Broncholiths are calcified peribronchial lymph nodes that can erode into the bronchial lumen causing symptoms of persistent cough, hemoptysis, and recurrent pneumonia. The diagnosis is often difficult to make even by bronchoscopy due to overlying and surrounding edema. Treatment often requires surgical intervention in the form of thoracotomy or a rigid bronchoscopy. We report an interesting case where not only were we able to diagnose the condition but were also able to perform a therapeutic fiberoptic bronchoscopy.
A 60 year old female with history of COPD and recurrent pneumonias presented with complaints of cough with yellow sputum and dyspnea on exertion for five months. She was febrile and hypoxic on presentation. Examination was unremarkable except for diminished air entry and bilateral crackles. Chest radiography revealed right middle lobe and right lower lobe airspace disease with a superimposed nodule; and a prominence in the right hilar paratracheal line. Non-contrast CT scan of the chest (Graphic 1) revealed diffuse airspace disease in the right middle and lower lobe with associated mediastinal and hilar adenopathy. Given the recurrent pneumonias and 30-pack-year smoking history, the patient underwent fiberoptic bronchoscopy, which revealed a necrotic, friable mass partially occluding the right mainstem bronchus. Transbronchial biopsies of the mass were performed with multiple attempts to dislodge it as we suspected it to be a broncholith. Unfortunately, the mass could not be removed bronchoscopically; however, later that day, the patient was finally able to cough and expectorate a 1.7 × 1.0 × 0.9 cm calcified, gray-tan stone (Graphic 2). Pathology from the procedures revealed squamous metaplasia with acute and chronic inflammation. The patient was subsequently discharged on antibiotics and had a follow-up CT scan that showed complete resolution of her infiltrate. Furthermore, at 3 month follow-up, the patient denied any complaints of shortness of breath, cough, hemoptysis, or fever.
Broncholithiasis is an uncommon and challenging diagnosis to make and is often discovered when clinical sequelae are prominent enough to warrant detailed investigation with bronchoscopy or a CT scan of the chest. Almost all broncholiths originate in the peribronchial lymph nodes, which calcify in response to an inflammatory process. Cough, hemoptysis and recurrent pneumonias are the usual symptoms while lithoptysis occurs rarely but is specific for broncholithiasis. In our patient with a post-obstructive pneumonia that was refractory to multiple courses of antibiotics, a diagnostic bronchoscopy was planned to rule out an endobronchial lesion. A broncholith was visualized and mobilized for the patient to subsequently expectorate the stone. Biopsy of the mucosa failed to show a concurrent underlying malignancy. Not only did she have clinical and radiological recovery but complications such as hemorrhage, airway obstruction, erosions, and fistulas were avoided.
Broncholithiasis is a diagnosis not often thought of when a patient presents with a post-obstructive pneumonia. However, failure of typical antibiotic regimens should serve to trigger a more extensive workup for broncholithiasis including a CT scan of the chest and potential bronchoscopy. Flexible bronchoscopy can be safely utilized not only for the diagnosis but also in therapeutic stone extraction.
Christopher Pastor, No Financial Disclosure Information; No Product/Research Disclosure Information