Relationship between bronchial anthracofibrosis and endobronchial tuberculosis

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1 ORIGINAL ARTICLE Koren J Intern Med 2013;28: Reltionship between bronchil nthrcofibrosis nd endobronchil tuberculosis Hyun Ji Kim, Sng Dong Kim, Dong Woo Shin, Soo Hyun Be, Ah Lim Kim, Ji N Kim, Seung Wook Jung, Byung Ki Lee, nd Yeon Je Kim Deprtment of Internl Medicine, Degu Ftim Hospitl, Degu, Kore Received : July 5, 2012 Revised : October 8, 2012 Accepted : October 31, 2012 Correspondence to Yeon Je Kim, M.D. Division of Pulmonry nd Criticl Cre Medicine, Deprtment of Internl Medicine, Degu Ftim Hospitl, 99 Ayng-ro, Dong-gu, Degu , Kore Tel: Fx: E-mil: kimyeonje@gmil.com Bckground/Aims: Vrious pulmonry diseses my be ssocited with bronchil nthrcofibrosis (BAF). Our im ws to identify reltionship between BAF nd endobronchil tuberculosis (EBTB). Methods: In totl, 156 ptients, dignosed with EBTB using bronchoscopy, between June 1999 nd My 2008, were included. Clinicl nd bronchoscopic findings between ptients with BAF (n = 72, BAF group) nd without BAF (n = 84, non- BAF) were nlyzed retrospectively. Results: The crude odds rtio (OR) of BAF for EBTB ws 8.88 (95% confidence intervl, 6.37 to 12.37). On multivrite nlysis, djusting for ge, history of biomss smoke exposure, nd comorbidities, the most significnt independent fctor for EBTB ws history of biomss smoke exposure (djusted OR, ; djusted p < 0.001). EBTB ws more frequent in the right lung, prticulrly the right middle lobr bronchus, in the BAF group. Actively cseting, edemtous-hyperemic, nd ulcertive were the mjor types, with 77 (49%), 33 (21%), nd 31 cses (20%), respectively. The BAF group hd more ulcertive type, while the non-baf group hd more ctively cseting type. The durtion of EBTB tretment ws similr between the groups. No significnt difference ws observed in the development of complictions during tretment nd posttretment bronchostenosis between the groups. Conclusions: These findings suggest tht BAF my be risk fctor for EBTB nd ffect the loction nd morphologicl type t the time of EBTB development. Keywords: Anthrcofibrosis; Endobronchil tuberculosis; Biomss; Smoke; Subtype INTRODUCTION Endobronchil tuberculosis (EBTB) is known to be specific inf lmmtory disese, cused by cid-fst bcilli in the trche or bronchi nd is prevlent in young femles [1-4]. However, in Kore, it is lso commonly observed in elderly individuls [5,6], prticulrly in ptients with bronchil nthrcofibrosis (BAF) [7]. BAF, typiclly induced by the long-term inhltion of biomss smoke [7], is chrcterized by bronchoscopic finding of multiple drk nthrcotic pigmenttion in the lrge irwy mucos with or without bronchil nrrowing or oblitertion [8]. In some ptients with EBTB, cused by erosion nd perfortion of nthrcotic lymph nodes into the bronchus from medistinl tuberculous lymphdenitis, col pigments my be deposited in the bronchil mucos [9,10], but this pthologicl feture is quite different from tht observed in BAF [7]. Copyright 2013 The Koren Assocition of Internl Medicine This is n Open Access rticle distributed under the terms of the Cretive Commons Attribution Non-Commercil License ( by-nc/3.0/) which permits unrestricted noncommercil use, distribution, nd reproduction in ny medium, provided the originl work is properly cited. pissn eissn

