Broncholithiasis in a 53-Year-Old Woman With Progressive Dyspnea: A Rare Yet Treatable Entity
Keywords: broncholithiasis, calcified lymph node, histoplasmosis, bronchoscopy, holmium laser, chronic cough, airway obstruction, interventional pulmonology
Introduction
Broncholithiasis, a rare pulmonary condition characterized by the erosion of calcified lymph nodes into the tracheobronchial tree, represents a fascinating diagnostic challenge in modern respiratory medicine. It is often underdiagnosed or misdiagnosed due to nonspecific respiratory symptoms. We present the case of a 53-year-old woman with a history of metastatic lung adenocarcinoma who presented with progressive dyspnea and cough. This case illustrates the dynamic imaging changes, diagnostic complexity, and therapeutic potential of bronchoscopic intervention in broncholithiasis.
Clinical Presentation
A 53-year-old woman with partially treated metastatic pulmonary adenocarcinoma presented to the pulmonary clinic complaining of progressive dyspnea and chronic cough lasting over three months. There was no history of fever, hemoptysis, or weight loss.
Her past medical history was significant for granulomatous infection consistent with histoplasmosis, a common etiology for calcified mediastinal lymphadenopathy in her region of residence.
Imaging Evaluation
Initial Chest CT
Three serial chest CT scans were reviewed:
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| Figure 1. Serial chest CT images showing progressive migration of a calcified lymph node into the left main bronchus (Panels A–C) |
Panel A: CT obtained 15 months prior, showing a calcified mediastinal lymph node adjacent to the left main bronchus.
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Panel B: CT 3 months prior, showing migration of the same node closer to the airway.
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Panel C: Current CT, demonstrating the calcified node eroding into the lumen of the left main bronchus.
These findings are classic for broncholithiasis, a condition often secondary to granulomatous infections such as histoplasmosis or tuberculosis.
Bronchoscopic Findings and Management
The patient was referred to interventional pulmonology for diagnostic and therapeutic bronchoscopy. During the procedure, a broncholith was visualized in the left main bronchus.
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| Figure 2. Bronchoscopic image (Panel D) showing a visible broncholith in the left main bronchus. |
Using a combination of holmium: YAG laser lithotripsy and rigid forceps, the broncholith was fragmented and extracted in multiple pieces.
Post-procedural outcome: The patient experienced marked improvement in dyspnea and cough, with no recurrence over a six-month follow-up period.
Pathophysiology of Broncholithiasis
Broncholithiasis develops when a calcified peribronchial lymph node erodes through the bronchial wall into the airway lumen. It may be:
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Intraluminal, causing obstruction
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Peribronchial, exerting extrinsic compression
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Transmural, partially embedded
Common Causes:
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Histoplasmosis (endemic mycosis in the Americas)
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Tuberculosis
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Silicosis
These infections lead to granulomatous lymphadenitis, which later undergoes dystrophic calcification.
Clinical Features
Symptoms are often nonspecific but include:
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Chronic productive or dry cough
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Progressive dyspnea
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Hemoptysis
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Rarely, expectoration of calcified fragments (lithoptysis)
Differential Diagnosis
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Endobronchial tumors (e.g., carcinoid)
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Bronchial tuberculosis
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Foreign body aspiration
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Bronchial calcifications in silicosis or sarcoidosis
Diagnostic Imaging Clues
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Non-contrast CT is the modality of choice for identifying:
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High-density calcified lesions
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Their relationship to the airways
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Serial imaging may demonstrate:
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Migration of calcified lymph nodes
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Progression from extrinsic compression to intraluminal obstruction
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Treatment
Conservative Management:
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Asymptomatic patients may not require intervention
Interventional Options:
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Bronchoscopic removal via:
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Rigid bronchoscopy
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Holmium laser lithotripsy
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Cryotherapy or electrocautery in select cases
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Surgical Intervention:
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Rarely required in cases of significant bleeding or failure of endoscopic removal
Quiz
1. Which of the following is the most likely etiology for broncholithiasis in this patient?
A. Silicosis
B. Histoplasmosis
C. Primary bronchial carcinoma
D. Idiopathic calcification
2. What is the imaging feature most suggestive of broncholithiasis on serial chest CT scans?
A. Progressive lymph node enlargement
B. Migration of a calcified lymph node into the bronchial lumen
C. Homogeneous parenchymal consolidation
D. Bilateral pleural effusions
Answer & Explanation
Prognosis and Follow-up
With complete removal, the prognosis is excellent. Recurrence is rare. Pulmonary function often improves significantly, and most patients resume normal activity levels.
Conclusion
This case of broncholithiasis in a middle-aged woman with a history of metastatic lung cancer highlights the importance of:
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Careful longitudinal imaging
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Awareness of rare airway disorders
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The therapeutic value of interventional bronchoscopy
Early recognition and minimally invasive management can dramatically improve symptoms and quality of life.
References
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K. P. Wang, et al., “Broncholithiasis: Clinical features and management,” Chest, vol. 104, no. 5, pp. 1543–1547, 1993.
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A. Sakula, “Broncholithiasis: A review of 51 cases,” Thorax, vol. 32, no. 5, pp. 512–517, 1977.
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B. A. Wood, et al., “Interventional bronchoscopic management of broncholithiasis,” Respiration, vol. 74, pp. 289–293, 2007.
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M. S. Boiselle, “Imaging of calcified mediastinal lymph nodes,” AJR Am J Roentgenol, vol. 178, no. 5, pp. 1261–1266, 2002.
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J. S. Lee et al., “Broncholithiasis and endoscopic removal using holmium laser,” J Thorac Dis, vol. 12, pp. 6421–6424, 2020.
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S. B. Field et al., “Histoplasmosis and its sequelae,” Ann Intern Med, vol. 81, no. 3, pp. 351–356, 1974.
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E. T. Haponik, “Broncholithiasis: Diagnostic and therapeutic considerations,” Chest, vol. 95, no. 6, pp. 1162–1166, 1989.
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