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1 기관지탄분섬유화증의임상양상 건양대학교의과대학내과학교실, 호흡기내과학교실임동미, 손지웅, 최유진 The Clinical Characteristics of Endobronchial Anthracofibrotic Pigmentation Dongmee Lim, M.D., Jiwoong Son, M.D., Eugene Choi, M.D. Department of Internal Medicine, Pulmonology College of Medicine, Konyang University, Daejon, Korea Objectives : Endobronchial anthracofibrotic, which presents as dark black or brown mucosal changes of multiple bronchi combined with bronchial fibrosis and obstruction, is not a rare finding when performing diagnostic bronchoscopy for Koreans. This study was performed to define the clinical characteristics and to determine the association of these finding with the Korean life style and such other diseases as coal workers, pneumoconiosis or tuberculosis in the patients with anthracofibrotic. Methods : This retrospective analysis was conducted on 70 (5.2%) patients with endobronchial anthracofibrotic, among a total of 1340 patients who underwent bronchoscopy. The distinctive clinical features, the personal life style, the past medical history, the histology and microbiology, the radiologic finding and the natures of the bronchoscopic lesions were analyzed. Results : This mean age of the patients with anthracofibrotic was 60.6 ± 9.2 year old and the male to female ratio was 1:1.7. The common respiratory symptoms of these patients were coughing and sputum (81%, 57/70), and this was followed in order by dyspnea and hemoptysisir. The symptoms were not related with smoking and an occupational history such as being a coal worker and so on. Pneumonia was most common finding on the radiologic studies. On bronchoscopy, the right middle lobe bronchus was most commonly involved. The most common associated disease was tuberculosis, and 40 cases (57.1%) were diagnosed by AFB staining, TB PCR, bronchoscopic guided tissue biopsy and a past history of tuberculosis. Other diseases related with anthracotic were hypertension, diabetes, COPD, lung cancer, pneumoconiosis and asthma. Conclusion : These results suggest that endobronchial anthracofibrotic was mostly related with pulmonary tuberculosis rather than with coal- related disease. Endobronchial anthracofibrotic was more prevalent in older age females in Korea. (Tuberc Respir Dis 2006; 60: ) Key words : Anthracofibrotic, Tuberculosis 서 기관지탄분섬유화증 (endobronchial anthracofibrotic ) 은국내에서드물지않게관찰되는소견으로, 기관지내시경상기관지점막에흑갈색색소침착및기관지협착의소견이관찰된다. 