Endobronchial leiomyoma: A rare and innocent tumour of the bronchial tree
A 42 years old, housewife presented with history of breathlessness on exertion and non –productive cough since 4 months. There was also history of mild fever inter-mittently. At the time of presentation patient was already on steroids for the last 10 days without any relief of symptoms. On examination she was afebrile. The vital parameters were within normal limits. There was no clubbing, cyanosis or lymphadenopathy. Auscultation revealed bilateral fine crepts at the bases. Rest of the physical examination was within normal limits. The patient's laboratory findings were as follows: Hb-13.0 gm/dl, Packed Cell Volume-41.0%. Total Leukocyte Count-9800/cumm, Polymorhs-65%, Lymphocytes-30%, Eosinophils-02%, Monocytes-03%, Platelets-3.325 lacs/cumm, Erythrocyte Sedimentation Rate-30mm/hr. Rheumatoid Arthiritis factor, Antinuclear Antibody profile:c- ANCA ,p- ANCA , anti-double stranded DNA were all negative. Other blood investigations like liver function tests, renal function tests, thyroid profiles were all within normal range. Sputum was negative for Acid Fast Bacilli. Chest X-ray showed Bilateral lower zone reticulonodular shadows. High resolution computed tomography (HRCT) thorax [Figures and ] showed areas of air space opacification, interlobular and subpleural interstitial thickening noted in both lower lobes and right middle lobe. Pulmonary function testing (PFT) showed severe restriction. 2D echocardiography was normal Left ventricular ejection fraction (LVEF) of 60 %. Bronchoscopy was done to obtain bronchioalveolar lavage for analysis. Upon bronchoscopy tumor like lesions were seen obstructing the apicoposterior segments of the Right upper lobe [Figure –]. Bronchial washings and biopsy samples were taken from the lesion. Microscopic examination of the bronchial lavage showed bronchial epithelial cells and polymorphs. Bronchial biopsy [] histopathological examination showed intact pseudostrafied ciliated columnar epithelium. The tumor was composed of bundles and whorls of spindle shaped cells with monomorphous fusiform nuclei and acidophilic cytoplasm without cytonuclear atypia, mitotic cells or areas of necrosis. A diagnosis of endobronchial leiomyoma with interstitial pneumonitis was made. Ultrasonography (USG) abdomen and complete gynecological examination did not reveal any evidence of a leiomyoma in the uterus or elsewhere. Immunohistochemistry was consistent with a myogenic tumor as it showed diffuse cytoplasmic reactivity for smooth muscle actin and desmin. Inspite of extensive search no literature regarding endobronchial leiomyoma with a coexisting interstitial pneumonitis could be found. We managed the two conditions as different unrelated entities and patient was treated with steroids and antibiotics to which she responded very well in two weeks time. On review there was near complete resolution of reticulonodular shadows in the lower zones seen at the initial visit. There was decrease in symptoms (cough, dyspnoea, fever.). Oncology opinion was taken but as tumor was benign and had caused no significant endobronchial obstruction with not even sub-segmental collapse conservative management was advised while keeping the patient on regular follow up.