A 75-year-old man with transbronchial broncholithiasis followed up for 9 years!

S Okauchi, H Satoh 
 Division of Respiratory Medicine, Mito Medical Center, University of Tsukuba, Mito-City, Ibaraki, Japan

Correspondence Address:
Prof. H Satoh
Division of Respiratory Medicine, Mito Medical Center, University of Tsukuba, Mito-City, Ibaraki
Japan

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A 75-year-old man was referred to our hospital due to an abnormal opacity in chest radiograph detected by a mass-screening. The patient had no complaint and had no medical history except for hypertension. He had history of 15 pack year of smoking. Physical examination was unremarkable. In non-contrast CT image, a nodule considered to be calcification (7.0 × 6.7 mm) was found at the orifice of the left superior segment (B6) bronchus [Figure 1]a. Its maximum Hounsfield unit (HU) was1399 HU. Calcified and noncalcified ipsilateral mediastinal lymph nodes were prominent in chest CT scan. Bronchoscopy confirmed a white and calcified nodule at the orifice of the left B6 bronchus. Longitudinal folds were conspicuous on the surrounding bronchial wall adjacent to the nodule [Figure 1]b. A biopsy of the bronchial wall at that location was performed in order to differentiate inflammation or tumors. The microscopic findings of the specimen obtained by biopsy of the bronchial wall near the calcified nodule were as follows: infiltration of lymphocytes, plasma cells, and eosinophils were observed in connective tissue of the sub-basement membrane. There was fragmented calcification, but no malignant cells. Based on the images, bronchoscopy and histological findings, the patient was diagnosed with transbronchial broncholithiasis. Thereafter, the patient was followed up once every few months and images including chest radiography and CT scan were done once every few years. Chest CT taken 9 years after the diagnosis showed slight changes in shape of the calcified nodules [Figure 1]c. The patient has had no respiratory symptoms and was doing well clinically.{Figure 1}

Broncholithiasis is defined as the presence of calcified material that erodes into the lumen of the tracheobronchial tree or lung parenchyma, potentially causing inflammation and obstruction.[1],[2] Based on the positional relationship with the bronchial tree, broncholithiasis can be classified as three types: endobronchial, peribronchial, or transbronchial types.[1] The most common cause of broncholithiasis is erosion and extrusion into the bronchial lumen by calcified adjacent lymph nodes, which are usually findings associated with tuberculosis or histoplasmosis.[1],[2],[3] The present patient had a transmural type broncholithiasis, but was asymptomatic. There are several management options for patients with broncholithiasis, including observation, endoscopic removal, and surgery. However, there are no established guidelines. For symptomatic broncholithiasis patients, bronchoscopic or surgical resection is indicated, although the best method is controversial.[4],[5] On the other hand, observation is usually recommended for asymptomatic patients. However, this recommendation is not well-founded. Krishnan et al.[2] reported that management of broncholithiasis depends on several factors including patient symptoms, the size of the broncholith, its relationship with the airway wall, and its proximity, or to involvement of adjacent thoracic structures. According to them, conservative management in the form of observation is warranted in asymptomatic patients and those with minimal or non-recurring, non-life-threatening symptoms.[2] Alshabani et al.[1] have described that patients who are asymptomatic or only minimally symptomatic can be managed conservatively with observation. But they have not indicated the duration of their follow-up data.

The natural history of broncholiths is poorly understood. Shah et al.[6] have reported a 43-year-old man who developed a broncholith in the transplanted lung within 10 months of the surgery.

The present case was followed up for 9 years and he did not develop any bleeding or pulmonary infection. The present case reiterates, with documented evidence, the current premise that aymptomatic broncholithiasis can be conservatively managed over a long period of almost a decade.

Declaration of patient consent

The authors certify that appropriate patient consent was obtained.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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