기관지내탄분침착및협착은흡연력이나재, 분진및다른무기혹은유기물질의침착과관련있는것으로생 론 Address for correspondence : Eu Gene Choi, M.D., Konyang University Hospital, Department of Pulmonlogy 685 Gasoowon-Dong, S 대 -Gu Daejon, Korea Phone : (042) Fax : (042) eugene@kyuh.co.kr Received : Jun Accepted : Feb 각되어왔으나 1,2,3 정확한원인이나기전은아직확실치않다. 이런병변에대한외국의보고는매우드물며, 국내의몇몇보고에서는결핵과의연관성, 연탄등의사용과진폐증등의질환과의연관성등을제시하기도하였으나 4,5 근거는부족한실정이다. 더욱이일부에서는결핵과의강한연관성으로항결핵치료를권고하기도하나 6,7 일부의의견에국한된실정이다. 이에저자들은호흡기증상을호소하는환자들을대상으로기관지내시경을시행한 1340명의환자들중기관지내탄분침착을보인환자를대상으로기관지탄분섬유화증의빈도, 임상양상및관련질환과의연관성등을알아보고자하였다. 337
2 DM Lim et al. : The clinical characteristics of endobronchial anthracofibrotic Table 1. Characteristics of subjects with endobronchial anthracofibrotic Number (n) 70 Age (years) 60.6 ± 9.2 Gender Male (%) 26 (37.1) Female (%) 44 (62.9) Smoking (%) 12 (20.0) Residence Urban (%) 36 (51.4) Rural (%) 34 (48.6) Occupation Housewife (%) 36 (51.4) Farmer (%) 14 (20.0) No occuupation (%) 10 (14.3) Others (%) 10 (14.3) 대상및방법 2000년 3월부터 2004년 3월까지 4년동안호흡기증상이나흉부엑스선촬영에서이상소견을보인환자들중본원에서기관지내시경검사를시행한 1340명을조사하여, 기관지탄분섬유화증을보인 70명의환자를대상으로하였다. 설문지를통해후향적분석을시행하였고환자들의성별, 나이, 직업력, 흡연력, 거주지, 과거결핵력및증상을조사하였다. 흉부방사 Table 3. Radiologic and bronchoscopic findings of study subjects with endobronchial anthracofibrotic Radiologic finding Pneumonia(%) 44(62.9) Atelectasis(%) 26(37.1) Mass or nodule (%) 23(32.9) Normal (%) 14(20.0) Bronchoscopic finding Stenosis(%) 21(30.0) RML 8 RUL 6 RML+RUL 4 LUL 3 RUL : right upper lobe, RML : right middle lobe, LUL : left upper lobe Table 2. Main symptoms of patients with anthracofibrotic Cough & Sputum (%) 57 (81) Dyspnea (%) 8 (11) Hemoptysis (%) 5 (7) 선검사 ( 흉부단순촬영및흉부전산화단층촬영 ) 와동맥혈가스분석, 폐기능검사, 객담검사, 기관지내시경과기관지세척액의검사소견 ( 항산균도말검사, 결핵균 PCR) 및조직학적검사소견등을분석하였고, 초기의진단적인상과최종진단을확인하였고기관지탄분섬유화증과결핵의연관성을비교하였다. 임상증상, 흉부방사선검사및기관지내시경검사에서결핵으로의심되었던환자에대해서는기관지세척액에서항산균도말검사, 배양검사, 결핵균 PCR 및조직검사를시행하였다. 결핵의진단으로는임상증상및흉부방사선검사상양성의소견을보이며객담의항산균도말및배양검사상양성이거나결핵균 PCR 양성또는조직검사상육아종건락형성을보인경우결핵으로진단하였고, 과거력상결핵력이있는경우또한결핵과관련있는것으로간주하였다. 결 기관지내시경검사상기관지탄분섬유화증의소견을보인환자는총검사자 1340명중 70명으로 5.2% 에서관찰되었으며, 이들의평균연령은 60.1 ± 9.2세였고, 44세부터 87세까지분포되어있었다. 남녀성비는남자 26명, 여자 44명으로여자에서 1.7배많았다. 대상환자중흡연력이있는사람은 14명, 흡연력이없는사람은 56명으로비흡연가가많았으며과거력상결핵이있었던환자는 19명이었고동반질환으로고혈압은 15명, 당뇨는 9명, 만성폐쇄성호흡기질환은 7명, 폐암 6명, 그외진폐증 1명, 천식 1명으로나타났다. 당시의현거주지는시이상의도시지역에거주하는사람이 36명이고농촌지역에거주하는 34명이었다. 직업별로는가정주부가 36명으로가장많았으며농부가 14명, 무직이 10명순이었다 (Table 1). 가정주부중 12명이재래식부엌에서난방및취 과 338
