Un unsual cause of chronic cough: broncholithiasis

Clinical History

An otherwise healthy 30-year-old man presented with a 4-week history of nonproductive cough accompanied by dyspnoea on exertion. He denied any history of fever, night sweat, or weight loss.

Imaging Findings

Thoracic computed tomography (CT) with a wide window setting showed impacted endobronchial calcified lesions located in the laterobasal segment of the left lower lobe; with no bronchial wall change, atelectasis or obstructive pneumonitis in the involved segment.
There was also mild bronchiectasis in several segmental bronchi bilaterally, without any wall thickening or parenchymal alteration.
No other signs of pathology were found elsewhere in this examination.

Discussion

Broncholithiasis is an unusual condition characterized by the presence of calcified or ossified material within the bronchial lumen [1].
The incidence of this anomaly is only 0.1% to 0.2% of all lung diseases [2].
A broncholith is frequently constituted by erosion and displacement of a calcified adjacent lymph node into the lumen of the bronchus and is generally correlated with long-lasting foci of necrotizing granulomatous lymphadenitis.
These calcified lymph nodes are generally the consequence of chronic granulomatous infection: histoplasmosis in the USA and tuberculosis in the rest of the world [3].
Broncholithiasis may also be due to: aspiration of bone tissue or foreign material that calcifies in situ; erosion by and displacement of ossified bronchial cartilage plates or migration of calcified material from pleural plaque or the kidney to a bronchus [1].
Most commonly, broncholithiasis manifests as nonproductive cough frequently associated with haemoptysis.
Less frequently, it is revealed by secondary infection after obstruction of the distal portion of the lung causing pain, chills, and fever [1, 4].
A history of lithoptysis (expectoration of calcified material) may indicate the diagnosis in some cases.
Plain chest X-ray may show a calcified nodule and/or airway obstruction (atelectasis, bronchiectasis, mucoid impaction, or expiratory air trapping) [5, 4]. Chest radiography often fails to show the calcification within the bronchus.
CT generally provides helpful information in the evaluation of suspected broncholithiasis [6, 7, 8]. A calcified material that is either endobronchial or peribronchial associated with findings of bronchial obstruction (atelectasis, obstructive pneumonitis, or bronchiectasis) can be strongly suggestive of broncholithiasis.
Multiplanar reformation of helical CT data is generally useful to show whether the calcified nodule is endobronchial or peribronchial.
Therapeutic options include observation, bronchoscopic treatment, and surgery.
Bronchoscopic removal can be considered in uncomplicated cases with easily movable broncholith, otherwise surgical resection (segmentectomy, lobectomy, or pneumectomy) is preferred [9, 10].

Differential Diagnosis List

Final Diagnosis

Broncholithiasis

URL:	https://eurorad.org/case/13324
DOI:	10.1594/EURORAD/CASE.13324
ISSN:	1563-4086