2 Kim HJ, et l. Anthrcofibrosis nd tuberculosis As tuberculosis is one of the most common diseses ssocited with BAF [7,11], ptients with EBTB nd BAF seem to hve two different pthologicl processes ffecting the sme irwy mucos. Consequently, it is expected tht their presenting demogrphic nd clinicl fetures would lso be different from those in EBTB ptients without BAF. The im of this study ws to evlute ny reltionship between BAF nd EBTB from comprtive nlysis ccording to the presence of BAF. METHODS Among the totl of 4,505 ptients who underwent bronchoscopies between June 1999 nd My 2008 t our 700-bed referrl hospitl, 156 ptients found to hve EBTB nd 455 ptients with BAF were included in this study. The clinicl fetures, bronchoscopic findings, nd outcomes between the EBTB ptients with BAF (n = 72, BAF group) nd without BAF (n = 84, non- BAF group) were nlyzed retrospectively. The definition of BAF nd history of biomss smoke exposure were described previously [7]. The history of biomss smoke exposure ws estimted from the beginning of the ptient s time of cooking nd heting in trditionl Koren rurl housing environment to the time t which chnges in the living environment, type of fuel used, or retirement occurred. The dignostic criteri for ctive EBTB were: 1) obvious endobronchil lesions observed by bronchoscopy; nd 2) tuberculosis, demonstrted by bronchoscopic biopsy of the lesions or positive cid-fst bcilli smer from bronchil wshing specimen. The morphologicl clssifiction of EBTB ws bsed on Chung nd Lee [12], s nonspecific bronchitic, grnulr, hyperemicedemtous, ctively cseting, ulcertive, tumorous, nd fibrostenotic types. In the cse of mixed lesions, we recorded the dominnt type. Bronchoscopic findings were bsed on primry bronchoscopy dt, becuse follow-up bronchoscopy ws conducted in only 23 subjects. All dignostic procedures were performed with informed consent from ptients. The study protocol ws pproved by the hospitl institutionl review bord. Dt re reported s mens ± SD or number (%). The risk fctor nlysis of BAF for EBTB ws mesured in terms of the estimted odds rtio (OR) with 95% confidence intervls (CIs). The BAF nd non-baf groups were compred using Student s t test for continuous vribles nd the chi-squred test for ctegoricl vribles. To evlute independent fctors ssocited with EBTB between the BAF nd non-baf groups, logistic regression ws used. The p vlues of < 0.05 were considered to indicte sttisticl significnce. Dt were nlyzed using the SPSS softwre version 14.0 (SPSS Inc., Chicgo, IL, USA). RESULTS Risk fctor nlysis of BAF for EBTB Of the 455 BAF subjects, 72 (15.8%) hd EBTB, while mong the 4,050 non-baf subjects, 84 (2.1%) hd EBTB. The OR of BAF for EBTB ws (95% CI, to ) (Tble 1). Subjects nd clinicl chrcteristics Bseline demogrphic chrcteristics of both the BAF nd non-baf groups re summrized in Tble 2. Femles nd nonsmokers were prevlent in both groups, but no significnt difference ws observed between the groups. The men ge in the BAF group ws 71.2 yers, significntly older thn tht of the non-baf group (45.8 yers). The BAF group hd significntly higher frequency of history of biomss smoke exposure nd comorbidities. Crdiovsculr disese nd obstructive irwy disese were two most common comorbidities Tble 1. Risk fctor nlysis of BAF for EBTB Fctor BAF, n Yes EBTB No Totl Yes No 84 3,966 4,050 Totl, n 156 4,349 4,505 χ 2 = ; df = 1; p < 0.001; odds rtio, (95% confidence intervl, to ). BAF, bronchil nthrcofibrosis; EBTB, endobronchil tuberculosis. 331

