To the Editor:
Broncholiths are calcified material within a bronchial tree. Patients with broncholiths might remain asymptomatic or develop a variety of pulmonary symptom including cough, dyspnea, chest pain, and hemoptysis. However, the diagnosis is often overlooked as physicians are generally not familiar with the condition, and chest x-ray often fails to demonstrate the characteristic calcification. Bronchoscopy can be diagnostic and sometimes provide a definitive treatment in uncomplicated cases with easily movable broncholiths.
An otherwise healthy 64-year-old woman presented with a 4-week history of nonproductive cough accompanied by dyspnea on exertion. She denied any history of fever, night sweat, weight loss, or aspiration. Physical examination was remarkable for decreased breath sound in the right upper lung. Chest x-ray revealed atelectasis in the right upper lobe (RUL) (Fig. 1A) and subsequent computed tomography of chest demonstrated a small soft-tissue mass with peripheral high-density foci in the RUL bronchus (Fig. 1B). The patient underwent bronchoscopy which revealed a yellow mass in the RUL bronchus (Fig. 1C). The mass was easily removed with forceps and was identified as calcified degenerated vegetable matter by microscopic examination (Fig. 1D). The patient’s symptoms resolved after bronchoscopy and repeated chest x-ray showed resolution of the atelectasis.
Broncholithiasis is an unusual condition characterized by the presence of calcified or ossified material within the bronchial lumen with an incidence of only 0.1% to 0.2% of all lung diseases.1 A broncholith is usually formed by compression and erosion of calcified peribronchial lymph nodes, as a result of respiratory movement and cardiac pulsation, into the lumen of the bronchus. These calcified lymph nodes are usually a result of chronic granulomatous infection with histoplasmosis being the most common etiology in the United States and tuberculosis in the rest of the world. However, primary endobronchial lesions, such as calcified endobronchial infection and aspirated foreign body, are responsible for broncholithiasis in a small portion of patients, as illustrated in this case.2 The chemical composition of a broncholith is similar to that of bone, consisting of 85% to 90% of calcium phosphate and 10% to 15% of calcium carbonate.3
The most common presenting symptom of broncholithiasis is nonproductive cough although fever, hemoptysis, localized wheezing, chest pain, and lithoptysis (stone expectoration) can also be present. Its complications, including recurrent pneumonia, massive hemoptysis, and fistula formation between the bronchi and adjacent mediastinal structures, are infrequent but had also been reported.4 Lithoptysis, the most common presenting symptoms in the prebronchoscopy era, was considered as pathognomonic sign of broncholithiasis but it is nowadays rare.1
Plain chest x-ray often fails to show calcification of broncholith though sign of obstruction, such as atelectasis and bronchiectasis, can be prominent. Computed tomography of chest usually provides more useful information. Presence of endobronchial or peribronchial calcified nodules with associated findings of bronchial obstruction is very suggestive for the diagnosis.2 Bronchoscopy is diagnostic when broncholiths are revealed although sometimes it is difficult to distinguish broncholith from tumor base on the gross appearance.
Therapeutic options include observation, bronchoscopic removal, and surgery as spontaneous broncholith expectoration may occur. However, bronchoscopic treatment or surgery should be exploited in symptomatic patient to avoid its potentially life-threatening complications. Bronchoscopic treatment can be considered in an uncomplicated case with easily movable broncholith, as in this case, otherwise surgical resection including segmentectomy, lobectomy, or pneumectomy, depending upon the size and location of broncholith is preferred.2,4
Patompong Ungprasert, MD
Narat Srivali, MD
Michael A. Bauer, MD
Lee C. Edmonds, MD
Department of Internal Medicine, Bassett Medical Center, Columbia University College of Physicians and Surgeons, Cooperstown, NY
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2. Seo JB, Song KS, Lee JS, et al..Broncholithiasis: review of the causes with radiologic-pathologic correlation.Radiographics.2002;22:S199–S213.
3. Dixon GF, Donnerberg RL, Schonfeld SA, et al..Advances in the diagnosis and treatment of broncholithiasis.Am Rev Respir Dis.1984;129:1028–1030.
4. De S, De S.Broncholithiasis.Lung India.2008;25:152–154.