Download Fibreoptic Bronchoscopic Removal of Broncholith in Treated

Fibreoptic Bronchoscopic Removal of Broncholith in Treated Pulmonary Tuberculosis
CASE REPORT
Fibreoptic Bronchoscopic Removal of Broncholith in Treated
Pulmonary Tuberculosis
Mahendra Kumar Bainara1, Ananda Datta2, Hemant Kumar3, Manoj Kumar Arya4
1
Associate Professor,
Udaipur
2,3
Third year resident, 4MD, Dept. of Respiratory Diseases and Tuberculosis, R.N.T. Medical College,
ABSTRACT
BACKGROUND: Broncholithiasis, although is a rare clinical condition but may exists commonly in old pulmonary
tuberculosis. The incidence is 0.1% to 0.2% of all lung diseases and about 0.8% among patients with haemoptysis.
Symptoms are nonspecific but patient may have lithoptysis. Diagnosis can be suspect on clinical and radiological
basis. Fibre-optic bronchoscopy is useful tool not only for confirmation but also for removal. We are describing a case
of broncholithiasis in treating pulmonary tuberculosis which was successfully removed by bronchoscopy.
INTRODUCTION
Broncholithiasis is a rare condition defined
as the presence of a calcified fragment of
tissue within the lumen of tracheobronchial tree.1 the incidence of
broncholithiasis is 0.1% to 0.2% of all
lung diseases and about 0.8% among
patients
with
hemoptysis.2
Walsh
classified broncholithiasis into two groups
on the basis of site of origin as extrinsic
calculi (arising from aspirated foreign
bodies including tissue and secretions) and
intrinsic calculi (arising within the lung ,
bronchi and lymph node).3 Symptoms of
broncholith are nonspecific, rarely
pathognomic symptom (lithoptysis) may
be present.4 Diagnosis can be made on
clinical ground (expectoration of calcified
material), radiological examination or by
fibre-optic bronchoscopy. Bronchoscopy is
an important component in the diagnostic
evaluation of broncholith.
Indeed,
bronchoscopy is often the only test to
document
the
diagnosis
of
5
broncholithiasis. Treatment should be
offered in symptomatic patients to avoid
catastrophic complications. Therapeutic
options
include
observation,
bronchoscopic removal and surgery.6,7,8,9
Bronchoscopy is safe and effective in the
*Corresponding Author:
Dr. Mahendra Kumar Bainara
77, Barkat Nagar,
Tonk Phatak Jaipur
Email: [email protected]
81
Int J Res Med. 2015; 4(3);81-84
removal of loose broncholith.
Bronchoscopy may be an option in
selected patients with partly eroding
broncholith. We are reporting a case of
broncholithiasis in which successful
removal of broncholith was performed by
fibre-optic bronchoscopy without any
complications.
CASE REPORT
Image 1: Chest x-ray showing left upper
and mid zone homogenous opacity and
calcified lesions with bilateral hilar
lymphadenopathy.
Image 2: A. Broncholith in lingular
bronchus. B. broncholith captured with
biopsy forceps
a.
e ISSN:2320-2742
p ISSN: 2320-2734
Fibreoptic Bronchoscopic Removal of Broncholith in Treated Pulmonary Tuberculosis
showed calcified density in lingular
bronchus with hilar lymph node
calcification in addition to left upper and
lingular segment consolidation. Diagnostic
Fibre-optic
video-bronchoscopy
was
performed to evaluate the cause of left
upper lobe collapse and lingular segment
consolidation which revealed a greyish
b.
white stony hard foreign body in lingular
Image 3: The extracted broncholith.
segment of upper lobe which was loosely
attached to the bronchial wall. (Image-2)
Toothed forceps was introduced through
the working channel of bronchoscope for
removal of broncholith. (Image-3) and the
broncholith was removed completely and
successfully. (Image-4) We also took BAL
and were sent for AFB, gram’s stain,
pyogenic culture, KOH mount and for
A 45 years old male, smoker, farmer was
malignant cytology but no organism and
admitted with complaints of cough with
malignant cells were detected. One day
white expectoration and off and on low
after successfully removal of broncholith
grade fever since 8 months. He also had
haemoptysis controlled.
complaint of blood in sputum since 10
DISCUSSION
days which was about 10ml per day.
The pathogenesis of broncholith can be
Patient denied any history of dyspnoea and
explained by three mechanisms.1 First, in
chest pain. He had past episode of
the course of chronic inflammation the
haemoptysis four months back which was
lymph nodes become calcified and erode
controlled with medications. He was
in to tracheo-bronchial tree by constant
admitted in another health facility prior to
motion created by respiration and beating
admission in our department where he was
heart. This is the commonest mechanism.
diagnosed as pneumonia in left upper lobe
Second, a portion of calcified or ossified
and was treated with broad spectrum
bronchial cartilage breaks apart from the
antibiotic with symptomatic medicines.
wall and remains inside the lumen. Third,
Patient has taken full course of ATT 7-8
inhaled material in the bronchi is mixed up
years back. Patient did not have any
with calcium and develops into
significant medical history. On general
broncholith.
