AJR:191, July 2008 247

underlying anthracobrosis [14]. In addition

to the radiologic resemblance, a high incidence
of the coexistence of TB and anthracobrosis
and a high prevalence of anthra cobrosis
among women support this relationship [14].
For these reasons, Chung et al. [1] reported that
empiric anti-TB medication may be helpful in
the treatment of anthracobrosis patients
without evidence of active TB.
We evaluated whether CT can be used to
differentiate anthracobrosis from endobron-
chial TB. Distinctive CT features of anth-
racobrosis can help radiologists diagnose
anthraco brosis with ease before broncho-
scopic evaluation and can be a rationale
negating the hypothesis that endo bronchial TB
is a major cause of anthra co brosis. To our
knowledge, this study is the rst comparison of
the CT ndings in these two diseases.
Materials and Methods
We reviewed the CT scans of 49 patients with
anthracobrosis diagnosed on the basis of
CT Differentiation of
Anthracobrosis from
Endobronchial Tuberculosis
Hyun Jin Park
1

Seog Hee Park
1

Soo Ah Im
1

Young Kyoon Kim
2

Kyo-young Lee
3
Park HJ, Park SH, Im SA, Kim YK, Lee K
1
Department of Radiology, Kangnam St. Marys Hospital,
College of Medicine, Catholic University of Korea, 505
Banpo-dong Seocho-gu, Seoul, 137-040, South Korea.
Address correspondence to S. H. Park
(parksh@catholic.ac.kr).
2
Department of Internal Medicine, Kangnam St. Marys
Hospital, College of Medicine, Catholic University of
Korea, Seoul, South Korea.
3
Department of Pathology, Kangnam St. Marys Hospital,
College of Medicine, Catholic University of Korea, Seoul,
South Korea.
Chest I magi ng Ori gi nal Research
AJR 2008; 191:247251
0361803X/08/1911247
American Roentgen Ray Society
B
ronchial anthracobrosis is a bron-
choscopic nding, dened as bron-
chostenosis associated with an-
thracotic pigmentation without a
relevant history of pneumoconiosis [1]. The CT
ndings have been reported to include smooth
bronchostenosis and peribronchial lymph
nodes along with peripheral atelectasis [24].
Bronchogenic carcinoma and endo bronchial
tuberculosis (TB) are two major causes of
bronchostenosis that can be ac companied by
peribronchial nodes and atelectasis [5, 6].
Bronchogenic carcinoma is known to be easily
differentiated from anthra cobrosis, which
usually manifests as an endobronchial mass in
a single lobar or segmental bronchus [2]. In
contrast to the study of carcinoma, there has
been, to our knowledge, no comparison study
of the relation between anthracobrosis and
endo bronchial TB. Therefore, differentiation
of anthracobrosis from TB has been difcult.
Because of the similar CT ndings, endobron-
chial TB has been suggested as a mech a nism
Keywords: anthracobrosis, bronchostenosis, CT,
tuberculosis
DOI:10.2214/AJR.07.2161
Received March 2, 2007; accepted after revision
January 7, 2008.
OBJECTIVE. The purpose of this study was to use CT to differentiate anthracobrosis from
endobronchial tuberculosis (TB), both of which are major causes of benign bronchostenosis.
MATERIALS AND METHODS. We retrospectively reviewed the clinical and CT
ndings of 49 patients with anthracobrosis and 35 patients with endobronchial TB diagnosed
on the basis of bronchoscopic, microbiologic, and pathologic ndings. Forty-ve patients with
anthracobrosis and 32 patients with endobronchial TB had bronchostenosis on CT and were
enrolled in the analysis. Nine (20%) of 45 patients with anthracobrosis had coexistent active
TB (two, endobronchial TB; six, pulmonary TB; one, TB pleurisy), and 13 (29%) had
pulmonary infections other than TB. Two patients with anthracobrosis and coexistent
endobronchial TB were excluded from the analysis. The CT ndings were analyzed with
emphasis on the pattern, distribution, and location of bronchostenosis and the number of
pulmonary lobes involved.
RESULTS. Anthracobrosis was more common than endobronchial TB among elderly
patients (p < 0.05). Statistically signicant ndings on CT were the pattern of bronchostenosis,
presence of main bronchus involvement, and number of pulmonary lobes involved (p < 0.05).
