A SOLITARY ENDOBRONCHIAL BRONCHOLITH AS AN UNCOMMON PRESENTATION OF HISTOPLASMOSIS

Abstract

TOPIC: Lung Pathology TYPE: Medical Student/Resident Case Reports INTRODUCTION: Broncholithiasis refers to calcified material within the airway lumen, often resulting from granulomatous reaction to endemic pathogens such as M. tuberculosis or Histoplasma, or aspiration of foreign material. Histoplasma broncholiths are thought to originate from adjacent lymph nodes that erode into the airway lumen. Here we present a case of a large isolated endobronchial broncholith secondary to Histoplasma without associated lymphadenopathy or parenchymal lung lesions. CASE PRESENTATION: A 69 year-old female with GERD presented with one month of dyspnea, cough, and wheezing thought to occur after a popcorn kernel aspiration. She was treated twice for bronchitis without improvement and was diagnosed with COPD based on obstruction on spirometry. The patient denied smoking or other inhalational exposures. Vital signs and oxygenation were normal on our evaluation. A CT pulmonary angiogram showed a 1.3 cm calcified foreign body (FB) consistent with an aspirated tooth in the left mainstem bronchus without significant lymphadenopathy. Bronchoscopy showed a white-yellow multilobulated FB partially embedded in and nearly occluding the left mainstem bronchus. Removal of the FB revealed a deep but not transmural ulceration of the mucosa. Though it grossly resembled a popcorn kernel, histologic examination of the broncholith showed well-formed granulomas and yeast forms consistent with Histoplasma capsulatum. The patient felt immediate relief of dyspnea post-removal and on follow up denied any symptoms. She was discharged and scheduled for repeat testing to ensure no further evidence of fungal disease. DISCUSSION: Although broncholithiasis from Histoplasma granulomata is common, to our knowledge this is the first report of the disease presenting as a solitary endobronchial broncholith. Given that no adjacent lymphadenopathy and/or calcifications were noted on CT, this case was likely secondary to calcification of a primary endobronchial inoculum. Patients with symptomatic or obstructing broncholithiasis should undergo attempted removal either with bronchoscopy or surgical intervention. Bronchoscopic removal should be undertaken with great caution since the extraluminal origin of many broncholiths can result in airway perforation or major hemorrhage with manipulation. Large broncholiths such as this sometimes require laser lithotripsy to facilitate extraction. CONCLUSIONS: Broncholithiasis is a condition often associated with pulmonary and mediastinal histoplasmosis and can present with transmural bronchial invasion. Isolated endobronchial lesions are uncommon. Prompt imaging and endoscopic evaluation is key to accurate diagnosis. Careful consideration of transmural extension and involvement of extrabronchial structures is crucial. REFERENCE #1: Alshabani K, Ghosh S, Arrossi AV, Mehta AC. Broncholithiasis: A Review. Chest. 2019 Sep;156(3):445-455. REFERENCE #2: Krishnan S, Kniese CM, Mankins M, Heitkamp DE, Sheski FD, Kesler KA. Management of broncholithiasis. J Thorac Dis. 2018;10(Suppl 28):S3419-S3427. REFERENCE #3: Olson EJ, Utz JP, Prakash UB. Therapeutic bronchoscopy in broncholithiasis. Am J Respir Crit Care Med. 1999 Sep;160(3):766-70. DISCLOSURES: No relevant relationships by Gregory Eisinger, source=Web Response No relevant relationships by Molly Howsare, source=Web Response No relevant relationships by Meghana Moodabagil, source=Web Response No relevant relationships by Alberto Revelo, source=Web Response No relevant relationships by Konstantin Shilo, source=Web Response