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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. 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