Unusual bronchoscopic appearance of active pulmonary tuberculosis “Black pigmentation “a case report

Introduction Black mucosal pigmentation of the bronchial tree (“black bronchoscopy”) is an uncommon bronchoscopic finding with diverse etiologies, including malignancy, environmental exposures, and infections. Active pulmonary tuberculosis (TB) is a rare cause. This case report describes a 67-year-old male with microbiologically confirmed active pulmonary tuberculosis presenting with diffuse bilateral black bronchial mucosal pigmentation in the absence of airway stenosis — a presentation that, to our knowledge, has rarely been documented in the literature. Most previous reports of tuberculosis-related “black bronchoscopy” describe localized pigmentation with significant airway narrowing, often in patients with biomass or smoking exposure. Our patient differed by having: 1. Diffuse pigmentation involving both main bronchi and multiple segmental branches 2. No airway stenosis, suggesting an earlier stage before fibrotic remodeling 3. Direct microbiological confirmation from the pigmentation site 4. No environmental exposure history 5. Minimal respiratory symptoms despite cavitary lung disease Case Presentation A 67-year-old male from Chad presented for routine evaluation with mild chest tightness. High-resolution CT revealed a thick-walled cavitary lesion with surrounding consolidation in the right upper lobe. Fiberoptic bronchoscopy showed diffuse black pigmentation of the bronchial mucosa, most pronounced in the right upper lobe bronchus. Bronchoalveolar lavage tested positive for Mycobacterium tuberculosis by Ziehl–Neelsen staining, in addition to Endobronchail biopsy from pigmented mucosa, which revealed caseating granuloma. The patient commenced standard anti-TB therapy, with symptomatic improvement and negative sputum microscopy after two months. Conclusion This case highlights active pulmonary TB as a rare cause of diffuse black bronchial mucosal pigmentation. Awareness of this presentation may facilitate timely diagnosis in patients with atypical bronchoscopic findings.