A70-20 Not All That Narrows Is Cancer: Unmasking Tracheobronchial Tuberculosis

Abstract Introduction Tracheobronchial tuberculosis (TBTB) occurs in up to 40% of patients with pulmonary tuberculosis (pTB). Because bronchoscopy is required for diagnosis, many cases may go unrecognized. Despite adequate therapy, up to 90% of patients develop tracheal or bronchial stenosis due to fibrosis from inflammation, leading to airway narrowing and persistent or worsening symptoms. We present a case of an older gentleman with a history of latent TB with chronic cough and dyspnea and was found to have a tracheal mass secondary to TBTB. Case A 76-year-old man with a remote history of treated latent TB in the 1970s and a 50-pack-year smoking history initially presented to an outside hospital with a persistent cough lasting three months and voice hoarseness that progressively worsened over the last month. He was afebrile and not hypoxic. Labwork was unrevealing. Chest imaging revealed distal tracheal thickening and narrowing of the right upper lobe bronchus with associated atelectasis and bronchiectasis. He was sent home with Dexamethasone, Doxycycline, and Augmentin, which led to partial symptom improvement. However, eight months later, the patient presented to our emergency department due to progressively worsening cough, voice hoarseness, dyspnea on exertion, and a 15-pound weight loss. He remained afebrile and did not require supplemental oxygen. Labwork again was unrevealing. Repeat imaging was significant for progressive distal tracheal narrowing and a right upper lobe mass, along with mesenteric lymphadenopathy concerning for malignancy. Bronchoscopy revealed an irregular tracheal lesion, right main stem stenosis, and biopsy confirmed Mycobacterium tuberculosis. Notably, acid-fast bacilli (AFB) sputum cultures were negative. The patient was initiated on RIPE therapy, resulting in significant improvement in cough, dyspnea, and a reduction in voice hoarseness. Discussion TBTB should be considered in patients with chronic cough, airway narrowing, or non-resolving pneumonia, especially those with a history of TB exposure. Its nonspecific presentation often leads to misdiagnosis as malignancy or chronic bronchitis, delaying appropriate therapy. Sputum AFB smear negativity is common in TBTB, making bronchoscopy the diagnostic gold standard for this condition. A delay in diagnosis can result in mucosal ulceration and fibrostenotic healing, leading to irreversible airway obstruction even after treatment.This case illustrates how TBTB can mimic neoplastic disease, emphasizing early recognition to prevent complications such as tracheobronchial stenosis, recurrent infections, and long-term ventilatory impairment. Maintaining a high index of suspicion in patients with historical or epidemiologic risk factors is essential to prompt bronchoscopy and targeted therapy, ultimately improving patient outcomes. This abstract is funded by: None