3 The Koren Journl of Internl Medicine Vol. 28, No. 3, My 2013 Tble 2. Demogrphic vribles ssocited with EBTB in the BAF nd non-baf groups Chrcteristic BAF (n = 72) Non-BAF (n = 84) Crude p vlue Adjusted p vlue Mle/Femle 11/61 18/ b - - Adjusted OR Age, yr 71.2 ± ± < c Smoker 10 (13.9) 15 (17.9) b - - History of biomss smoke 62 (86.1) 15 (17.9) < b < Comorbidities < b Pulmonry tuberculosis 4 (5.6) 3 (3.6) Crdiovsculr diseses 21 (29.2) 8 (9.5) Dibetes mellitus 6 (8.3) 7 (8.3) Obstructive irwy diseses 16 (22.2) 7 (8.3) Chronic liver disese 0 (0.0) 1 (1.2) Vlues re presented s men ± SD or number (%). EBTB, endobronchil tuberculosis; BAF, bronchil nthrcofibrosis; OR, odds rtio. ORs nd corresponding p vlues by logistic regression, djusted for ge, history of biomss smoke, nd comorbidities. b Chi-squred test. c Student s t test. in the BAF group. On multivrite nlysis, djusted for ge, history of biomss smoke, nd comorbidities, the most significnt vrible ws history of biomss smoke exposure (djusted OR, ; djusted p < 0.001). Cough ws the most common presenting symptom nd ws significntly more frequent in the non-baf group, while dyspne ws more frequent in the BAF group. Infiltrtion nd telectsis were common dominnt rdiologicl findings, followed by mss nd pleurl effusion, but no significnt difference ws noted between the groups (Tble 3). Bronchoscopic findings The right lung ws commonly involved site of EBTB in 97 ptients (62%), prticulrly the right middle lobr bronchus in 39 ptients (25%) nd the right upper lobr bronchus in 32 ptients (21%). In the left lung, the left upper lobr bronchus ws common site of EBTB, in 28 ptients (18%). EBTB ws observed significntly more commonly in the right lung, especilly in the right middle lobr bronchus, in the BAF group. However, EBTB ws more significntly observed in the left lower lobr bronchus in the non-baf group thn in the BAF group. By morphologicl clssifiction of EBTB, ctively cseting, edemtous-hyperemic, nd ulcertive types were the predominnt types observed, in 77 (49%), 33 (21%), nd 31 cses (20%), respectively (Fig. 1). Ptients with BAF hd more ulcertive type, while ptients without BAF hd more ctively cseting type disese (Tble 4). The rtes of AFB smer nd Mycobcterium tuberculosis culture positivity frequencies in sputum were 28.8% nd 45.9%, respectively, nd in bronchil wshings, 75% nd 87.2%, respectively. The most frequently observed histologicl feture ws chronic grnulomtous inf lmmtion (83.3%), followed by chronic nonspecific inflmmtion (13.5%) nd nondignostic (3.2%). No significnt difference in dignostic yield ws observed in ny smple between the groups (Tble 5). Outcomes Among the non-baf group, one ptient ws trnsferred to primry hospitl. For tretment of EBTB, most ptients strted with the isonizid (H), ethmbutol (E), rifmpicin (R), nd pyrzinmide (Z) regimen. In the non-baf group, the proportion of ptients treted with the HERZ regimen ws significntly higher thn tht of the BAF group. The durtion of 332

4 Kim HJ, et l. Anthrcofibrosis nd tuberculosis tretment ws 7.6 months in the BAF group nd 7.3 months in the non-baf group. No significnt difference ws seen in development of complictions during tretment or posttretment bronchostenosis between the two groups (Tble 6). DISCUSSION In this study, ptients who hd BAF on bronchoscopic exmintion hd higher chnce of EBTB thn those without BAF (OR, 8.88). Among the EBTB ptients, the BAF group ws significntly older thn the non-baf group nd hd significntly higher frequency of his- Tble 3. Comprison of clinicl chrcteristics in the BAF nd non-baf groups Chrcteristic Presenting symptoms BAF (n = 72) Non-BAF (n = 84) Significnce Cough 28 (38.9) 47 (56.0) p < 0.05 Dyspne 16 (22.2) 5 (6.0) p < 0.01 Hemoptysis 6 (8.3) 5 (6.0) NS Abnorml chest X-ry 8 (11.1) 8 (9.5) NS Others 14 (19.4) 19 (22.6) NS Dominnt rdiologicl findings Infiltrtion 39 (54.2) 51 (60.7) Atelectsis 14 (19.4) 17 (20.2) Mss 9 (12.5) 5 (6.0) Pleurl effusion 4 (5.6) 2 (2.4) Norml 2 (2.8) 1 (1.2) Others 4 (5.6) 8 (9.5) Vlues re presented s number (%). BAF, bronchil nthrcofibrosis; NS, not significnt. Chi-squred test. NS A B C Figure 1. Three common types of endobronchil tuberculosis in ptients with bronchil nthrcofibrosis. (A) Actively cseting type in the right middle lobr bronchus. (B) Hyperemic-edemtous type in the left upper lobr bronchus. (C) Ulcertive type in the right middle lobr bronchus, ssocited with hyperemic-edemtous surrounding mucos. 333