3 Tuberculosis and Respiratory Diseases Vol. 60. No. 3, Mar Table 4. Biopsy findings of patients with anthracofibrotic 고 찰 Atypical chronic inflammation (%) 14 (63.6) Canner (%) 6 (27.3) Caseous necrosis and AFB stain(%) 2 (9.1) Total (%) 22 (100) 사를위해장작을연료로사용하였고 24명은연탄을연료로사용하였다. 무직이었던환자중 6명은과거광부생활을하였으며, 화재를경험한환자는없었다. 입원당시환자들의주증상으로는기침, 가래가 57 명으로가장많았으며그외호흡곤란, 객혈의증상이있었다 (Table 2). 환자들이내원하여시행한흉부엑스선검사상폐렴이 44명으로가장많았고, 그밖에무기폐, 종괴, 정상의소견이있었다 (Table 3). 기관지내시경상탄분침착의소견을보인 70명중에서기관지협착을동반한경우는 21명이었고, 협착을동반하지않았던경우가 49명이었다. 기관지내시경상협착소견이관찰된위치는우중엽과우하엽에주로많았다 (Table 3). 폐기능검사를시행한 10명의환자들의소견을보면폐쇄성소견을보인경우가 5 명으로가장많았고, 혼합형이 3명, 그리고 2명은정상의폐기능을보였다. 기관지내시경을통한조직검사는 22례에서시행되었고조직검사는기관지탄분섬유화증주변부에서시행하였다. 조직검사결과상비특이적만성염증소견이 14례, 폐암이 6례, 건락성괴사등의소견이있어결핵으로진단된경우가 2례였다 (Table 4). 결핵과의연관성에대한조사에서객담항산균검사양성소견을보인경우가 18명, 결핵균 PCR 양성은 30명 ( 이중 16명은객담검사에서도양성을보임 ), 조직소견상건락성괴사및육아종을보인경우가 2 명으로검사실결과에서결핵의증거를보인환자가 34명이었고, 그외의나머지환자중에서과거에결핵을앓은병력이있던환자 6명을합하여총 40명 (57.1%, 40/70) 에서결핵과연관성이있는것으로추정되었다. 그외의동반질환은고혈압, 당뇨병, 만성폐쇄성폐질환, 진폐증, 천식등이었다. 기관지탄분섬유화증 (Endobronchial anthracofibrotic ) 은기관지점막에흑갈색의색소침착과기도협착으로관찰되는기관지내의병변으로이들색소의성분은철, 납, 카드뮴, 실리카, 페놀, 탄화수소복합체등으로구성되어있다 1,2,3. 이러한색소침착을보이는환자에서결핵의동반비율이높아, 임파선결핵이나기관지결핵이발병기전으로제시되기도한다 5,16. 또한, 연탄이나진폐증과의관련성및대도시에거주하는성인에서의빈도가높아환경분진노출과의관련성등이제시되고있다 4. 이러한기관지탄분섬유화증은한국에서는드물지않게볼수있는소견이나, 외국문헌에서는매우드물게보고되었다. 기관지탄분섬유화증을보인다수의환자에서결핵이동반되어있지만, 본연구에서와마찬가지로결핵이없는환자에서도기관지탄분섬유화증의소견이적지않게보이고있어, 결핵만으로는이를충분히설명할수없으며, 아직기관지탄분섬유화증의확실한원인및발생기전에대해서는연구가부족하다. 본연구자들은호흡기증상을보여기관지내시경을시행한총 1340명의환자중탄분섬유화증을보인 70명의환자 (5.2%) 에대한후향적관찰을통한결과로남성에비해주로고령의여자 (60.6 ± 9.2세, 62.9%) 가많은것으로나타났다. 이는본연구에서의대상군이남성에비해고령의여자환자가많았으며또한기관지결핵이여자환자에서남자의 3.8배로호발하고 17, 결핵성림프선염이여성에흔하고섬유화반응이고령에서흔한점등 12, 재래식부엌에서의난방및취사로장작용나무의사용과연소로인한만성기관지염과폐쇄성기도질환발생및만성적인탄소를함유한무기질입자에노출됨으로써기도내대식세포에의해탐식되고, 상피와점막하층에잔존함으로써탄분증이발생하는것으로설명할수있다 6,7. 본연구에서는가정주부들은대부분연탄과장작을사용하였고, 남성의경우에는탄광근무력과작업장에서장작을연료로사용한경우는 7명이었다. 이러한환경적원인에대한조사는단순히환자의기억에 339
