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Pulmonary Procedures |

An Interesting Case of Broncholithiasis Leading to Recurrent Lithoptysis

Sharon George, MD; Sabine Khan, BS
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SUNY Upstate Medical Center, Syracuse, NY


Chest. 2014;146(4_MeetingAbstracts):782A. doi:10.1378/chest.1992053
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Abstract

SESSION TITLE: Bronchology/Interventional Student/Resident Case Report Posters I

SESSION TYPE: Medical Student/Resident Case Report

PRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PM

INTRODUCTION: Broncholithiasis is a rare entity characterized by erosion into the tracheobronchial tree due to hilar or parenchymal calcifications. It can cause an equally rare symptom called lithoptysis, which refers to stone expectoration. Granulomatous lymphadenitis caused by mycobacterial infections is the most common cause of broncholithiasis. Silicosis, malignancy and granulomatous fungal infections are other rare causes. Patients with symptomatic broncholithiasis must be specifically treated to avoid complications such as massive hemoptysis, bronchio-esophageal fistulas, bronchiectasis, and obstructive pneumonia

CASE PRESENTATION: We present the case of 41 year old war veteran who was found to have recurrent empyema after presenting with a two week of hemoptysis and lithoptysis associated with night sweats and chills. The patient had had been treated two months ago for left sided empyema with Video Assisted Thoracic Surgery (VATS) decortication, chest tube placement and antibiotics. Repeat CT showed evidence for recurrent empyema, subcarinal lymphadenopathy with calcification that was protruding into the left mainstem bronchus. Bronchoscopy revealed a mucosal protrusion just distal to the carina in the left mainstem proximally and superficial mucosal ulceration that was the site of bleeding.

DISCUSSION: In such cases, mediastinal and hilar fibrocalcific reaction increases blood vessels and leads to a higher risk of complications. Bronchoscopic removals should be considered in cases of uncomplicated and loose broncholithiasis. Difficult bronchoscopic broncholithectomy, massive hemoptysis and irreversible complications such as chronic pulmonary suppurative disease are indications for surgery. Laser therapy can be used to fragment a mobile broncholith that is too hard to be broken with a biopsy forceps and too large to be pulled through airway.

CONCLUSIONS: Major airway obstruction due to broncholithiasis produces significant morbidity, and management is controversial. Awareness of the typical imaging findings of broncholithiasis, along with knowledge of its multiple causes, is crucial to arriving at an accurate diagnosis to ensure appropriate therapeutic management. Through this patient, we also hope to highlight the necessity for further research into therapeutic management of broncholithiasis.

Reference #1: Minami, H. et al. Broncholithiasis managed by surgical resection. Gen Thorac Cardiovasc Surg 2007; 55(3): 138-142.

Reference #2: Menivale, F. et al. Therapeutic management of broncholithiasis. Ann Thorac Surg 2005; 79:1774-1776

Reference #3: Cerfolio, RJ et al. Rigid bronchoscopy and surgical resection for broncholithiasis and calcified mediastinal lymph nodes. J Thorac Cardiovasx Surg 2008; 136: 186-190.

DISCLOSURE: The following authors have nothing to disclose: Sharon George, Sabine Khan

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