This document describes a case of a 48-year-old male admitted with hemoptysis and cough who was found to have a tree-in-bud pattern seen on CT scan, indicative of endobronchial spread of infection in the right upper lobe. The tree-in-bud pattern represents small pulmonary nodules or masses in the secondary pulmonary lobules and is often seen in conditions like tuberculosis. Bronchoscopy revealed white granulation tissue, confirming endobronchial tuberculosis as the cause in this patient.

1. PROF.DR.G.SUNDARAMURTHY’S UNIT M7
DR.BHARGAVI.K

2. HISTORY IN BRIEF
 48 yr old male was admitted
 With c/o hemoptysis for 1 day-10 episodes
 c/o giddiness
 k/c/o HT on Rx
 not a k/c/o PT
 On examination:Gen exmn- was normal
 Cvs-NAD
 Rs-fine crepts + right interscapular and
subscapular areas.

3.  INVESTIGATIONS
 Rbs,Rft- within normal limits
 Hb-9.2 gms, complete profile- normal
 Sputum AFB- negative
 Further imaging ensued…….

8.  Lung parenchyma shows TREE IN BUD
OPACITY S/O ENDOBRONCHIAL SPREAD OF
INFECTION, noted in R UPPER LOBE
INVOLVING AZYGOUS LOBE ,LIMITED BY
AZYGOUS fissure, apical anterior segment.
 Tiny nodular opacities noted in throughout
lung tissues on both sides.
 ?TB etiology.

9. .

10. Figure 1. High-resolution CT scan (far left) and drawings of the lung (middle left), a budding
tree (middle right), and tree buds (far right) show the tree-in-bud pattern.

11. Rossi S E et al. Radiographics 2005;25:789-801
©2005 by Radiological Society of North America

12.  THE TERMINAL
TUFTS
-inflammation
with caseous
material in the
respiratory
bronchioles and
alveolar ducts
 STALKS
-caseous
material within
the terminal
bronchiole

13. Secondary PULMONARY lobule is
supplied by a lobular bronchiole and a lobular
artery that are located in the center of the
lobule.

14.  Under normal circumstances, the
intralobular bronchiole is less than 1 mm in
diameter and is not normally visible on
CT scans
 However, diseased bronchioles with
mucous plugging with pus,fluid, wall
thickening, or dilatation and peribronchiolar
inflammation can be visualized on thin-
section CT scans, often displaying the tree-
in-bud phenomenon

15. Abnormal – tree in bud Normal ct section

16. TREE IN BUD PATTERN
 Infection
 Bacterial
 Tuberculosis(72%)
 Non-tuberculosis-MAC,staph aureus,H.influenzae.
 Fungal
 Aspergillus
 Viral
 Cytomegalovirus
 Respiratory syncytial virus
 Idiopathic disorders
 Obliterative bronchiolitis
 Diffuse panbronchiolitis

17. CONGENITAL DISORDERS
Cystic fibrosis
Kartagener’s syndrome
IMMUNOLOGICAL DISORDERS
 Allergic bronchopulmonary aspergillosis
CONNECTIVE TISSUE DISORDER
 Rheumatoid arthritis
Sjogren’s syndrome
MISCELLANEOUS
 Aspiration
Inhalation of toxic fumes of gases
Langerhans cell histocytosis
Sarcoidosis
TUMOURS
PERIPHERAL PULMONARY VASCULAR DISEASE
Thrombotic micro-angiography

18. ENDOBRONCHIAL TB
-TUBERCULOUS INFECTION
OF THE TRACHEOBRONCHIAL
TREE WITH MICROBIAL AND
HISTOPATHOLOGICAL
EVIDENCE
-10-40% OF PATIENTS WITH
ACTIVE
PULMONARY TUBERCULOSIS.

19. ENDOBRONCHIAL TB
PATHOGENESIS
direct implantation of tubercle bacilli
into the bronchus from an adjacent pulmonary
parenchymal lesion
direct airway infiltration from an
adjacent tuberculous mediastinal lymph node
Erosion and protrusion of an intrathoracic tuberculous
lymphnode into the bronchus
hematogenous spread
extension to the peribronchial region by lymphatic
drainage.

20. CLASSIFICATION OF ENDOBRONCHIAL TB
(chung n lee)
 ACTIVELY CASEATING(43%)
 EDEMATOUS-HYPEREMIC,
 FIBROSTENOTIC
 TUMOROUS
 GRANULAR
 ULCERATIVE
 NONSPECIFIC

21. CLINICAL SYMPTOMS
 COUGH
 DYSPNEA
 LOCAL WHEEZE
 HEMOPTYSIS
 HOARSENESS
 ANOREXIA

22. SEQUELAE….
 BRONCHOSTENOSIS
 BRONCHOSTRICTURES
 bronchiolitis obliterans
 bronchocentric granulomatosis
 BRONCHIECTASIS

23. DIAGNOSIS
SPUTUM EXAMINATION is the essential and first step .
C X-RAY: NORMAL IN 10-20%
BRONCHOSCOPY(BRONCHIAL
BIOPSY/BRUSHING/ WASHINGS) AND CT
are the methods of choice for accurate diagnosis of Bronchial involvement .
Typical bronchoscopic finding is the presence of white gelatinous granulation
tissue. The mucosa is nodular, red, vascular and some times ulcerated. It may
simulate a bronchogenic Carcinoma
Nucleic acid amplification tests, such as PCR
and other methods for amplifying DNA

24. TREATMENT
 ATT-conventional chemotherapy containing INH,
rifampicin, pyrazinamide and ethambutol.
 CORTICOSTERIODS
 balloon dilatation, self expanding metallic
stent(FOR BRONCHIAL STENOSIS)
 laser, curettage, resection and anastomosis