5 The Koren Journl of Internl Medicine Vol. 28, No. 3, My 2013 tory of biomss smoke exposure nd comorbidities. On multivrite nlysis, history of biomss smoke exposure ws the most importnt fctor for EBTB. Previous studies hve reported high rtes of tuberculosis in ptients with BAF [7,8,13]. Most BAF ptients in Kore were older femles nd hd experienced long-term exposure to smoke from biomss fuels, such s wood, leves, nd crop residues [7]. Thus, the resons for the high rtes of tuberculosis in ptients with BAF my be s follows: first, n ssocition with biomss smoke s n independent risk fctor for pulmonry tuberculosis [14-17]; second, n increse in tuberculosis prevlence relted to old ge [18]; nd third, compromise of pulmonry nd bronchil immune defense mechnisms due to exposure to toxic substnces in biomss smoke or the pthology of BAF itself [7,19]. The results of the present study re consistent with this explntion. EBTB shows diverse symptoms, such s chronic cough, hemoptysis, nd dyspne ccompnied by sputum, tht re not llevited redily by conservtive tretments. In our series, cough nd dyspne were the most common symptoms. In prticulr, dyspne ws seen frequently in the BAF group, s this group consisted mostly of elderly ptients who hd significntly higher frequencies of comorbidities, prticulrly obstructive irwy diseses nd crdiovsculr diseses. Tble 4. Comprison of the bronchoscopic findings of EBTB in the BAF nd non-baf groups Vrible Loction BAF (n = 72) Non-BAF (n = 84) Significnce R/L 54/18 43/39 p < 0.01 Trche 0 2 NS RM 5 (6.9) 7 (8.3) NS RUL 17 (23.6) 15 (17.9) NS RIB 1 (1.4) 2 (2.4) NS RML 27 (37.5) 12 (14.3) p < 0.01 RLL 4 (5.6) 7 (8.4) NS LM 3 (4.2) 10 (11.9) NS LUL 13 (18.1) 15 (17.9) NS LLL 2 (2.8) 14 (16.7) p < 0.01 Morphology Actively cseting 26 (36.1) 51 (60.7) p < 0.01 Edemtous-hyperemic 14 (19.4) 19 (22.6) NS Fibrostenotic 3 (4.2) 1 (1.2) NS Tumorous 3 (4.2) 3 (3.6) NS Grnulr 2 (2.8) 0 (0.0) NS Ulcertive 23 (31.9) 8 (9.5) p < 0.01 Nonspecific bronchitic 1 (1.4) 2 (2.4) NS Vlues re presented s number (%). EBTB, endobronchil tuberculosis; BAF, bronchil nthrcofibrosis; R, right lung; L, left lung; NS, not significnt; RM, right min bronchus; RUL, right upper lobr bronchus; RIB, right intermedius bronchus; RML, right middle lobr bronchus; RLL, right lower lobr bronchus; LM, left min bronchus; LUL, left upper lobr bronchus; LLL, left lower lobr bronchus. Chi-squred test. 334

6 Kim HJ, et l. Anthrcofibrosis nd tuberculosis In chest X-ry findings of EBTB, s in this study, infiltrtion, consolidtion, nd telectsis predominte; however, norml findings hve been reported in 3% to 8.3% of cses [1,2,4-6]. BAF rdiologicl exmintions show primry nd secondry findings [7]. The chrcteristic primry finding is curviliner bronchil nrrowing or telectsis with enlrgement of lymph nodes, which re usully clcified, nd re seen commonly with chest computed tomogrphy [8,20]. However, secondry findings re determined by ssocited diseses [7,8,20]. Although telectsis or clcified lymph nodes re encountered occsionlly, most simple chest rdiogrphic findings re secondry, such s consolidtion, interstitil infiltrtion, nd Tble 5. Comprison of the microbiologic nd histologicl findings in the BAF nd non-baf groups Vrible BAF Non-BAF Totl Significnce Nturl sputum NS AFB smer positivity 15 (27.3) 17 (30.4) 32 (28.8) M. tuberculosis