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Allergy and Airway |

Lithoptysis: An Uncommon Cause of Hemoptysis

David Weir, MD; Terence McGarry, MD
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Mount Sinai, New York, NY


Chest. 2013;144(4_MeetingAbstracts):2A. doi:10.1378/chest.1664441
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Abstract

SESSION TITLE: Airway Case Report Posters

SESSION TYPE: Affiliate Case Report Poster

PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM

INTRODUCTION: Hemoptysis is relatively common with most cases arising from either infection or malignancy; however, hemoptysis from lithoptysis is quite rare. We present a case of hemoptysis with concurrent lithoptysis as the initial presentation of a prior granulomatous pulmonary process.

CASE PRESENTATION: A 72-year-old former Ecuadorian farmer presents after coughing up three to four tablespoons of bright red blood for three days. His past medical history is significant for cholelithiasis with a complicated cholecystectomy. He has no known history of tuberculosis or exposures. On exam his vital signs are normal with an oxygen saturation of 98% on room air. His lungs are clear and there is a surgical scar in the right upper quadrant of his abdomen. The rest of his exam is normal. On hospital day two he reported coughing up “some stones” (figure 1) that he presumed originated from his gallbladder. Bronchoscopy revealed multiple broncholiths (figure 2) corresponding to areas of calcification seen on a chest CT. His sputum smear and respiratory cultures were negative for acid-fast bacilli, bacterial, and fungal organisms. A serum QuantiFERON-TB Gold test was reactive and serum antibodies for Histoplasmosis and Cryptococcus were negative. Histologic examination of an endobronchial biopsy revealed chronic inflammation with no stainable fungal elements.

DISCUSSION: Broncholiths arise from the calcification of peribronchial lymph nodes that distort or obstruct the lumen of the airways and lithoptysis is the result of expectorated broncholiths that have eroded into the airways; most commonly as the result of a chronic granulomatous lymphadenitis. Worldwide Mycobacterium tuberculosis is responsible for most cases of broncholithiasis, but in North America Histoplasmosis capsulatum is more common.(1) Other causes include cryptococcosis, aspergillosis, coccidioidomycosis, actinomycosis, and silicosis. Common complications include hemoptysis, chronic cough, bronchial obstruction, recurrent pneumonia, and bronchoesophageal fistulas.(2) In symptomatic patients, without massive hemoptysis, initial removal can be attempted via bronchoscopy. However, surgical management is reserved for symptomatic patients with bronchoesophageal fistula, massive hemoptysis, or failed bronchoscopic management. Asymptomatic patients can be managed with observation alone.(3)

CONCLUSIONS: This case highlights an unusual and late presentation of a patient with a prior granulomatous pulmonary process, presumably from past tuberculosis exposure.

Reference #1: Antao VCS, Pinheiro GA, Jansen JM. Broncholithiasis and lithoptysis associated with silicosis. Eur Respir J 2002;20:1057-1059.

Reference #2: Seo JB, Song KS, et al. Broncholithiasis: Review of the Causes with Radiologic-Pathologic Correlation. RadioGraphics 2002;22:S199-S213.

Reference #3: Cerfloio RJ, Bryant AS, Maniscalco L. Rigid bronchoscopy and surgical resection for broncholithiasis and calcified mediastinal lymph nodes. J Thorac Cardiovasc Surg 2008;136:186-190.

DISCLOSURE: The following authors have nothing to disclose: David Weir, Terence McGarry

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