BRONCHOLITHIASIS

A 47 year old female who had past history of incomplete treatment for pulmonary tuberculosis presented with increased breathlessness, generalized swelling and loss of ap-petite for last one month. X-ray chest PA view showed bilateral fibrocalcific opacities with blunting of costophrenic angle on both sides. She underwent bronchoscopy to collect bronchial wash to rule out relapse of tuberculosis. On bronchoscopy a loose broncholith with sharp and speculated margins were detected in right middle lobe bronchus. This broncholith was successfully removed through flexible bronchoscope without any complications.


INTRODUCTION
Broncholiths are calcified material within tracheobronchial tree. They originate from calcified peribronchial lymph nodes which had subsequently erode the bronchus. They may remain asymptomatic or may produce nonspecific symptoms. Clinical signs and radiological investigations are usually inconclusive. Broncholiths are often detected during evaluating symptoms of complications e.g. haemoptysis, recurrent chest infection. Broncholiths should be removed preferably through rigid bronchoscope.

CASE SUMMARY
A 47 year old female was admitted with complaints of increased breathlessness, generalized swelling of the body and loss of appetite for the past one month. Five years back, she was diagnosed as a case of smear positive pulmonary tuberculosis. She took the treatment for 2 months and left on her own. She denied any other signifi cant past history. Her family history was unremarkable.
On examination, she was conscious and oriented but dyspneic. Her pulse rate was 110/min, respiratory rate was 30/min and blood pressure was 110/80 mm of Hg. No clubbing or cervical lymphadenopathy was detected but JVP was raised. Respiratory system examination showed laboured breathing with bilateral inspiratory crackles and rhonchi. Abdominal examination showed tender hepatomegaly with ascitis. Oxygen on room air was 88%. Her routine investigation were normal.
ECG showed evidence of cor pulmonale. Echocardiography showed severe pulmonary hypertension with dilated right atrium and poorly contracting dilated right ventricle. X-Ray chest (Fig. I) showed mediastinal widening with bilateral fi brocalcifi c opacity. Costophernic angle on both sides were blunt.

DISCUSSION
Broncholiths are endogenous calcifi ed material within tracheobronchial tree. According to extended defi nition 1 , broncholithiasis include all patients with peribronchial calcifi c node with distortion of the bronchi, as demonstrated by roentgenography or by bronchoscopy.
Broncholiths are classifi ed into two groups 2 according to their origin: (a) Intrinsic calculi, developed from the lung, bronchi and lymph nodes and which may be subdivided as follows: (i) Senile calcifi cations\of the elastic cartilage of the bronchi and subsequent sequestration. (ii) Metastatic calcification due to hyperparathyroidism, multiple myeloma, renal rickets, etc. This type of calcification occurs peripherally and rarely results in broncholithiasis. (iii) Dystrophic calcification of necrotic, inflamed or degenerated tissue (the most common mechanism).(b) Extrinsic calculi, developed from aspirated foreign bodies, secretions and dusts (rare).
Broncholithiasis has a various etiology. The commonest etiology is granulomatous lymphadenitis due to fungal or mycobacterial infection. The calcifi ed peribronchial lymph nodes may erode the tracheobronchial tree due to respiratory movement or cardiac pulsation. Preferential sites are known to be the proximal right middle lobe bronchus and the origin of the anterior segmental bronchus of the upper lobes because of the airway anatomy and lymph node distribution. 3 The broncholiths are usually gray-white and variable in size and usually irregular in shape and often possess spurlike projections or sharp edges. The chemical composition is of calcium phosphate (85-90%) or calcium carbonate (10-15%).
Organisms are rarely detected in extracted broncholiths. However, Weed et al 4 histopathologically examined broncholith from 9 patients and observed that they had originated from either Histoplasma capsulatum or Nocardial infection. Broncholiths arise within intrathoracic tissues previously infected with tubercle bacilli. However, broncholiths are infrequent during active pulmonary tuberculosis. Stivelman 5 reported one case in 5,000 active tuberculosis while Zahnlo 6 noted a single case among 4,000 patients.
USG abdomen showed moderate to gross ascitis with bilateral pleural effusion with normal kidney and altered hepatic echotexture. Diagnostic ascitic and pleural fl uid aspiration were done.
CT scan thorax showed large (2x2 cm) calcifi ed right paratracheal lymphadenopathy with multiple bilateral calcifi ed hilar lymph node with bilateral pleural effusion. Fig. II shows calcifi ed right hilar lymph node protruding inside the right middle lobe bronchus.

Fig. 3: Broncholith in side the right middle lobe bronchus
As she was not able to produce sputum, she under went videobronchoscopy. On bronchoscopy a large loose broncholith was seen at the opening of right middle lobe bronchus (Fig. III). The margin of broncholith was sharp and speculated. Broncholith was successfully removed by the bronchoscope and no complication was observed. Bronchial aspirate taken from both side of lung which was negative for acid fast bacilli and no organism was grown on culture. Smear prepared with the fragments failed to show any organism.
Subsequently pulmonary function test was done which showed Forced Vital Capacity (FVC) 0.421 (16% of predicted), Forced Expiratory Volume in 1 sec (FEV 1 ) was 0.351/s (16% of predicted) and FEV 1 /FVC 65.19% and there was no reversibility. She was unable to perform lung volumes and diffusion. She treated with bronchodilator and diuretic therapy and was discharged with improved condition.
Radiologically broncholiths are very difficult to diagnose. CT fi ndings 10 of a suspected broncholith is either endobronchial or peribronchial calcifi ed nodule which is associated with fi ndings of bronchial obstruction. However, with conventional CT, it can be diffi cult to determine whether a calcifi ed nodule is endobronchial in position because thicker sections result in a volume-averaging artifact of broncholith, bronchus, and peribronchial tissues including adjacent lymph nodes. High resolutions CT scan have better ability to identify broticholiths 11 . Treatment options are simple observation, bronchoscopic removal or surgery. Spontaneous broncholith expectoration may occasionally lead to resolution of symptoms.
Management of the large symptomatic broncholith is controversial. Review of literature 12 suggested bronchoscopic removals should be considered in cases of uncomplicated and loose broncholithiasis, whereas surgical management should be chosen in complicated cases. The majority of broncholiths can be managed by bronchoscope. Nollet AS et al 13 suggested broncholiths should be removed under rigid bronchoscope. As broncholiths are usually associated with extensive granulation tissue, removal of symptomatic broncholith by fi ber optic bronchoscope is diffi cult and may cause massive bleeding 14 . Large broncholith can be fragmented by YAG laser and subsequently fragments can be removed by fi bre optic bronchoscope 15 . However, safe removal of partially embedded broncholiths by fl exible bronchoscopy had been reported 8 .
We are reporting a case of uncomplicated asymptomatic post tubercular broncholith which was successfully removed by the fl exible bronchoscope.