4 DM Lim et al. : The clinical characteristics of endobronchial anthracofibrotic 근거하였기때문에장작과연탄의사용여부및사용기간과노출정도를정량적으로파악할수없어, 추후전향적인연구가더필요할것이라사료된다. 탄분증과흡연과의관련성은비흡연환자가 80% 로흡연은관계는적은것으로나타났다. 이는 1997년결핵연구소연구보고서와일치하는소견이나, 흡연가의기관지및폐의단핵구에서탄분침착이증가되는것과는상이한결과이다 8. 이는본연구의대상군이고령의여자환자가많았으며, 또한기관지결핵이여자환자에서호발하기때문에설명할수도있으나 17,18,19, 이에대해서는좀더연구가필요할것이라생각된다. 도시와농촌간의거주지역의차이는 36명과 34명으로도농간의유의한차이는없어박등 5 의보고와일치하였으며이등 9 의보고와는상반된결과를보였다. 이는현대화로인한인구이동에의하여농촌지역주민들의도시로의이동에의한것으로보이나전주거지역에대한자료가미흡하여더많은조사가되어야할것으로보인다. 대상환자들의증상으로는기침, 가래가 81% 로가장많았으며이러한증상의대부분은 1-2년이상의경과를보였다. 기관지내시경상기관지폐쇄를동반한환자는 21명 (30%) 에서나타났으며기관지폐쇄를동반하지않는환자는 49명 (70%) 이었다. 우중엽부위가 67% 로가장높았으나, 한부위에국한되기보다는여러부위에다발성으로나타나는경향을보였다. 이러한부위들은폐결핵의호발부위와일치하는것으로기관지결핵의초기에는기관지점막에림프구들의침윤이나타나고다음단계로기관지점막의상당한울혈과부종에의한부분적인협착이형성되며 10-12, 점막내결핵성육아종형성을동반한건락화괴사조성을나타낸다. 편평상피화생을동반하든안하든점막궤양들이나미란들의치유와함께고유판 (lamina propria) 의섬유화변화가오고, 결과적으로반흔성협착을초래하게된다 우폐중엽에림프조직이많은점도탄분섬유화증의호발부위를설명할수있다. 기관지탄분섬유화증의동반질환빈도를살펴보면결핵이 40례 (57.1%) 로가장많았으며, 그외고혈압, 당뇨병, COPD, 폐암, 진폐증, 천식등의순으로나타 났다. 결핵에의한기관지탄분침착의기전은기관지결핵에의해서또는결핵성림프선염이기관지를뚫고들어간부위에탄소침착이일어나고염증에의해기관지협착이일어난다고설명하며 16, 기관지내시경으로진단한기관지결핵환자들에있어서결핵약복용후기관지결핵이치유되면서기관지내탄분증의발생을확인된경우도있다 5. 결론적으로기관지탄분섬유화증은한국인에게드물지않은질환으로이는결핵의발병과강한연관성을나타내며, 발생부위도결핵이호발하는부위와다소연관이있고, 기관지의염증및협착을보이나, 확실한원인규명을위한연구는더욱필요할것으로보인다. 또한주로고령의여자에게서잘발생하는경향을보이며, 이는역시기관지결핵이여자에게서호발하는등의특성과일치하는소견이나, 아직인과관계에대한확실한증거는부족하다. 따라서이의발생원인에대한연구와그임상적중요성및예후에대해좀더많은연구가필요하다고생각한다. 요약목적 : 기관지탄분섬유화증은국내에서드물지않게관찰되는특징적인소견으로, 기관지내시경상기관지내탄분침착및협착소견이관찰된다. 이는외국의보고에서는찾아보기힘든병변이며, 아직결핵과의관련성만추측할뿐뚜렷한원인이나발병기전에대해알려진바는없다. 이에본저자들은기관지내시경상탄분침착을보이는환자들의임상양상및연관된질환을알아보고자본연구를시행하게되었다. 방법 : 2000년부터 2004년까지건양대학교병원에서기관지내시경검사를시행한환자 1340명중에서기관지탄분섬유화증의병변이기술된 70명 (5.2%) 의환자의임상양상및최종진단을확인하여후향적으로분석하였다. 결과 : 대상자의평균연령은 60.6 ± 9.2세로대부분고령이었고, 여성이 44명 (62.9%) 으로남성26명 (37.1%) 보 340
5 Tuberculosis and Respiratory Diseases Vol. 60. No. 3, Mar 다많았다. 탄분증과흡연의관계는비흡연가가 56명, 흡연가가 14명으로비흡연가가흡연가에비해 4배정도많아탄분증과흡연은관계가없는것으로보였다. 거주지를도시와농촌으로비교하였을때도농간차이는보이지않았다 (34명 vs 36명 ). 기타특별한사회인구학적차이는없었다. 입원당시환자들의증상은대부분기침이주된증상이었다. 기관지내시경상기관지폐쇄소견을보인환자는 21명 (30.0%) 이었고주로우상엽과우중엽부위가많았다. 최종진단으로는객담항산균검사및조직소견 (PCR 포함 ) 등으로확진된결핵이 34례 (48.6%) 이고, 나머지환자중에과거에결핵을앓은병력이있는환자가 6례로총 40례 (57.1%) 에서결핵과연관성을확인할수있었다. 그밖에고혈압 15례 (21%), 당뇨병 9례 (13%), 만성폐쇄성폐질환 7례 (10%), 폐암 6례 (8.6%), 진폐증 1례 (1.4%), 천식 1례 (1.4%) 로나타났다. 결론 : 기관지내시경상기관지탄분섬유화증의병변은 5.2% 의유병률을보였으며, 고령의여자에서높은빈도를보이며, 57.1% 에서결핵과는연관성이있었다. 