Clinical History
Α 54 year-old man, heavy smoker suffered pneumonia of the RLL. One year later, he developed empyema of the right pleural cavity (fig. 1e, 1f) and partial segmentectomy of the RLL was performed. One and a half years later, he presented with decreased respiratory sounds, end inhalation wheezing.
Imaging Findings
The CT-scan which followed revealed a calcified lesion within the intermediate bronchus and the proximal parts of the lower and middle lobe bronchi, possibly a broncholith (Fig. 2), which was also present on three previous CT-scans (Fg. 1) with no significant change. This finding had not been reported at the previous CT-scans, either because it was missed or because it was misinterpreted as calcified bronchial walls. Other significant radiological findings included: cicatrization atelectasis, scarring and ground-glass opacification of the RLL (Fig. 2). Enlarged lymph nodes were not noted.
Bronchoscopy revealed the broncholith at the lateral part of the intermediate bronchus (Fig. 3a, 3b). Its diameter was more than 1cm and it had a trapezoid shape. After removal, granulation tissue was revealed at the bronchial walls (Fig. 3c). Histology revealed a calcified lesion which consisted of trabecular formations with many bacterial colonies.
Discussion
Broncholithiasis is a condition in which calcified or ossified material is present within the bronchial lumen. An extended definition includes patients with peribronchial calcific nodes with distortion of the bronchi [1]. The most common cause is erosion and extrusion of calcified peribronchial lymph node into the bronchial lumen, which is generally associated with necrotizing granulomatous lymphadenitis. Other pathophysiological mechanisms include: aspiration of a bone fragment, in situ calcification of an aspirated foreign object, erosion by and extrusion of calcified or ossified bronchial cartilage plates and migration to a bronchus of calcified material from a distant site [2].
The clinical symptoms are caused by the presence of the broncholith and by the irritation, erosion or obstruction of the airway. The most common are chronic cough (100%), fever (50%-60%) hemoptysis (45-50%) and these are followed by localised wheezing (25-60%) chest pain (20%) and lithoptysis i.e. the actual expectoration of the broncholith (15-26%). Rarely broncholiths can cause acute symptoms by penetrating into a major vessel or into the esophagus [3]. Hence the recurring respiratory infections that our patient had suffered before the extraction of the broncholith can be closely correlated with the presence of the broncholith and the obstruction of the airway.
HRCT is needed to confirm the diagnosis of broncholithiasis. X-ray findings are rarely diagnostic. Conventional CT can be strongly suggestive of broncholithiasis [4] when there is a calcified nodule that is either endobronchial or peribronchial and is associated with findings of bronchial obstruction, such as atelectasis, obstructive pneumonitis or bronchiectasis.
Treatment includes bronchoscopic extraction or surgery. Occasionally a broncholith can be expectorated via lithoptysis [5]. Bronchoscopic removal should be considered in cases of an uncomplicated and loose broncholith, whereas surgery should be considered in complicated cases [6].
Differential diagnosis includes endobronchial infections with calcified fungus ball, calcified endobronchial tumours, tracheobronchial diseases with mural calcification (most commonly tracheobronchial amyloidosis), and hypertrophied bronchial artery with intraluminal protrusion [2].
Differential Diagnosis List
Broncholithiasis of the lateral part of the intermediate bronchus
calcified endobronchial tumours
calcified endobronchial fungus ball
tracheobronchial diseases with mural calcification most commonly tracheobronchial amyloidosis
Final Diagnosis
Broncholithiasis of the lateral part of the intermediate bronchus
