Extensive unilateral pulmonary tuberculosis with segmental atresia of principal bronchus.

Sir,

I read with interest the article titled “Extensive unilateral pulmonary tuberculosis with segmental atresia of principal bronchus”[1] and would like to furnish the following comments. The authors have labeled a diagnosis of “segmental atresia of principal bronchus” on their 38-year-old female patient that seems difficult to deduce, given the facts of the case. Bronchial atresia is conventionally defined as “severe focal narrowing or obliteration of a segmental, subsegmental, or lobar bronchus, usually associated with distal air trapping and bronchial mucoid impaction distal to the obstruction.”[2] The diagnosis hinges on computed tomography (CT) pattern and pathological features besides suggestive bronchoscopic features. The characteristic CT findings include mucocele, occlusion of bronchus central to mucocele, and emphysematous changes of adjacent lung field.[3] Pathological features include presence of blind-ending bronchus associated with distal mucous-filled bronchocele surrounded by hyperinflated lung parenchyma.[4] The case described by authors does not exhibit the above-mentioned features that can suggest a diagnosis of congenital bronchial atresia (CBA). The authors’ admission of “bronchial stump” being not seen in the pathological specimen does not throw light on the nature of pathology at the level of “atretic” bronchus. The diagnosis of CBA requires exclusion of acquired bronchial obstruction like inflammation. Given that their patient was ultimately proved to have pulmonary tuberculosis, what seems more likely is that endobronchial tuberculosis lead to bronchial stricture in the patient. The authors have rightly mentioned (albeit in passing) that endobronchial tuberculosis can lead to bronchial stenosis but have not alluded to how they have excluded the contribution of the same in the genesis of bronchial “atresia” in their patient.