Bronchostenosis with anthracobrosis usually involves multiple lobar or segmental bronchi. The
main bronchus, however, tends to be preserved in anthracobrosis. Most cases of endobronchial
TB involve one lobar bronchus and the ipsilateral main bronchus with contiguity in extent.
CONCLUSION. Anthracobrosis can be differentiated from endobronchial TB on CT.
Furthermore, CT is helpful in the diagnosis of anthracobrosis before bronchoscopy is performed.
Park et al.
CT of Anthracofibrosis and Tuberculosis
Chest Imaging
Original Research
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248 AJR:191, July 2008
Park et al.
bronchoscopic criteria, including anthracotic pig-
mentation and bronchostenosis, over 3 years (July
2003April 2006). Forty-one (91%) of the 45
patients had bronchostenosis on CT. The other
four were excluded from analysis. None of the
patients had an occupational history of exposure
to mining or industry. Thirty-four (76%) of the
patients did not smoke. Six (13%) of the patients
had a history of pulmonary TB, and four of the six
took anti-TB medication.
All 45 patients with anthracobrosis underwent
bronchoscopy with bronchial washing and brushing,
and 23 (51%) of the 45 underwent biopsy. The
biopsy specimens exhibited chronic nonspecic
inammation (n = 22) and edema with mononuclear
cell inltration (n = 1). Broncho scopic biopsy re-
vealed coexistent endobronchial TB in two patients
with anthracobrosis. These two patients were
excluded from the statistical analysis. Two patients
with anthracobrosis underwent pulmonary lobec-
tomy. Four lymph nodes were dissected after lobec-
tomy in one patient. All lobectomy specimens re-
vealed anthra cotic pigmentation with focal bro sis
of bronchi. Dissected lymph nodes proved to have
reactive hyperplasia with anthracotic pigmentation.
CT scans of 35 patients with endobronchial TB
were available. Thirty-two (91%) of the 35 patients
had CT ndings of bronchostenosis and were
enrolled in the analysis. Fourteen (40%) of the 35
cases of endobronchial TB were in the active
inammatory phase with acid-fast bacilli. The
other cases were in the chronic state, and the
patients had been treated for active endobronchial
TB. The diagnoses of endobronchial TB were
based on bronchoscopic, microbiologic, and patho-
logic ndings.
Both the anthracobrosis and endobronchial TB
groups of patients underwent CT before broncho-
scopy. Two CT scanners (Volume Zoom, Siemens
Medical Solutions; LightSpeed, GE Healthcare)
were used. All scans were reconstructed into axial
images with 5-mm slice thickness at 5-mm
intervals. Both unenhanced and contrast-enhanced
images were obtained. Two chest radiologists re-
trospectively reviewed the CT scans, and a con-
sensus diagnosis was reached. CT ndings were
analyzed with emphasis on bronchostenosis. The
pattern of bronchostenosis was analyzed with a
focus on a smooth or irregular endobronchial
contour. The number of pulmonary lobes with
broncho stenosis was recorded. Main bronchus
involvement and bilaterality of bronchostenosis in
the two groups were assessed. Concomitant lymph-
adeno pathy and pulmonary lesions were included in
the analysis. Enlarged nodes greater than 1 cm in
short-axis diameter were dened as lympha deno-
pathy. Students t and Pearsons chi-square tests
were used for statistical analysis.
Results
Thirty-four women and nine men (median
age, 76 years; range, 5690 years) had
anthracobrosis; 24 women and eight men
(median age, 51 years; range, 1980 years)
had endobronchial TB. There were more
women than men in both groups. The
anthracobrosis group had a higher mean
age than the endobronchial TB group (p =
0.000, Pearsons chi-square test). Twenty-
seven (63%) of 43 patients with anthra co-
brosis had concomitant disease at the time
of diagnosis. Most of the concomitant disease
was reactivated TB (nine cases, 33%) and
pneumonia (13 cases, 48%). The CT features
and location of disease are summarized in
Tables 1 and 2.
Most of the 43 cases of anthracobrosis
were characterized by smooth luminal
narrowing (41 cases, 95%) and peribronchial
lymphadenopathy (39 cases, 91%) (Fig. 1).
Sixteen of the 32 cases of endobronchial TB
were characterized by irregular bronchial
narrowing (Fig. 2). Peribronchial and
mediastinal lymphadenopathy were more
commonly associated with anthracobrosis
than with endobronchial TB (p < 0.05,
Students t test).
