Broncholithiasis Masquerading as Asthma

Abstract

Broncholithiasis is the presence of osteoid material molded in the bronchial lumen.1Krishnan S. Kniese C.M. Mankins M. Heitkamp D.E. Sheski F.D. Kesler K.A. Management of broncholithiasis.J Thorac Dis. 2018; 10: S3419-S3427Crossref Scopus (10) Google Scholar It produces chronic inflammation leading to airway obstruction mimicking asthma. A 52-year-old lifelong nonsmoker woman complained of constant, progressive, dry cough for 3 months. The patient denied precipitating factors, previous events, and aggravating or alleviating factors. Her cough was associated with halitosis, subjective weight loss, chest tightness, wheezing, urinary stress incontinence, and dyspnea. Past medical history was significant for exercise-induced bronchospasm, she denied the use of prescribed or over-the-counter medication, and the physical examination revealed expiratory wheezing. On the basis of findings, we diagnosed asthma. The result of the methacholine challenge was positive; nonetheless, the patient did not improve after a trial of 2 dry-powder inhalers with high-dose inhaled corticosteroids/long-acting beta-agonist (fluticasone propionate/salmeterol and fluticasone furoate/vilanterol), and systemic steroids. Two episodes of pneumonia complicated her course, and a chest computed tomography performed after the second episode revealed a broncholith in the right bronchus (Figure 1). Finally, the foreign material was extracted with a bronchoscope (Figure 2), leading to complete symptomatic relief.Figure 2Broncholith material after bronchoscopic removal.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Most cases of broncholithiasis are secondary to chronic lymphadenitis caused by histoplasmosis, foreign body aspiration, ossified bronchial cartilage, and osteoid material migration from other parts of the body.1Krishnan S. Kniese C.M. Mankins M. Heitkamp D.E. Sheski F.D. Kesler K.A. Management of broncholithiasis.J Thorac Dis. 2018; 10: S3419-S3427Crossref Scopus (10) Google Scholar Patients often present with chronic cough, dysphagia, lithoptysis, hemoptysis, and recurrent pneumonias.1Krishnan S. Kniese C.M. Mankins M. Heitkamp D.E. Sheski F.D. Kesler K.A. Management of broncholithiasis.J Thorac Dis. 2018; 10: S3419-S3427Crossref Scopus (10) Google Scholar Often, findings in x-rays are nonspecific (hilar calcification or parenchymal infiltrates, depending on the etiology), so a computed tomography is required to diagnose, localize, and detect the degree of airway obstruction.1Krishnan S. Kniese C.M. Mankins M. Heitkamp D.E. Sheski F.D. Kesler K.A. Management of broncholithiasis.J Thorac Dis. 2018; 10: S3419-S3427Crossref Scopus (10) Google Scholar Clinical management is preferred over surgery because of the risk of bleeding; however, severe cases require bronchoscopic or surgical extraction.1Krishnan S. Kniese C.M. Mankins M. Heitkamp D.E. Sheski F.D. Kesler K.A. Management of broncholithiasis.J Thorac Dis. 2018; 10: S3419-S3427Crossref Scopus (10) Google Scholar In conclusion, broncholithiasis can produce airway obstruction and chronic inflammation resembling asthma.1Krishnan S. Kniese C.M. Mankins M. Heitkamp D.E. Sheski F.D. Kesler K.A. Management of broncholithiasis.J Thorac Dis. 2018; 10: S3419-S3427Crossref Scopus (10) Google Scholar Physicians must consider alternative diagnoses in patients with atypical asthma, unresponsive to medical treatment in spite of a positive methacholine challenge test result.2Coates A.L. Wanger J. Cockcroft D.W. Culver B.H. Carlsen K. Diamant Z. et al.ERS technical standard on bronchial challenge testing: general considerations and performance of methacholine challenge tests.Eur Respir J. 2017; 49: 1601526Crossref PubMed Scopus (176) Google Scholar