참고문헌 1. Vorwald AJ. The Pneumoconiosis and other occupational lung disease. In: Spencer H, editor. Pathology of the lung. Vol I. 4th ed. Pergamon; p Woodruff CE, Moerke AG. The pneumoconiosis and other occupational lung disease. In: Spencer H, editor. Pathology of the lung. Vol 1. 4th ed. Pergamon; p Scheid KF. Ueber exogene und endogene eisenablagerungen in der lunge. Beitr Path Anat Dennis RJ, Maldonado D, Norman S, Baena E, Martinez G. Woodsmoke exposure and risk for obstructive airways disease among women. Chest 1996;109: Park IW, Yoo CG, Kwon OJ, Kim YW, Han SK, Shim YS, et al. Clinical study of dark-blue in the bronchial mucosa. Tuberc Respir Dis 1991;38: Pandey MR. Domestic smoke pollution and chronic bronchitis in a rural community of the Hill Region of Nephal. Thorax 1984;39: Kradine RL, Spirin PW, Mark EJ. Intrapulmonary lymph nodes. Chest 1985;87: Brody AR, Craighead JE. Cytoplasmic inclusions in pulmonary macrophages of cigarette smokers. Lab Invest 1975;32: Lee HS, Maeng JH, Park PG, Jang JG, Park W, Ryu DS, et al. Clinical features of simple bronchial anthracofibrosis which is not associated with tuberculosis. Tuberc Respir Dis 2002;53: Choi DW, Park JN, Suh JE, Baik JH, Ma SD, Kim EB, et al. Chest CT finding of endobronchial tuberculosis patients. Tuberc Respir Dis 1990;37: Kim HY, Im JG, Goo JM, Kim JY, Han SK, Lee JK, et al. Bronchial anthracofibrosis (inflammatory bronchial stenosis with anthracotic ): CT findings. AJR Am J Roentgenol 2000;174: Chung MP, Lee KS, Han JH, Kim HJ, Rhee CH, Han YC, et al. Bronchial stenosis due to anthracofibrosis. Chest 1998;113: Arbert RK, Petty TL. Endobronchial tuberculosis progressing to bronchial stensis. Chest 1976;70: Pierson DJ, Lakshminarayan S, Petty TL. Endobronchial tuberculosis. Chest 1973;64: Wilson NJ. Bronchoscopic observations in tuberculosis tracheobronchitis. Chest 1945;11: Cohen AG. Atelectasis of the right middle lobe resulting from perforation of the tuberculosis lymph node into bronchi in adult. Ann Intern Med 1951;35: Lee JH, Lee DH, Park SS. Endobronchial tuberculosis: clinical and bronchofiberscopic features. Korean J Intern Med 1986;1: Han SW, Lee DH, Park SS, Lee JH. Clinical study of endobronchial tuberculosis. Tuberc Respir Dis 1984;3-1: Song JH, Han SK, Heo IM. Clinical study on endobronchial tuberculosis. Tuberc Respir Dis 1985;3-2:
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