The distribution of bronchostenosis was
statistically different in comparisons of the
CT ndings for the two groups (p < 0.05,
Students t test and Pearsons chi-square test).
More lobes were involved in anthracobrosis
than in endobronchial TB (mean, 3.1 vs 1.3
lobes; p = 0.0001). Bilateral lung involvement
was more common in anthracobrosis than
in endobronchial TB (65% vs 6% of patients,
p = 0.0001). The most common location of
bronchostenosis in anthracobrosis was the
right upper lobe (42 [98%] of 43 cases) and
in endobronchial TB was the left upper lobe
(22 [69%] of 32 cases). Bronchostenosis in
TABLE 2: Location of Bronchostenosis Lesions on CT
Location Anthracobrosis (n = 43) Tuberculosis (n = 32) p
a
Right upper lobe 42 (98) 7 (22) 0.0001
Right middle lobe 36 (84) 2 (6) 0.0001
Right lower lobe 17 (40) 1 (3) 0.0001
Left upper lobe 23 (53) 22 (69) 0.236
Left lower lobe 15 (35) 10 (31) 0.808
Mean no. of lobes involved 3.1 1.3 0.0001
Involvement
Right lung only 15 7 0.80
Left lung only 0 23
Both lungs 28 2 0.0001
NoteUnless otherwise indicated, values are number of patients with percentage in parentheses.
a
Statistical analysis with Pearsons chi-square test and Students t test.
TABLE 1: CT Features in Anthracofibrosis and Tuberculosis Groups
CT Finding Anthracobrosis (n = 43) Tuberculosis (n = 32) p
a
Bronchostenosis
Pattern 0.0001
Smooth 41 16
Irregular 2 16
Mean no. of lobes involved 3.1 (range, 15) 1.3 (range, 15) 0.0001
Bilaterality 28 (65) 2 (6) 0.0001
Involvement of main bronchus 3 (7) 28 (88) 0.0001
Lymphadenopathy
Peribronchial 39 (91) 20 (63) 0.0001
Mediastinal 38 (88) 22 (69) 0.005
NoteUnless otherwise indicated, values are number of patients with percentage in parentheses.
a
Pearsons chi-square test and Students t test.
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AJR:191, July 2008 249
CT of Anthracofibrosis and Tuberculosis
the right upper lobe, or in any lobe of the right
lung, was more common in anthra co brosis
than in TB (p < 0.05). Both anthra co brosis
and TB commonly involved the left upper
lobe, but the difference was not statistically
signicant (53% vs 69%, p = 0.236). Only
left lung involvement was absent in anthraco-
brosis. In anthracobrosis, the main bron-
chus and trachea were usually unaffected
(three of 43 cases, 7%) (Fig. 3). Endobronchial
TB extended contiguously along the ipsilat-
eral main bronchus and distal trachea (28
[88%] of 32 cases) (Fig. 4).
Discussion
The diagnosis of anthracobrosis is based
on two major bronchoscopic ndings: bron-
chostenosis and anthracotic pigmentation of
overlying mucosa. This condition occurs
commonly among Asian and black persons
and is especially common among older women
who present with a chronic cough, sputum,
and dyspnea [14].
The pathogenesis of anthracobrosis remains
unknown [14]. Two major hypotheses have
been suggested. One is related to wood smoke
inhalation. Many patients with anthracobrosis
are elderly women from rural regions. They
are commonly described as homemakers who
have handled rewood or soft coals in a closed
cooking area. Ciliary movement removes most
inhaled anthracotic particles, but residual
particles can accumulate at the branching
points of the airway. Anthracotic pigmentation
itself does not induce focal bronchial narrowing
because carbon is inert. However, various
changes in the integrity and immunity of the
bronchial mucosa can occur in association
with the presence of anthracotic pigmentation,
and infection and other forms of air pollution
can induce brosis [2, 79].
The other hypothesis on the pathogenesis
of anthracobrosis is the association of
anthracobrosis with endobronchial TB.
There is a high incidence (4161%) of co-
existence of TB and anthracobrosis, and the
CT ndings are similar for the two conditions.
