JOURNAL OF THE LOUISIANA STATE MEDICAL SOCIETY
The Non-Innoculous Hilar Calcification: Recurrent Pneumonia Secondary to Broncholith-Associated Actinomyces Oluwayemisi Ojemakinde, MD; AdamWellikoff, MD; Catherine Chaudoir, MD; Guillermo Sangster, MD; Alberto Simoncini, MD; Carlos Previgliano, MD; Disha Adelle Desouza Dystrophic calcification of hilar lymph nodes is a common response to chronic inflammation related to several etiologies and rarely is associated with any clinical findings. A clinical scenario related to these calcified lymph nodes can thus be delayed by the low clinical suspicion associated with such a presumably innocuous finding. Normal respiratory movements however, can cause erosion into adjacent bronchi leading to a broncholith, complications of which can result in morbidity. We illustrate one of these complications, a partial obstruction with subsequent recurrent infection due to normal oral flora - actinomyces.
FIGURE 1: Frontal view of the chest shows left hilar calcification with a mass-like consolidation and scattered calcification of the upper lobe.
CASE REPORT
A53-year-oldmalepresentedwitha sixmonthhistoryof pleuritic left-sided chest pain associated with night sweats, fever, cough, and occasional frank hemoptysis. His past medical history was significant for chronic obstructive pulmonary disease (COPD) and coronary artery disease. He had a 70-pack-year smoking history and had worked in a prison for four years. Findings on examination included bilateral finger clubbing, wheezing in the left mid-lung field, and no palpable lymphadenopathy. A chest radiograph (Figure 1) revealed left hilar calcification with a mass-like consolidation and scattered calcification in the upper lobe. Computed tomography (CT) chest (Figure 2) favored a chronic infection, however review of CT images and multiple chest radiographs performed between six years and 12 months earlier, revealed a similar appearance and interval resolution of infection. A suspected broncholith was observed (Figure 3). Sputum for mycobacteria and fungi, and an interferon-gamma release assay (IGRA) were negative. A bronchoscopy and endobronchial biopsy was performed confirming a broncholith (Figure 4A and B). Gomori methenamine silver (GMS) and periodic acid schiff stain (PAS) stains were performed and highlighted thin filamentous organisms. These morphologic features were suggestive of Actinomyces spp (Figure 5). Treatment with Doxycycline resulted in resolution of symptoms as well as radiographic improvement.
FIGURE 2: Axial non-contrast CT showing consolidation, scarring, and scattered calcification of the upper lobe. These findings favor a chronic infection.
DISCUSSION
Hilar calcification from prior granulomatous disease is a frequent finding on imaging, especially where granulomatous diseases such as histoplasmosis and tuberculosis are endemic. Other causes such as coccidioidomycosis, sarcoidosis, silicosis, and treated lymphoma are also well recognized. 1 These calcifications appear innocuous and are generally associated with remote and quiescent events. They do however, move with respiratory movements and cardiac pulsations and can slowly erode adjacent
18 J La State Med Soc VOL 169 JANUARY/FEBRUARY 2017
Made with FlippingBook Digital Publishing Software