Broncholithiasis is a rare condition characterized by the presence of calcified material within the lumen of the tracheobronchial tree. This material can have multiple origins, but by far the most common is as a result of previous fungal, mycobacterial, or actinomyces infection. We report a case of bilateral post-obstructive pneumonia and respiratory failure secondary to broncholithiasis in a patient with known bilateral cystic bronchiectasis and a history of tuberculosis.
A 51 year old male with a history of remote tuberculosis infection was transferred to this institution after being admitted to an outside hospital for pneumonia leading to respiratory failure. He was intubated and bronchoscopy demonstrated a “foreign body” in the superior segment of the right lower lobe with purulent material behind it. The patient was sent to this hospital for a repeat bronchoscopy. CT scan revealed calcified material within the airways of both superior segments of the lower lobes with associated post-obstructive infiltrates. Bronchoscopy was performed via the endotracheal tube with a flexible bronchoscope. Bilateral broncholiths within the superior segment airways were encountered. With close inspection, the broncholiths were slightly embedded in the airway wall. Using endoscopy forceps, the broncholiths were removed without complication (Graphic 1). The purulent secretions were suctioned and sent for culture. The patient had rapid resolution of his respiratory failure and was able to be extubated within 24 hours. On histologic examination, the presence of actinomyces was confirmed. The origin of his broncholithiasis could be related to both the remote tuberculosis and superimposed actinomyces infection. The patient was seen in followup approximately one month later and was doing well. He was without supplemental oxygen requirement and completed a 28 day course of antibiotic therapy for the actinomyces.
Hemoptysis, infection, abscess formation, and respiratory failure have been reported as a direct consequence of broncholithiasis (2,3). This case demonstrates two of the complications of broncholithiasis (post obstructive pneumonia and respiratory failure) and the ability to resolve these complications using flexible rather than rigid bronchoscopy or surgery despite the fact that the broncholiths were partially embedded in the airway. Controversy remains throughout the surgical and medical communities on the definitive optimal management of broncholithiasis. The vast majority of broncholiths that are managed nonsurgically by extraction (broncholithectomy) are done so using rigid bronchoscopy (1). Surgical approaches including thoracotomy and lung resection have been recommended for many cases, but also carry the risks of major thoracic surgery. Retrospective studies have demonstrated that the incidence of massive hemorrhage (the most frequent concern among physicians) and other postoperative complications of broncholithectomy via bronchoscopy were low (1). However, the majority of these cases were performed with rigid bronchoscopy. We contend that partially embedded broncholiths can be safely removed using flexible bronchoscopy.
Even broncholiths that are partially embedded in the airways are amenable to removal with a flexible bronchoscope and endoscopy forceps.
J.W. Toth, None.