JOURNAL OF THE LOUISIANA STATE MEDICAL SOCIETY
bronchial walls resulting in extrusion into the bronchial lumen. 2 These eroding calcified lymph nodes are called broncholiths, and produce partial or total luminal narrowing, distal obstruction, and infection. Such erosions and extrusions have also been reported to produce chronic pneumonia, bronchiectasis and bronchopleural fistulas. 3 Organisms which have been reported for broncholith- associated pneumonia include fungi, Nocardia, Histoplasma, and Actinomyces, with actinomycosis appearing in the largest number of case reports. 4-6 Aspiration of secretions containing actinomyces is the usual mechanism of infection; nevertheless, actinomycosis may result from introduction of organisms via esophageal perforation, direct extension from a process in neck or abdomen or via hematogenous dissemination. There is at least one case in which actinomyces was cultured from the broncholith, and hence thought to precede formation of the broncholith. 7 The clinical presentation of post-obstructive actinomycosis is the same as seen in most broncholith-related pneumonias; these include hemoptysis, wheezing, weakness, fatigue, increased sputum production and pleural effusion as seen in our case. 5,7 Gradual erosion of bronchial lumen is initially imperceptible, as respiratory movements of calcified nodes are normally in the range of 7-20 millimeters. 5,8 A broncholith should be suspected in the presence of calcified hilar lymph nodes when associated with recurrent pneumonia.
FIGURE 3: CT chest axial, slice inferior to Figure 2, showing broncholith in left lower lobe bronchus (arrow).
FIGURE 4A: Bronchoscopic view of the broncholith partly buried in the airway wall.
CONCLUSION
This case report highlights broncholith-associated actinomyces pneumonia as a potential rare complication of a calcified hilar lymph node diagnosed with classical imaging and bronchoscopic findings.
FIGURE 4B: Bronchoscopic view of the broncholith as it is attached to the end of the scope via suction as it passes through the nasopharynx on its way out.
REFERENCES
1. Chan ED, Morales DV, Welsh CH, et al. Calcium deposition with or without bone formation in the lung. Am J Respir Crit Care Med 2002; 165:1654– 1669. 2. Nollet AS, Vansteenkiste JF, Demedts MG. Broncholithiasis: rare but still present. Respiratory Medicine 1998; 92:963–965. 3. Yi KY, Lee HK, Park SJ, et al. Two cases of broncholith removal under the guidance of flexible bronchoscopy. Korean J Intern Med 2005; 20:90-91. 4. Tam WO, Wong CF, Wong PC. Endobronchial nocardiosis associated with broncholithiasis. Monaldi Arch Chest Dis 2008; 69:183-185. 5. Seo JB, Song K, Lee JS. Broncholithiasis: Review of the causes with radiologic-pathologic correlation. Radiographics 2002; 22:S199–S213. 6. Kim TS, Han J, Koh W, et al. Endobronchial actinomycosis associated with broncholithiasis: CT findings for nine patients. AJR Am J Roentgenol 2005; 185:347-353. 7. Henry NR, Hinze JD. Broncholithiasis secondary to pulmonary actinomycosis. Respir Care 2014; 59(3):e27-e30. 8. Jenkins P, Salmon C, Mannion C. Analysis of the movement of calcified lymph nodes during breathing. Int J Radiat Oncol Biol Phys 2005; 61:329– 334. Oluwayemisi Ojemakinde is a radiology resident PGY3 in the department of radiology at LSUHSC-Shreveport; AdamWellikoff is in the interventional pulmonary program at LSUHSC-Shreveport; Catherine Chaudoir is a cytopathology fellow in the department of pathology at LSUHSC-Shreveport; Guillermo Sangster, Alberto Simoncini, and Carlos Previgliano are all professor of radiology at LSUHSC-Shreveport; Disha Adelle Desouza is a fourth-year medical student on radiology rotation at LSUHSC-Shreveport.
FIGURE 5: Gomori methenamine silver (GMS) stain performed on the lingula biopsy specimen highlights thin filamentous organisms with morphologic features suggestive of Actinomyces spp. (x 40).
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