culture positivity 27 (49.1) 24 (42.9) 51 (45.9) Bronchil wshing NS AFB smer positivity 53 (73.6) 64 (76.2) 117 (75.0) M. tuberculosis culture positivity 64 (88.9) 72 (85.7) 136 (87.2) Bronchil histology NS Chronic grnulomtous inflmmtion 58 (80.6) 72 (85.7) 130 (83.3) Chronic nonspecific inflmmtion 13 (18.1) 8 (9.5) 21 (13.5) Nondignostic 1 (1.4) 4 (4.8) 5 (3.2) Vlues re presented s number (%). BAF, bronchil nthrcofibrosis; NS, not significnt; AFB, cid-fst bcilli; M. tuberculosis, Mycobcterium tuberculosis. Chi-squred test. Tble 6. Comprison of outcomes in the BAF nd non-baf groups Vrible BAF (n = 72) Non-BAF (n = 83) Significnce HER/HERZ 26/46 10/73 p < 0.01 Durtion of therpy, mon 7.6 ± ± 2.26 NS b Complictions during therpy 11 (15.3) 18 (21.7) NS Skin rsh 4 6 GI upset 4 6 Visul disturbnce 2 4 Heptopthy 1 1 Others 1 Posttretment bronchostenosis 3 (4.2) 12 (14.5) NS Vlues re presented s men ± SD or number (%). BAF, bronchil nthrcofibrosis; H, isonizid; E, ethmbutol; R, rifmpicin; Z, pyrzinmide; NS, not significnt; GI, gstrointestinl. Chi-squred test. b Student s t test. 335

7 The Koren Journl of Internl Medicine Vol. 28, No. 3, My 2013 pleurl lesions [7]. From this point of view, in our series, no significnt difference between the two groups in dominnt rdiologicl findings with simple chest X-rys would be expected. Thus, these two diseses re difficult to discriminte using simple chest rdiogrphic findings. Generlly, bronchoscopic exmintion is not only useful for dignosing EBTB, but lso for evluting the prognosis by observing the degree of progression nd morphology. It is lso n essentil test in dignosing BAF. The pthophysiologicl mechnisms of EBTB re thought to involve direct invsion onto bronchus from n infected lung prenchym, implnttion from infected sputum, hemtogenous spred, erosion into bronchus from tuberculous lymph node, or extension into the peribronchil region by lymphtic dringe from n infected prenchym [21]. In the present study, EBTB ws more frequent in the right lung (62.2%), nd the upper lobr (38.5%) nd right middle lobr bronchi (25%) were the most frequent sites. This trend ws even more prevlent in the BAF group. These findings re likely becuse these regions include not only the most common site of pulmonry tuberculosis [2,5,22] but lso the min pthologicl site of BAF [7,23]. The principl pthologicl bronchil finding of BAF ws multiple pigmenttion nd bronchil stenosis [7,8]. In prticulr, the right middle lobr bronchus is the most common site of bronchil stenosis, due to its ntomicl loction [7]. This pthology my lter the locl immune defense mechnism nd provide good plce for the implnttion of M. tuberculosis from ny origin [7,19]. Morphologicl clssifiction of EBTB ws conducted ccording to Chung nd Lee s method [12], s nonspecific bronchitic, grnulr, hyperemic-edemtous, ctively cseting, ulcertive, tumorous, nd fibrostenotic types. This clssifiction scheme provided us with not only the morphologicl types but lso the degree of disese progression reltively well. Moreover, the therpeutic outcome of ech type, except the tumorous type, cn be predicted by follow-up bronchoscopy during the initil 2 to 3 months of tretment [12]. As in previous studies [4-6,12], in our series, ctively cseting nd edemtous-hyperemic types were encountered most frequently, in 49.4% nd 21.8% of cses, respectively. Vrious bronchil findings cn evolve within 3 months fter clinicl presenttion [12,24]. Differences in the times for bronchoscopic dignoses of EBTB my be prtilly responsible for the somewht different composition of morphologicl types between the two groups. The ulcertive type ws lso frequently observed (19.9%), prticulrly in the BAF group. This my be explined by the fct tht EBTB is ccompnied loclly by regions of severe nthrcofibrotic chnge, nd tissue destruction develops rpidly (Fig. 1C) [7]. Becuse mucus entrpment by proximl bronchil grnultion tissue in EBTB cn prevent expectorting sputum, s in our cses, the dignostic yield on sputum AFB smers ws generlly poor in studies with lrge numbers of cses [2,4,12]. Accordingly, bronchoscopic smpling hs been key to dignosis. However, the presence of BAF could not lter the dignostic yield on ny smple for EBTB. For EBTB tretment, we used either the HERZ or HER regimen for 6 to 9 months or longer, s needed. The HER regimen ws used more in the BAF group, becuse we hd severl older ptients, compred with the non-baf group. However, no significnt difference in the development of complictions during tretment nd posttretment bronchostenosis ws observed between the two groups. Controversy regrding the effects of corticosteroids in EBTB remins [25-29], but we use these in limited fshion in cses with trchel or min bronchil involvement or in cses with ctively cseting type in the upper lobr bronchus with invsion to the proximl portion of the min bronchus. According to Chung nd Lee [12], ll subtypes of EBTB cn trnsform into nother subtype during tretment, nd bronchil stenosis is inevitble if the disese progresses beyond criticl point, determined minly by the extent of disese progression nd relted closely to grnultion tissue formtion. In the present study, in just 15 cses with cliniclly suspected bronchostenosis fter tretment, we performed follow-up bronchoscopy nd observed mild bronchil stenosis, which did not need n interventionl procedure. Although we could not monitor chnges in morphology or the degree of stenosis in ll subjects, it seems tht the presence of BAF did not lter the nturl course of EBTB or tretment outcomes. In conclusion, BAF is n emerging pulmonry disese worldwide due to biomss fuel exposure [30]; 336

8 Kim HJ, et l. Anthrcofibrosis nd tuberculosis indeed, it is estimted tht over 50% of ll households nd 90% of ll rurl households worldwide continue to use biomss fuel s their min domestic source of energy [31]. The structurl, physiologicl, nd locl immunologicl bnormlities of the disese my led to the development of multiple pulmonry diseses [7,30]. Our dt suggest tht BAF is risk fctor for EBTB nd ffects the loction nd morphologicl type t the time of EBTB development. Becuse this study ws limited by its retrospective design, further prospective studies re needed to clrify the reltionship between the presence of BAF nd the nturl course nd tretment outcome of EBTB. KEY MESSAGE 1. Ptients who hd bronchil nthrcofibrosis (BAF) hd higher chnce of endobronchil tuberculosis (EBTB) thn those without BAF. 2. EBTB ws more frequent in the right lung, prticulrly the right middle lobr bronchus, nd ws more ulcertive in the BAF ptients. 3. BAF cn be risk fctor for EBTB nd ffect the loction nd morphologicl type of EBTB. Conflict of interest No potentil conflict of interest relevnt to this rticle is reported. REFERENCES 1. Smith LS, Schillci RF, Srlin RF. Endobronchil tuberculosis: seril fiberoptic bronchoscopy nd nturl history. Chest 1987;91: Lee JH, Prk SS, Lee DH, Shin DH, Yng SC, Yoo BM. Endobronchil tuberculosis: clinicl nd bronchoscopic fetures in 121 cses. Chest 1992;102: Kim YH, Kim HT, Lee KS, Uh ST, Cung YT, Prk CS. Seril fiberoptic bronchoscopic observtions of endobronchil tuberculosis before nd erly fter ntituberculosis chemotherpy. Chest 1993;103: Prk EJ, Kim MO, Yng SC, et l. Clinicl nd bronchoscopic fetures of 280 ptients with endobronchil tuberculosis ( ). Koren J Med 2003;64: An JY, Lee JE, Prk HW, et l. Clinicl nd bronchoscopic fetures in endobronchil tuberculosis. Tuberc Respir Dis 2006;60: Kim HJ, Kim HS, M JE, et l. Clinicl chrcteristics of endobronchil tuberculosis tht develops in ptients over 70 yers of ge. Tuberc Respir Dis 2007;63: Kim YJ, Jung CY, Shin HW, Lee BK. Biomss smoke induced bronchil nthrcofibrosis: presenting fetures nd clinicl course. Respir Med 2009;103: Chung MP, Lee KS, Hn J, et l. Bronchil stenosis due to nthrcofibrosis. Chest 1998;113: Cohen AG. Atelectsis of the right middle lobe resulting from perfortion of tuberculous lymph nodes into bronchi in dults. Ann Intern Med 1951;35: Vn den Brnde PM, Vn de Mierop F, Verbeken EK, Demedts M. Clinicl spectrum of endobronchil tuberculosis in elderly ptients. Arch Intern Med 1990;150: Hwng J, Puttgunt L, Green F, Shimnovsky A, Brrie J, Long R. Bronchil nthrcofibrosis nd tuberculosis in immigrnts to Cnd from the Indin subcontinent. Int J Tuberc Lung Dis 2010;14: Chung HS, Lee JH. Bronchoscopic ssessment of the evolution of endobronchil tuberculosis. Chest 2000;117: Mirsdree M, Seedi P. Anthrcosis of lung: evlution of potentil underlying cuses. J Bronchology 2005;12: Mishr VK, Retherford RD, Smith KR. Biomss cooking fuels nd prevlence of tuberculosis in Indi. Int J Infect Dis 1999;3: Perez-Pdill R, Perez-Guzmn C, Bez-Sldn R, Torres-Cruz A. Cooking with biomss stoves nd tuberculosis: cse control study. Int J Tuberc Lung Dis 2001;5: Pokhrel AK, Btes MN, Verm SC, Joshi HS, Sreermreddy CT, Smith KR. Tuberculosis nd indoor biomss nd kerosene use in Nepl: cse-control study. Environ Helth Perspect 2010;118: Kolppn C, Subrmni R. Assocition between biomss fuel nd pulmonry tuberculosis: nested csecontrol study. Thorx 2009;64: Rjgopln S. Tuberculosis nd ging: globl helth problem. Clin Infect Dis 2001;33: Zelikoff JT, Chen LC, Cohen MD, Schlesinger RB. The 337

9 The Koren Journl of Internl Medicine Vol. 28, No. 3, My 2013 toxicology of the inhled woodsmoke. J Toxicol Environ Helth B Crit Rev 2002;5: Kim HY, Im JG, Goo JM, et l. Bronchil nthrcofibrosis (inf lmmtory bronchil stenosis with nthrcotic pigmenttion): CT findings. AJR Am J Roentgenol 2000;174: Smrt J. Endo-bronchil tuberculosis. Br J Tuberc Dis Chest 1951;45: Pitchenik AE, Rubinson HA. The rdiogrphic ppernce of tuberculosis in ptients with the cquired immune deficiency syndrome (AIDS) nd pre-aids. Am Rev Respir Dis 1985;131: Sndovl J, Sls J, Mrtinez-Guerr ML, et l. Pulmonry rteril hypertension nd cor pulmonle ssocited with chronic domestic woodsmoke inhltion. Chest 1993;103: Jokinen K, Plv T, Nuutinen J. Bronchil findings in pulmonry tuberculosis. Clin Otolryngol Allied Sci 1977;2: Sung UP, Kim SH, Shin JW, et l. The effect of steroid on the tretment of endobronchil tuberculosis. Tuberc Respir Dis 1995;42: Lee JY, Kim CM, Moon DS, et l. The clinicl fetures of endobronchil tuberculosis: retrospective study on 201 ptients for 6 yers. Tuberc Respir Dis 1996;43: Hoheisel G, Chn BK, Chn CH, Chn KS, Teschler H, Costbel U. Endobronchil tuberculosis: dignostic fetures nd therpeutic outcome. Respir Med 1994;88: Chn HS, Png JA. Effect of corticosteroids on deteriortion of endobronchil tuberculosis during chemotherpy. Chest 1989;96: Ip MS, So SY, Lm WK, Mok CK. Endobronchil tuberculosis revisited. Chest 1986;89: Gupt A, Shh A. Bronchil nthrcofibrosis: n emerging pulmonry disese due to biomss fuel exposure. Int J Tuberc Lung Dis 2011;15: Bruce N, Perez-Pdill R, Alblk R. Indoor ir pollution in developing countries: mjor environmentl nd public helth chllenge. Bull World Helth Orgn 2000;78:

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