Should I perform a bronchoscopy to investigate scanty hemoptysis in a 21-year-old male with a history of pulmonary tuberculosis (TB), who completed a 6-month treatment course with HRZE (isoniazid, rifampicin, pyrazinamide, and ethambutol) and HRE (isoniazid, rifampicin, and ethambutol), and has a negative Cartridge-Based Nucleic Acid Amplification Test (CBNAAT) result?

Management of Hemoptysis After Completed Tuberculosis Treatment

A bronchoscopy is recommended to investigate the source of scanty hemoptysis in this patient who has completed tuberculosis treatment and has a negative CBNAAT result.

Clinical Assessment of the Case

This 21-year-old male patient presents with:

• Completed 6-month TB treatment (2 months HRZE followed by 4 months HRE)
• Negative CBNAAT result indicating microbiological cure
• Scanty hemoptysis that was present before treatment, absent during treatment, and has now recurred
• No other reported symptoms

Diagnostic Approach

Initial Evaluation

1. Chest Imaging:

   • A chest radiograph is the first-line imaging study (rated 9/9 for appropriateness) 1
   • CT chest without IV contrast should be performed if the chest X-ray is equivocal (rated 7/9 for appropriateness) 1
   • CT angiography would be particularly useful to identify potential vascular causes of hemoptysis 2

2. Sputum Examination:

   • Despite negative CBNAAT, collect three consecutive sputum samples for AFB smear and culture 3
   • Testing for inhibitors should be considered when CBNAAT is negative but clinical suspicion remains high 3
   • Culture remains the gold standard for TB diagnosis 3

Bronchoscopy Indication

Bronchoscopy is indicated in this case for several important reasons:

1. Rule out active TB despite negative CBNAAT:

   • CBNAAT inhibitors are present in 3-7% of sputum specimens, which can cause false-negative results 3
   • A single negative NAA test should not be used to exclude TB when clinical suspicion is moderate to high 3

2. Identify source of bleeding:

   • Bronchoscopy allows direct visualization of the bleeding source 2
   • Can distinguish between TB-related and non-TB-related causes of hemoptysis

3. Evaluate for potential complications of TB:

   • Post-TB bronchiectasis
   • Residual granulation tissue
   • Aspergilloma in healed cavities
   • Rasmussen aneurysm (pulmonary artery aneurysm associated with cavitary TB) 4

Potential Causes of Hemoptysis in This Patient

1. TB-related causes:

   • Residual granulation tissue in healing TB lesions
   • Bronchiectasis as a sequela of TB
   • Endobronchial TB with incomplete healing
   • Rasmussen aneurysm (pulmonary artery aneurysm) - a rare but potentially fatal complication 4

2. Non-TB related causes:

   • Acute respiratory infection
   • Bronchiectasis from other causes
   • Malignancy
   • Coagulopathy

Management Algorithm

1. Immediate assessment:

   • Determine severity of bleeding (currently scanty, but could progress)
   • Assess hemodynamic stability
   • Check complete blood count, coagulation profile

2. Imaging:

   • Chest X-ray
   • If normal or inconclusive, proceed to CT chest with contrast or CT angiography

3. Bronchoscopy:

   • To directly visualize the source of bleeding
   • To obtain samples for microbiological and cytological examination
   • To perform therapeutic interventions if needed (e.g., control of bleeding)

4. Based on bronchoscopy findings:

   • If residual TB is found: Consider extending TB treatment 1
   • If bronchiectasis is found: Manage with appropriate antibiotics, postural drainage
   • If vascular abnormality is found: Consider bronchial artery embolization 2
   • If malignancy is suspected: Obtain biopsy for histopathological examination

Important Considerations

1. Post-TB sequelae:

   • Up to 40-60% of patients with cavitary TB develop structural lung changes that can cause hemoptysis even after microbiological cure

2. Recurrent TB vs. post-TB sequelae:

   • Negative CBNAAT suggests absence of active TB, but culture remains the gold standard 3
   • Hemoptysis that was present before treatment, absent during treatment, and recurred after treatment suggests a structural cause rather than active TB

3. Risk of pulmonary artery aneurysm:

   • Though rare, pulmonary artery aneurysms are a potentially fatal complication of cavitary TB, reported in about 5% of patients with chronic cavitary TB on autopsy 4
   • Intractable hemoptysis among patients with TB even after completion of anti-TB course should raise suspicion for pulmonary artery aneurysm 4

Conclusion

The recurrence of hemoptysis after successful TB treatment requires thorough investigation. While the negative CBNAAT suggests microbiological cure, structural changes from TB can cause persistent or recurrent hemoptysis. Bronchoscopy is essential to visualize the source of bleeding, rule out active TB definitively, and guide appropriate management.