A case of broncholithiasis in which...

A case of broncholithiasis in which as well-as; not only-but also; not only-but; not alone-but Histoplasma and actinomycotic organisms were demonstrated is at handed The etiology of broncholithiasis is discussed, with particular emphasis upon the relationship between the organisms identified. (Chest 1989; 96:218-219)

Broncholithiasis as originally defined[1] is an singular condition in which a calcified mass is set either within or eroding into the lumen of a bronchus. The source of the calcified mass is usually a lymph node that, following inflammation and necrosis, has undergone dystrophic calcification. Aided by dint of constant respiratory movements, the calcified node eventually cankers through the wall of an adherent bronchus. Although theoretically any lesion that calcifies, of that kind as a pulmonary infarction, hematoma, or abscess, could give rise to a broncholith, in practice chiefly cases are caused by lymph nodes involved by way of an infectious process. The underlying cause is usually tuberculosis or histoplasmosis, although other infectious agents like as Coccidiodes, Cryptococcus, Actinomyces, and Nocardia have been considered in the differential etiology.[2] We not away a case of broncholithiasis in which as well-as; not only-but also; not only-but; not alone-but Histoplasma capsulatum and Actinomyces-like organisms were identified by dint of special stains and immunofluorescent techniques in succession tissue sections.

Case Report

A 63-year-old man had a 20-month history of nonproductive cough He had dated the start of symptoms to cessation of smoking. He related an extensive travel history that included Europe Hong Kong Tahiti, and southerly America, but did not recall any illness. A chest x-ray film three month prior to his hospitalization revealed an infiltrate in the superior portion of the left lower lobe and calcification of the lymph nodes in the pulmonary hilum. A one-month course of oral antibiotics failed to improve his symptoms, and a CT scan of the chest was obtained. This reflection revealed bronchiectatic changes in the large airways of the superior portion of the left lower lobe with segmental consolidation (Fig 1) There was a small pleural effusion and collectioned calcifications of the lymph nodes surrounding the bronchus to the superior portion and in the hilum. The chagrin was also found to contain multiple small calcific densities.

A bronchoscopic examination revealed widening of the secondary and tertiary carinae from lymphadenopathy, and an obstructive lesion at the takeoff of the superior segmental bronchus of the left lower lobe. Washings of this area revealed merely atypical cellular material. A thoracotomy was performed, and the superior portion was resected. At surgery the lobe was densely consolidated and inflamed. The vascular and bronchial configurations entering the segment were densely adherent to the local lymph nodes. The patient made an monotonous recovery from this procedure.

Pathology

Gros examination of the resect specimen revealed large, calcified lymph nodes eroding the main bronchus to the part of lung. There were, also, multiple small calcified nodules within the lung parenchyma and bronchial wall. Extensive bronchiectatic changes and consolidation were associated with the obstructive calcified masses. Histologic examination of the larger calculi after decalcification showed predominantly necrotic structureles material with calcification. Within these necrotic and calcified areas, there were bands of suppuration in which typical brimstone granules, containing branching bacteria were identified (Fig 2A). Extensive further sampling revealed rare necrotizing and partially calcified granulomas encloseed by palisading histiocytes and Langhans symbol giant cells. Within the central areas of necrosis numerous budding yeast forms were identified by the agency of GMS stain (Fig 2B). The CDC confirmed a diagnosis of H capsulatum onward the basis of immunofluorescent staining of the yeast forms. The branching bacteria, although members of the order Actinomycetales, could not be identified immunologically as Actinomyces israeli or Nocardia asteroides.

civilization studies were not helpful.

Discussion

It is widely accepted that greatest in number cases of broncholithiasis result from calcification of lymph nodes following tuberculosis or Histoplasma infection. However, not many studies have directly addressed the question of etiology through use of special staining techniques or refinement The inability to demonstrate organisms from these techniques in fact does not except infection either, as the broncholith in reality exhibits the burned out and inactive stage of the disease.

In an attempt to define the etiology of broncholithiasis, Weed and Anderson[3] from the Mayo Clinic applied special staining and agriculture techniques to 12 broncholiths of nine patients with broncholithiasis. Although the cultivation results were thought to be unhelpful, the special stain findings were of interest. Five stones from five patients contained piles with the morphologic features of H capsulatum, while eight stones from five patients contained acid-fast branching filaments consistent with N asteroides. In sum of two units stones from two patients, erections resembling both Histoplasma and Nocardia were not absent in generous numbers. The branching organisms that we identified had morphologic features similar to those illustrated on Weed and Anderson,[3] but the acid-fast stain performed through our technique was negative. In addition, we were able to reject an Actinomyces or Nocardia species forward the basis of immunologic techniques applied to tissue sections. Actinomyces and related organisms have a aptitude to colonize devitalized tissue, and they have been identified in association with the calcified lymph nodes of tuberculosis.[4] The nearness of these Actinomyces-like organisms in as well-as; not only-but also; not only-but; not alone-but our case and the Mayo Clinic meditation probably represents a phenomenon of secondary invasion of tissue previously devitalized by dint of earlier Histoplasma infection. The secondary infection may have riseed from blood-borne seeding or aspiration.