There also is evidence of development of
anthracotic pigmentation during the course
of endobronchial TB [14]. Some authors
have reported bronchostenosis with anthraco-
brosis in patients responding to anti-TB
medication [3, 10]. Endobronchial TB is
common among young women, and this
majority is a common nding in both endo-
bronchial TB and anthracobrosis. According
to the second hypothesis, bronchostenosis is
thought to be caused by an exaggerated
immunologic response to TB antigens in the
lymphatic vessels or contiguous lung, to intra-
luminal infection from bacilli originating in
upstream cavities, or to extrinsic compression
from proximal intrathoracic lymph nodes
[14]. On the basis of this hypothesis, Chung
et al. [1] reported that ant-TB medication was
empirically taken by anthracobrosis patients
without evidence of active TB, and empiric
therapy may be necessary.
Our anthracobrosis patients were most
commonly women older than 70 years. Co-
existent TB was present in 20% of these
patients. The rate of coinfection with TB in
our study, however, was lower than that re-
ported in a previous study [2]. Non tuberculous
pneumonia was present in 30% of our anthra-
cobrosis patients. The pathologic specimens
from patients with anthracobrosis who had
undergone lobe ctomy and node dissection ex-
hibited only chronic in ammation and anthra-
cotic pigmentation without evidence of TB.
The CT ndings of anthracobrosis are
bronchostenosis and peribronchial lympha-
denopathy [14]. Bronchostenosis and lymph-
a denopathy, however, are nonspecic ndings
and can be manifestations of a number of
diseases, both benign and malignant. Among
all of the possible causes of bronchostenosis,
carcinoma and TB are two major diseases
that must be differentiated from anthra-
cobrosis. Bronchogenic carci noma usually
forms endobronchial nodular protrusion and
commonly involves focal areas of a single
lobe or segment of bronchus. With these
A
D
Fig. 181-year-old woman with anthracobrosis who presented with cough and sputum.
A, Axial CT scan obtained with lung window setting at level of right main pulmonary artery shows smooth
luminal narrowing (arrows) at segmental bronchi of right upper lobe.
B, Contrast-enhanced CT scan at same level as A shows enlarged nodes around right upper lobe bronchus
(black arrows), in subcarinal region (arrowhead), and around left upper lobe bronchus (white arrow).
C, Unenhanced CT scan at same level as A and B shows tiny hyperdense foci (arrows) within enlarged nodes.
D, Bronchoscopic image shows luminal narrowing of right upper lobe bronchus with focal deposition of black
pigmentation (arrows). Pathologic specimen obtained at bronchoscopic biopsy revealed chronic inammation
without granuloma.
C B
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250 AJR:191, July 2008
Park et al.
endobronchial TB, which are major causes of
benign bronch ostenosis in Korea.
Bronchostenosis was a common CT nding
among our patients with anthracobrosis and
those with TB. Our study showed that bronch-
ostenosis from anthracobrosis could be
differentiated from bronchostenosis from TB
with CT alone. Bronchostenosis with anthra-
cobrosis is multifocal and tends to involve
segmental or lobar bronchi in both lungs. The
main bronchus and trachea are preserved, and
there is no contiguity in extent of disease. On
the other hand, bronchostenosis with TB
involves a single lobar bronchus in a contiguous
spreading pattern along the bronchus. The
presence of luminal narrowing of the ipsi lateral
main bronchus and distal trachea is common.
These differences be tween anthra cobrosis
and endobronchial TB may be evidence against
the earlier hypo thesis that TB is a major
causative factor in anthra cobrosis.
The major limitations of our study were
small sample size and selection bias. Broncho-
genic carcinoma, another major cause of
considerations, malignant broncho stenosis
can be easily differentiated from anthra-
cobrosis [2]. Differentiation, however, is more
difcult when endobronchial TB is considered.
Because of the similarity be tween the radiologic
features of endo bronchial TB and those of
anthra cobrosis, anthracobrosis can be dia-
gnosed only with bronchoscopy, not with CT,
and a relation between the two diseases has
been suggested [14]. To our knowledge,
there has been no report of a comparison of
the differences between anthracobrosis and
A
Fig. 234-year-old woman with endobronchial tuberculosis who presented with dyspnea. Sputum acid-fast stain result was positive for acid-fast bacilli.
A, Axial CT scan obtained at lung window setting shows uneven contiguous luminal narrowing (black arrow) of left main and upper lobe bronchi. Multiple small nodules
are clustered with linear branching opacities (white arrows).
B, Contrast-enhanced CT scan at same level as A shows focal soft-tissue attenuation around stenotic airway (arrow).
