Download A Case of Postobstructive Pneumonia Secondary to Broncholithiasis

A Case of Postobstructive Pneumonia
Secondary to Broncholithiasis
By Sara Luckhaupt, MD; LeAnn Coberly, MD—Guest Editors
Greg Rouan, MD—Column Editor
ABSTRACT
An otherwise healthy 54-year-old man presented
with shortness of breath and cough that had persisted for
2 weeks, yellow-green sputum, pleuritic chest pain, and
orthopnea. His chest examination revealed bibasilar
rhonchi—greater on the left side—and intermittent
wheezing over the left lung base. Upon evaluation, his
condition was diagnosed as community-acquired pneumonia with possible bronchial obstruction. He was
admitted to the general medicine service, and despite
intravenous (IV) antibiotics, IV fluids, and supplemental
oxygen, the patient’s condition worsened.
Severe pneumonia with localized wheezing and
effusion is typically suggestive of bronchial obstruction
due to carcinoma. Though rare, broncholithiasis—
endobronchial or peribronchial calcified lymph nodes
protruding into the airways—can cause similar postobstructive pneumonia and should be considered in
patients with atypical presentations.
INITIAL PRESENTATION
An otherwise healthy 54-year-old man presented to the
emergency department with shortness of breath and cough that
had persisted for 2 weeks. At the time of presentation, his
symptoms included yellow-green sputum, pleuritic chest pain,
and orthopnea. He smoked 1 pack per day for many years, but
was not taking any medications. Except for a brother with a
diagnosis of lung cancer at age 60, his family history was unremarkable. When examined, he was febrile (temperature,
101.4ºF), with a pulse of 130 beats per minute, and blood
pressure of 149/98 mm Hg. His breathing was labored, and his
peripheral oxygen saturation was 89% on room air. A chest
examination revealed bibasilar rhonchi, which were
Dr Luckhaupt is a preventive medicine resident at the University
of Michigan Medical School, Ann Arbor, Mich.
Dr Coberly is Associate Professor of Clinical Medicine,
Department of Internal Medicine, University of Cincinnati College of
Medicine, Cincinnati, Ohio.
Dr Rouan is Richard W. and Sue Vilter Professor of Clinical Medicine
and Associate Chairman of Education, Deprtment of Internal Medicine,
School of Medicine, University of Cincinnati, Cincinnati, Ohio.
376
greater on the left side, and intermittent wheezing over the left
lung base. An arterial blood gas performed with the patient
breathing room air showed a normal pH (7.36-7.44) and PCO2
(normal, 32-48 mm Hg), but a low partial pressure of oxygen
(PO2) of 64 mm Hg (normal, 83-108 mm Hg). The initial
chest x-ray suggested left lower lobe air space disease with
pleural effusion (Figure). The general medicine service admitted the patient with a diagnosis of community-acquired pneumonia, with possible bronchial obstruction.
HOSPITAL COURSE
Despite intravenous (IV) antibiotics, IV fluids, and supplemental oxygen, the patient’s oxygen requirements steadily
increased during the first few days of hospitalization, and serial chest x-rays showed increasing infiltrate and effusion. A
chest computed tomography (CT) on the third hospital day
revealed extensive loculated left pleural effusion with a compressed lower lobe, which was possibly caused by calcified left
hilar lymph nodes. Chest tubes were placed with CT guidance
by interventional radiology, and tissue-type plasminogen activator was used to assist in drainage. A repeat CT showed
improvement in the effusion, but compression of the left
lower lobe persisted. Bronchoscopy was then performed and
confirmed the diagnosis of obstructing broncholiths.
Figure. Presenting Chest X-ray Showing Left Lower
Lobe Consolidation With Pleural Effusion
A.
B.
A. Posteroanterior chest x-ray showing left lower lobe consolidation with
pleural effusion, taken upon presentation to the emergency room.
