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CLINICAL NOTE

Diagnosis of silicotuberculosis by Endobronchial

Ultrasound-Guided Transbronchial Needle Aspiration
(EBUS-TBNA)

ALVIN H. M. TUNG,1 JENNY C. L. NGAI,1 FANNY W. S. KO,1 BETTY P. K. CHAK,2 LOUIS CHOW2 AND
DAVID S-C. HUI1

Departments of 1Medicine and Therapeutics, and 2Anatomical and Cellular Pathology, Prince of Wales Hospital, Hong Kong

Key words: EBUS-TBNA, silicotuberculosis, silicosis, crystals with granulomatous inflammation in Station
tuberculosis. 10R consistent with silicosis. Stains for Acid Fast Bacilli
(AFB) were negative. Stations 4R and 7 were negative
Abbreviations: EBUS-TBNA, Endobronchial Ultrasound- for malignancy or granulomatous inflammation. The
Guided Transbronchial Needle Aspiration.
patient had his antituberculous therapy prolonged to 8
months to reduce the chance of relapse in accordance
A 74-year-old chronic smoker was found to have a to local guidelines, together with a referral for com-
solitary 3-cm Right Lower Lobe (RLL) Lung shadow on pensation assessment.
Chest radiograph following investigation of cough by Silicotuberculosis is infrequently reported in the lit-
his general practitioner. Occupational history revealed erature.1 Patients with chronic silicosis often present
construction site work involving handling of concrete with associated conditions, such as tuberculosis in
building materials for 50 years from the age of 25. our case. Establishing a diagnosis has important
Initial Positron Emission Tomography-Computed implications for compensation and for the duration
Tomography (PET-CT) demonstrated its fludeoxyglu- of antituberculosis therapy. Occupational history is
cose (FDG) avidity with multiple hypermetabolic frequently underutilized. As demonstrated in a patho-
mediastinal and bilateral hilar lymph nodes, without logical case series, 25% of silicosis was missed in lung
other parenchymal lesions. Sputum culture was posi- biopsies referred for idiopathic pulmonary fibrosis.2
tive for Mycobacterium tuberculosis complex, and he The difficulty in diagnosis is compounded by the fact
was started on Rifampicin, Isoniazid, Ethambutol and that FDG uptake in lymph nodes secondary to silico-
Pyrazinamde. He declined further investigation for sis has previously been reported as false-positives in
fear of invasive procedures. After 6 months, Computed
Tomography thorax (CT thorax; see Supporting Infor-
mation Figs S1–3) demonstrated reduction of the RLL
lesion in size to 2.2 cm, with multiple subcentimetre,
non-specific nodules in both lungs. There was also
enlargement of his right hilar lymph node, which
appeared to be non-calcified and necrotic. Given his
occupational history, silicosis was a differential diag-
nosis, but lung malignancy needed to be excluded.
After discussion with the patient and his family, he
agreed to Endobronchial Ultrasound-Guided Trans-
bronchial Needle Aspiration (EBUS-TBNA) that
showed multiple, hypoechoic enlargement of his
Right paratracheal (Station 4R, 2 cm), Right hilum
(Station 10R, 1.5 cm) and subcarinal (Station 7, 1 cm)
lymph nodes. Cytological examination of these
sampled nodes (Fig. 1) demonstrated birefringent

Correspondence: Dr Alvin Hon Man Tung, Department of

Medicine and Therapeutics, Prince of Wales Hospital, Ngan
Shing Street, Shatin, Hong Kong. Email: ahm_tung@
hotmail.com
Received 9 October 2012; invited to revise: 17 October 2012;
revised 18 October 2012; accepted 18 October 2012 (Associate
Editor: Chi Chui Leung).
Figure 1 EBUS-TBNA of R hilar lymph node demonstrating
granulomatous inflammation with presence of birefringent crys-
tals under polarized light. Stains for Acid Fast Bacilli (AFB) were
negative.

© 2012 The Authors Respirology (2013) 18, 383–384

Respirology © 2012 Asian Pacific Society of Respirology doi: 10.1111/resp.12020
384
Non-Small Cell Lung Cancer (NSCLC) staging.3 It was
difficult to label the case radiologically as silicosis
given the atypical features in this case, and lymph
node sampling was ultimately required for diagnosis.
Lung biopsy is seldom required to establish the diag-
nosis if clinical and radiological criteria are met,
although it is used to exclude other diagnoses.
EBUS-TBNA is a useful tool in the diagnosis and
staging of lung malignancy, although a large multi-
centre study reported that its negative predictive
value could be as low as 11%.4 Recent evidence sug-
gests that it is also an effective investigative tool for
tuberculous5 and granulomatous intrathoracic lym-
phadenopathy,5 with high diagnostic yield and low
complication rates. While it was possible that our
patient’s initial RLL lung lesion could harbour malig-
nancy, the decrease in its size was reassuring.
To conclude, we report a case of chronic silicosis
presented with antituberculous therapy treatment
failure despite microbiological confirmation. EBUS-
TBNA was used to pinpoint the diagnosis when radio-
logical features were inconclusive of silicosis. To the
best of our knowledge, this is the first reported case of
silicotuberculosis diagnosed by EBUS-TBNA.
REFERENCES
1 Martins P, Marchiori E, Zanetti G et al. Cavitated conglomerate
mass in silicosis indicating associated tuberculosis. Case Report.
Med. 2010; 2010: pii: 293730.
Respirology (2013) 18, 383–384
AHM Tung et al.
2 Monso E, Tura JM, Marsal M et al. Mineralogical microanalysis of
idiopathic pulmonary fibrosis. Arch. Environ. Health 1990; 45:
185–88.
3 O’Connell M, Kennedy M. Progressive massive fibrosis secondary
to Pulmonary silicosis appearance on F-18 fluorodeoxyglucose
PET/CT. Clin. Nucl. Med. 2004; 29: 754–5.
4 Herth FJ, Eberhardt R, Vilman P et al. Real-time endobronchial
ultrasound guided transbronchial needle aspiration for sampling
mediastinal lymph nodes. Thorax 2006; 61: 795–8.
5 Navani N et al. Utility of endobronchial ultrasound-guided trans-
bronchial needle aspiration in patients with tuberculous intratho-
racic lymphadenopathy: a multicentre study. Thorax 2011; 66:
889–93.
Supporting Information
Additional Supporting Information may be found in the online
version of this article:
Figure S1 Repeat Computed Tomography (CT) thorax showing right
lower lobe (RLL) lesion.
Figure S2 Repeat Computed Tomography (CT) thorax showing
necrotic 10R lymph node.
Figure S3 Repeat Computed Tomography (CT) thorax showing
enlarged 4R lymph node.
© 2012 The Authors
Respirology © 2012 Asian Pacific Society of Respirology