Turner JF, Mehta AC Flexible Bronchoscopy. 20042nd ed Oxford Blackwell Publishers