The
first
mechanism
physical examination clubbing was
explained broncholith in our case as in
evident. Finding on chest examination was
chest X-ray there were hilar enlargement
consistent with left upper lobe collapse
with calcification. Etiology of broncholith
and consolidation of lingular segment.
in majority of cases is secondary to
Routine haematological and biochemical
granulomatous mycobacterial or fungal
tests were within normal limit. HIV test
infections. The most common cause of
was non-reactive and Mantoux test was
broncholith worldwide is tuberculosis.1
9mm after 72 hours.
Two sputum
Other infectious causes are histoplasmosis,
examinations under RNTCP were negative
actinomycosis, coccidioidomycosis and
for AFB. Sputum for Gram’s stain and
11
cryptococcosis.10,
Silicosis
and
KOH stain does not revealed any
malignancy are the non-infectious causes.
pathogenic organism. Sputum was also
Pulmonary symptoms in broncholithiasis
negative for malignant cell. Chest X-ray
are usually nonspecific, sometimes
showed left upper and mid zone
patients may be asymptomatic and
homogenous opacity with calcified lesion
coughing up stones (lithoptysis) is very
and bilateral hilar enlargement with
rare
but
pathognomic
symptom.12
calcification.(Image-1)
CECT
thorax
Common clinical presentations reported in
82
Int J Res Med. 2015; 4(3);81-84
e ISSN:2320-2742
p ISSN: 2320-2734
Fibreoptic Bronchoscopic Removal of Broncholith in Treated Pulmonary Tuberculosis
the literatures are chronic cough, fever,
87%.19 Flexible bronchoscopy as the
haemoptysis, wheeze, chest pain etc.
method for removal of broncholith had
Complication like recurrent pneumonia,
been tried by many pulmonologists.
massive haemoptysis, fistula between
However as yet, there is no consisting
bronchi and adjacent mediastinal structure
guideline for broncholithectomy or
5, 13-15
has been reported.
Diagnosis of
broncholithotomy
using
flexible
broncholith is difficult clinically
as
bronchoscopy.20 A variety of methods
symptoms
are
nonspecific
and
such as pulling with the forceps, using a
pathognomic symptom (lithoptysis) is very
balloon catheters and YAG laser incision
rare. In chest X-ray, hilar calcification or
to
broncholithotomy
have
been
parenchymal infiltrations are common
performed.21, 22 In 2007 there was a first
radiological findings but the key finding of
attempt to removal the broncholith by
calcified lymph node material in or near a
using a cryoprobe with flexible
bronchus is very unusual.16 CT thorax and
bronchoscope.23 A conventional method to
flexible bronchoscopy are the most
remove broncholith is to pull them out
important diagnostic tools to allow the
with a forceps. This method is applicable
assessment of the relationship between
when the broncholith is not firmly attached
calcification and bronchus. On CT-scan,
to the bronchial wall. In the present case,
however, calcified endo-or peribronchial
broncholith was loosely attached to
lymph node can be identified and correctly
bronchial wall so we extracted it by
located, especially on high resolution CTpulling with the help of forceps
scan. Post obstructive pneumonitis,
successfully and without complications.
atelectasis, parenchymal infilteration, post
CONCLUSION
obstructive bronchiectasis, air trapping,
We conclude that broncholith is a rare but
and lung over-inflation are other common
distinct
and
potentially dangerous
16, 17
findings.
Fibre-optic bronchoscopy is
pulmonary problem. The diagnosis can be
an important component in the diagnostic
made easily with the use of CT scan and
evaluation of broncholith. Mostly the
fibre-optic bronchoscopy and it can be
diagnosis can be made by combination of
removed with the help of forceps through
history,
radiological
findings
and
working channel easily without major
bronchoscopy
and
now-a-days
complications even more easily if the
thoracotomy to rule out malignancy is
broncholith is loosely attached to bronchial
rarely needed.7 In this index case we
wall.
suspect broncholith on CT thorax which
REFERANCES
later
confirmed
by
fibre-optic
1. Muhammad
Anwar,
Sindhafhatta
bronchoscopy.
Available
therapeutic
Venkatram.
Broncholithiasis:
options for treating broncholithiasis are
“Incidental
Finding
During
simple observation, surgical resection,
Bronchoscopy”- Case report and
bronchoscopic broncholith removal and
Review of the Literature. J Bronchol
broncholithectomy.