B. Lateral chest x-ray, emphasizing the extent of the left lower lobe consolidation, taken upon presentation.
Vol. 5, No. 7
n
July/August 2005
CLINICAL VIGNETTE
Symptoms of Broncholithiasis
•
•
•
•
•
•
•
Cough
Recurrent hemoptysis
Fever and chills
Purulent sputum
Coughing up stones (lithoptysis)
Pleuritic chest pain
Localized wheezing
FOLLOW-UP
After recovering from pneumonia, the patient was readmitted to the thoracic surgery team for removal of the
obstruction to prevent recurrent pneumonia. Since the broncholiths could not be safely removed via bronchoscopy, left
lower lobectomy was performed. Surgical pathology revealed
stones consistent with broncholiths, measuring 0.4 to 1.5 cm
in diameter, and lymph nodes with necrotizing granuloma,
which were negative for neoplasia. Fungi, acid-fast bacilli, or
other organisms were not identified in the pathology specimens or in the pleural fluid.
DISCUSSION
EPIDEMIOLOGY
Throughout the last several decades, numerous series of
patients with broncholithiasis have been described in the surgical, pulmonology, and radiology literature (Table).1-4 In these
series, patients with broncholithiasis ranged from 48.5 to 56.8
years of age; the ratio of men to women was fairly even.
Commonly reported symptoms included cough, recurrent
hemoptysis, fever and chills, purulent sputum, and lithoptysis
(ie, expectoration of stones). Some patients presented with
pleuritic chest pain, localized wheezing, or massive hemoptysis. Broncholiths appeared to be more common in the rightside airways than in the left side.
Historically, a diagnosis of broncholithiasis was reserved for
cases in which at least part of a calcified lymph node actually
eroded into the lumen of a bronchus, often resulting in lithoptysis. In order to encompass earlier stages of this dynamic disease,
investigators from the Mayo Clinic proposed an extended definition of broncholithiasis in 1971. The updated definition
included all patients with peribronchial calcific nodal disease
resulting in distortion of the bronchi, as demonstrated by
roentgenography or bronchoscopy. Using this broadened definition, 253 cases of broncholithiasis were identified and described
at the Mayo Clinic over the course of 30 years.1,2,5 In the early
Mayo Clinic series, 86 patients (34%) experienced lithoptysis;
obstructive pneumonitis was present in 85 cases (34%) by x-ray
(Table). The average duration of clinical manifestations from
onset to diagnosis in this series was 41/2 years, whereas the average duration of symptoms in a later study was only 8 months.2
Although asymptomatic broncholithiasis may be found
incidentally on chest radiography, broncholithiasis sometimes
presents very dramatically. Potential complications include
Johns Hopkins Advanced Studies in Medicine
bronchoaortic or bronchoesophageal fistula, fatal hemoptysis
due to rupture of a pulmonary artery branch, mediastinal
abscess, granulomatous mediastinitis with both hemoptysis
and hematemesis, and bronchial dehiscence in a lung transplant recipient.3,4,6-9
ETIOLOGY
Broncholithiasis has a variety of potential causes.
Although organisms are rarely found in extracted broncholiths, evidence exists that broncholithiasis is often preceded
by tuberculosis or a fungal infection, such as histoplasmosis.1,2,5
Another cause of broncholithiasis may be silicosis.2,3 Though the
reasons are unclear, only a small number of persons with pulmonary hilar calcifications—a common finding on routine
chest x-ray—develop broncholithiasis. When calcified material
itself has not eroded into the airway, distortion may be caused
by an associated inflammatory process.4 In the present case, the
exact cause of broncholithiasis was unclear, but the patient lived
in a region where histoplasmosis was endemic. Miks et al reported that chemical analysis of a removed broncholith revealed
hydroxyapatite crystals, which contained calcium and phosphorus.10 Lin et al reported a broncholith composed of calcium magnesium phosphate and a small amount of calcium carbonate.6
DIAGNOSIS
The diagnosis of broncholithiasis usually can be made from a
combination of history, radiographic studies, and/or bronchoscopy. The key radiologic finding is a calcified endobronchial
or peribronchial lymph node. Other CT findings, including
atelectasis, infiltration, bronchiectasis, air trapping, and fluid
bronchograms, are due to bronchial obstruction.2,4,11
TREATMENT
Depending on the severity of the symptoms, experts recommend observation, or bronchoscopic or surgical treatment.3
Table. Selected Broncholithiasis Case Series
Author
Year
Arrigoni1
(n = 253)
Dixon2
(n = 19)
Conces4
(n = 15)
Olson3
(n = 95)
1971
1984
1991
1999
Male (%)
48
63
53
52
Mean age
54.5 (male)/
50.6 (female)
52.1
48.5
56.8
Lithoptysis (%)
34
16
13
16
Pneumonia (%)
34*
52†
27‡
11†
Surgery (%)
27
73
60
28
*Radiologic finding of obstructive pneumonitis.
