Trakeobronşiyal tüberküloz

Özet

Trakeobronşiyal tüberküloz, bronş mukozası ve duvarını tutarak fokal ya da uzun segment daralma, tıkanma ve daha sonra fibrotik stenoz oluşturabilir. Kontrastlı toraks BT hava yolu duvarını, komşu lenf düğümlerini ve distal akciğer etkilenmesini; ince kesit akciğer görüntüleri ise eşlik eden küçük hava yolu yayılımını gösterir. Nekrotik lenf düğümünün bronşa komşuluğu veya endobronşiyal yayılım tanıyı destekler, fakat BT mikrobiyolojik doğrulamanın yerini almaz. Tanınmayan darlık kalıcı obstrüksiyon, postobstrüktif enfeksiyon, atelektazi ve bronşektaziyle sonuçlanabilir.

Faz ve pencere

Portal tanısal

İntravenöz kontrast sonrası venöz fazda fokal/uzun segment bronş ya da trakea duvar kalınlaşması ve düzensiz lümen daralması; komşu lenf düğümlerinde düşük atenüasyonlu nekrotik merkez ve çevresel kontrastlanma görülebilir. Hava yolu duvarı ve mediastinal lenf düğümü ilişkisini değerlendirmek için kontrast yararlıdır.

HRCT tanısal

İnce kesit akciğer algoritmasında stenozun distalinde mukus birikimi, lobar/segmental atelektazi, bronşiektazi ve endobronşiyal yayılımı gösteren sentrilobüler nodüller ya da tomurcuklanan ağaç aranır.

Önerilen pencereler: Mediasten (G 350 / M 50), Akciğer (G 1500 / M -600), Yumuşak doku (G 400 / M 40).

BT bulguları

• Fokal bronş duvar kalınlaşması — sıklıkla ana, lobar veya segment bronşta asimetrik yumuşak doku kalınlaşması hava kolonu kenarını bozar.
• Uzun segment santral hava yolu tutulumu — trakea veya ana bronş boyunca düzensiz duvar kalınlaşması ve lümen çapında azalma gelişebilir.
• Düzensiz endoluminal daralma — mukozal/duvar hastalığı bronş lümenini eksantrik biçimde daraltır; iyileşme döneminde fibrotik stenoz kalabilir.
• Nekrotik lenf düğümü — merkezinde düşük atenüasyon, çevresinde kontrastlanan doku bulunan hiler ya da mediastinal lenf düğümü bronşa komşu olabilir.
• Lenf düğümünden hava yoluna uzanım — komşu lenf düğümü ile bronş arasında duvar düzensizliği, bası veya fistül benzeri devamlılık görülebilir.
• Distal postobstrüktif değişiklik — stenozun beslediği lobda mukus, atelektazi, konsolidasyon veya tekrarlayan enfeksiyon izlenebilir.
• Endobronşiyal yayılım — stenoz dışındaki akciğerde sentrilobüler nodüller ve tomurcuklanan ağaç deseni aktif bronşioler yayılımı destekleyebilir.
• Kronik sekeller — etkilenen lobda bronşiektazi, hacim kaybı ve fibrotik bantlar kalıcı hale gelebilir.

Normalde

Normal trakea ve bronşlarda duvar ince, kontur düzgün ve hava kolonu kesintisizdir; aynı düzeyde komşu lenf düğümleri bronş duvarına yapışık nekrotik kitle oluşturmaz. Sağ ve sol ana bronşları ve dallarını yan yana izleyerek duvar simetrisini, lümen açıklığını ve stenozun distalindeki lob hacmini karşılaştırın.

Ayırıcı tanı

Endobronşiyal primer tümör

bronş içinde fokal, kitle benzeri yumuşak doku ve ani kesilme yapabilir; eşlik eden atelektazi TB ile örtüşür, nodal nekroz tek başına ayrım sağlamaz.

Nükseden polikondrit

trakeal kıkırdak duvarında yaygın kalınlaşma ve kalsifikasyon, bazen posterior duvar korunumu veya ekspiratuvar çökme görülür.

Trakeobronşiyal amiloidoz

düzensiz duvar kalınlaşması ve kalsifikasyon daha çevresel olabilir; posterior membranöz duvar da tutulabilir.

Bronkojenik karsinom dışı postobstrüktif stenoz

eski entübasyon/cerrahi sonrası kısa, düzgün skar darlığı ve eşlik eden nekrotik lenf düğümlerinin yokluğu ayırıcıdır.

Sarkoidoz

hiler/mediastinal lenfadenopati ve bronş çevresi tutulum yapabilir; lenf düğümleri çoğunlukla nekrotik merkezli değildir ve parankimde perilenfatik nodüller eşlik edebilir.

Tuzaklar

• Nekrotik lenf düğümünü tek başına tüberküloz kabul etmeyin; metastaz ve diğer enfeksiyonlar da merkez nekrozu yapabilir, mikrobiyoloji ve klinik bağlam gerekir.
• Stenoz çevresindeki bronş duvarını yalnız kısmi hacim etkisi sanmayın; ince kesit ve koronal eğri düzlem boyunca gerçek duvar sürekliliğini doğrulayın.
• Distal atelektazi görüldüğünde, BT’de hava yolunu stenoz düzeyine kadar izleyerek obstrüksiyonun yerini ve komşu lenf düğümleriyle ilişkisini değerlendirin.
• Kronik fibrotik darlıkta aktif duvar inflamasyonu ve lenf düğümü nekrozu bulunmayabilir; skar görünümü tüberküloz sekeli olasılığını dışlamaz.

Kendini dene

1. Sol ana bronşta düzensiz daralma, komşu nekrotik lenf düğümü ve distal atelektazi görülüyor. Hangi süreç öncelikle düşünülür?

   • Trakeobronşiyal tüberküloz
   • Alerjik bronkopulmoner aspergilloz
   • Pulmoner emboli
   • Trakeobronkopati osteokondroplastika
   Cevabı göster

   Trakeobronşiyal tüberküloz. Bronş duvarı stenozu, komşu nekrotik lenf düğümü ve aynı alanda postobstrüktif atelektazi tüberküloz lehine birlikte bulgulardır; mikrobiyolojik doğrulama gereklidir. Alerjik bronkopulmoner aspergilloz santral bronşektazi, mukus tıkaçları ve yüksek atenüasyonlu mukus ile karakterizedir; bu bulgular tüberkülozun postobstrüktif değişikliklerinden farklılaşır.

2. Trakea ve ana bronşlarda düzgün sınırlı, çevresel kalsifiye duvar kalınlaşması; posterior membran da tutulmuş. En yakın alternatif nedir?

   • Trakeobronşiyal amiloidoz
   • Trakeal bronş
   • Bronş atrezisi
   • Akut bronkopnömoni
   Cevabı göster

   Trakeobronşiyal amiloidoz. Çevresel kıkırdaklı duvarda kalsifikasyon ve posterior membranöz duvarın tutulması, trakeobronşiyal amiloidozun ayırıcı özelliğidir; relapsing polikondrit ve osteokondroplastikada arka membran korunur. Trakeal bronş doğumsal bir dallanma varyantıdır; bronş atrezisi fokal bronş kesilmesiyle seyreder ve havayolu obstrüksiyonuna yol açar.

Kaynaklar

Bu sayfadaki 39 cümle ve 2 quiz sorusu aşağıdaki kaynaklardan alıntılarla tek tek karşılaştırıldı; 10 cümle bu karşılaştırmada düzeltildi (2026-10-08).

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