Spontaneous
Intervent Pulmonol 2011; 18: 181-183.
broncholith
expectoration
may
2. Hiroyuki M, Isao S, Santoshi M, et al.
occasionally lead to resolution of
Broncholithiasis managed by surgical
8
symptoms. Eric J Olson et al experience
resection. Gen Thorac Cardiovasc Surg.
with the largest series, indicated that
2007; 55:138-142.
lithoptysis was infrequent. Thoracotomy
3. Walsh JJ. Broncholithiasis: report of a
remains indicated in complicated cases
case occurring in active pulmonary
with fistula formation, severe haemoptysis,
tuberculosis. Dis Chest. 1954; 26: 235bronchiectasis and uncertainty about the
238; doi: 10.1378/chest. 26.2.235.
diagnosis.18 Preferred operative procedures
4. Manson RJ, Broaddus VC, Martin T, et
are segmentectomy, lobectomy and
al. Murray and Nadel’s Test book of
pneumectomy. Rigid bronchoscopy is
Respiratory Medicine. 5th ed. Elsevier
another option for the broncholith removal
Saunders; 2010: 1302-1303.
with success rates ranging from 67%83
Int J Res Med. 2015; 4(3);81-84
e ISSN:2320-2742
p ISSN: 2320-2734
Fibreoptic Bronchoscopic Removal of Broncholith in Treated Pulmonary Tuberculosis
5. Eric J Olson, James P UTZ, Udaya B.S.
15. Bollengier W.E., J.M. Guernsey.
Prakash. Therapeutic Broncoscopy In
Broncholithiasis with aprtotracheal
Broncholithiasis: Am J Respir Crit Care
fistula. J. Thorac. Cardiovasc. Surg.
Med; 1999; 160: 766-770.
1974:68: 588-592.
6. Arrigoni MG, Bernatz PE, Donoghue
16. Ferreth G., Coulomb M, Blanc-Jouvan
FE.
Broncholithiasis.
J
Thorac
F, et al. Diagnosis of broncholithiasis.
Cardiovasc Surg. 1971; 62: 231-237.
Role
of
high
resolution
7. Dixon GF, Donnerberg RL, Schonfeld
tomodensitometry. J Radiol 1994;
SA, et al. Advance in the diagnosis and
75531-536.
treatment of broncholithiasis. Am Rev
17. Conces DJ, Traver RD, Vix VA.
Respir Dis. 1984; 129: 1028-1030.
Broncholithiasis: CT features in 15
8. Olson EJ, Utz JP, Prakash UBS.
patients. AJR 1991: 157: 249-253.
Therapeutic
bronchoscopy
in
18. Faber LP, R.J. Jensik, S.K. Chawla et
broncholithiasis. Am J Respir Crit Care
al. The surgical implication of
Med. 1999; 160: 766-770.
broncholithiasis. J. Thorac. Cardiovasc.
9. Cole FH, Cole FH, Khandekar A, et al.
Surg. 1975: 70: 779-789.
Management of broncholithiasis: is
19. Ferguson JS, Rippentrop JM, Fallon B,
thoracotomy necessary? Ann Thorc
et al. Management of obstructing
Surg. 1986; 42: 255-257.
pulmonary broncholithiasis with three10. Galdermans D, Verharrt J, Van
dimensional imaging and holmium
Meerbeeck J, et al P. Broncholithiasis:
laser lithotripsy. Chest 2006; 130: 909present clinical spectrum. Resp Med
12.
1990; 84: 155-156.
20. Jong Hwan Lee, Joong Hyun Ahn, Ah
11. Cole FH, Cole Jr FH, Khandekar A,
Young Shin, et al. A Promising
Watson
DC.
Management
of
Treatment for Broncholith Removal
broncholithiasis:
is
thoracotomy
Using Cryotherapy during Flexible
necessary? Ann Thorac Surg 1986; 42:
Bronchoscopy: Two Case Reports.
255-257.
Tuberc Respir Dis 2012; 73:282-287.
12. A. S. Nollet, J.F. Vansteenkiste, M.G.
21. Yi KY, Lee HK, Park SJ, et al. Two
Demedts. Broncholithiasis: rare but still
cases of broncholith removal under the
present: Respiratory medicine; 1998:
guidance of flexible bronchoscopy.
92;963-988.
Korean J Intern Med 2005; 20: 90-91.
13. McLean, T. R., A.C. Beall, and
22. Miks VM, Kvale PA, Riddle JM, et al.
J.W.Jones. Massive hemoptysis due to
Broncholith removal using the YAG
broncholithiasis. Ann. Thorac Surg.
laser. Chest 1986; 90: 295-97.
1991; 52; 1173-1175.
23. Reddy AJ, Govert JA, Spom TA, et al.
14. Davis E.W., S. Katz and J.W, Peabody.
Broncholith removal using cryotherapy
Broncholithiasis a neglected cause of
during flexible bronchoscopy: a case
bronchoesophageal fistula. J.A.M.A.
report. Chest 2007; 132: 1661-3
1956: 160: 555-557.
84
Int J Res Med. 2015; 4(3);81-84
e ISSN:2320-2742
p ISSN: 2320-2734