†Symptoms of fever or purulent sputum.
‡Symptomatic pneumonia.
377
CLINICAL VIGNETTE
Removal of broncholiths by fiberscopic bronchoscopy is difficult and carries a high risk of bleeding. Therefore, rigid
bronchoscopy2—with or without fragmentation by forceps,9 laser,10 or surgical resection1,2—may be required to
relieve obstruction and prevent bleeding and recurrent
infection. The success of bronchoscopic removal depends
upon the stage of broncholithiasis. Olson et al reported a
success rate of 100% for bronchoscopic removal of broncholiths that were free in the airway lumen. Yet, when
removing partially eroded broncholiths, a 48% success rate
was achieved. Attempts to remove broncholiths that were
distorting airways but had not yet eroded into the lumen
were not reported.3
CONCLUSION
Broncholithiasis is a less common cause of bronchial
obstruction. This patient’s presentation provided several
clues that he did not have a typical case of communityacquired pneumonia. Despite having no comorbid illnesses, he was very ill at presentation with significant
hypoxemia that progressed despite appropriate therapy.
Wheezing localized to the left lower lobe raised suspicion
for bronchial obstruction, and the medical team was concerned about the possibility of carcinoma given the
patient’s smoking history. Further evaluation and bronchoscopy confirmed the diagnosis of broncholithiasis,
which, while rare, also should be considered in any patient
with postobstructive pneumonia.
378
References
1. Arrigoni MG, Bernatz PE, Donoghue FE. Broncholithiasis. J Thorac
Cardiovasc Surg. 1971;62:231-237.
2. Dixon GF, Donnerberg RL, Schonfeld SA, Whitcomb ME. Advances
in the diagnosis and treatment of broncholithiasis. Am Rev Respir Dis.
1984;129:1028-1030.
3. Olson EJ, Utz JP, Prakash UB. Therapeutic bronchoscopy in broncholithiasis. Am J Respir Crit Care Med. 1999;160:766-770.
4. Conces DJ Jr, Tarver RD, Vix VA. Broncholithiasis: CT features in 15
patients. AJR Am J Roentgenol. 1991;157:249-253.
5. Meyer M, O’Regan A. Images in Clinical Medicine. Broncholithiasis.
N Engl J Med. 2003;348:318.
6. Lin CS, Becker WH. Broncholith as a cause of fatal hemoptysis. JAMA.
1978;239:2153.
7. Studer SM, Heitmiller RF, Terry PB. Mediastinal abscess due to passage
of a broncholith. Chest. 2002;121:296-297.
8. Kefri M, Dyke S, Copeland S, Morgan CV Jr, Mehta JB. Hemoptysis
and hematemesis due to a broncholith: granulomatous mediastinitis.
South Med J. 1996;89:243-245.
9. Doud JR, Bakhos M, McCabe MA, Garrity ER Jr. Bronchial dehiscence associated with a large broncholith in a lung transplant recipient.
Chest. 1992;102:1273-1274.
10. Miks VM, Kvale PA, Riddle JM, Lewis JW Jr. Broncholith removal
using the YAG laser. Chest. 1986;90:295-297.
11. Shin MS, Ho KJ. CT fluid bronchogram: observation in postobstructive pulmonary consolidation. Clin Imaging. 1992;16:109-113.
Vol. 5, No. 7
n
July/August 2005