C, Bronchoscopic image shows diffuse stenosis of left main bronchus with luminal irregularity. Left main bronchus is hyperemic with purulent secretions. Pathologic
specimen obtained at bronchoscopic biopsy revealed chronic inammation and epithelioid granuloma with caseous necrosis.
C B
A
D
Fig. 382-year-old woman with anthracobrosis who presented with dyspnea.
AC, Axial CT scans obtained at lung window setting (main bronchus level, A; right middle lobe bronchus level,
B; right inferior pulmonary vein level, C) show multifocal smooth bronchial narrowing of segmental bronchi of
three lobes of right lung and left upper lobe (straight arrows, AC). Both main bronchi are preserved. There is no
contiguity in disease extent. Volume loss of right middle lobe (curved arrow, C) is evident.
D, Contrast-enhanced CT scan at same level as A shows multiple enlarged nodes around stenotic bronchi and
high-attenuation foci (arrowheads) in subcarinal region.
C B
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AJR:191, July 2008 251
CT of Anthracofibrosis and Tuberculosis
bronchostenosis that should be differentiated
from anthracobrosis, was not included in this
comparison study, and anthracobrosis patients
with a history of pulmonary TB were included.
Thus a few patients with old endobronchial TB
might have been included in the anthracobrosis
group because TB history among anthraco-
brosis patients depended only on medical
records and the patients memory. In addition,
we did not include follow-up data, so we did not
know how many cases of anthracobrosis
would later prove to be endobronchial TB.
Anthracobrosis can be differentiated from
endobronchial TB on CT, so CT is a useful
technique for the diagnosis of anthra cobrosis
before bronchoscopic evaluation. Endobron-
chial TB seems not to be a major causative
factor in anthracobrosis, and empiric anti-TB
medication pending conrm ation of an or-
ganism is unnecessary for anthra cobrosis
patients. Further study is needed to disclose
the pathogenesis of anthra cobrosis.
References
1. Chung MP, Lee KS, Han J, et al. Bronchial stenosis
due to anthracobrosis. Chest 1998; 113: 344350
2. Kim HY, Im JG, Goo JM, et al. Bronchial anthraco-
brosis (inammatory bronchial stenosis with an-
thracotic pigmentation): CT ndings. AJR 2000;
174:523527
3. Long R, Wong E, Barrie J. Bronchial anthraco-
brosis and tuberculosis: CT features before and
after treatment. AJR 2005; 184:[suppl]S33S36
4. Choe HS, Lee IJ, Lee Y. The CT ndings of bron-
chial anthracobrosis: comparison of cases with
or without active tuberculosis. J Korean Radiol
Soc 2004; 50:109114
5. Moon WK, Im JG, Yeon KM, Han MC. Tubercu-
losis of the central airways: CT ndings of active
and brotic disease. AJR 1997; 169:649653
6. Kim Y, Lee KS, Yoon JH, et al. Tuberculosis of
the trachea and main bronchi: CT ndings in 17
patients. AJR 1997; 168:10511056
7. No TM, Kim IS, Kim SW, et al. The clinical inves-
tigation for determining the etiology of bronchial
anthracobrosis. Korean J Med 2003; 65: 665674
8. Sandoval J, Salas J, Martinez-Guerra ML, et al.
Pulmonary arterial hypertension and cor pulmon-
ale associated with chronic domestic woodsmoke
inhalation. Chest 1993; 103:1220
9. Gold JA, Jagirdar J, Hay JG, Addrizzo-Harris DJ,
Naidich DP, Rom WN. Hut lung: a domestically
acquired particulate lung disease. Medicine (Bal-
timore) 2000; 79:310317
10. Han SH, Cha GY, Lee YM, et al. Study of antitu-
berculous medications in anthracobrosis. Tuberc
Respir Dis 2001; 50:224231
A
Fig. 456-year-old man with history of endobronchial tuberculosis 10 years in past who presented with dyspnea.
A, Contrast-enhanced CT scan at level of carina shows smooth luminal narrowing of right main bronchus (straight arrow). Right upper lobe bronchus is completely
obstructed, resulting in peripheral atelectasis (curved arrow).
B, Contrast-enhanced CT scan at level of aortic arch shows luminal narrowing of distal trachea with evenly thickened tracheal wall (straight arrow). Collapse of right
upper lobe (curved arrow) is evident.
C, Bronchoscopic image shows bronchostenosis of right main bronchus. Opening of right upper lobe bronchus is obstructed without evidence of mucosal change.
C B
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