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Not Everything That Wheezes Is Asthma
October 2013, Vol 144, No. 4_MeetingAbstracts Allergy and Airway | October 2013
Not Everything That Wheezes Is Asthma Paula Duran, MD; Juan Sanchez, MD Scott and White Healthcare. Texas A&M College of Medicine, Temple, TX Chest. 2013;144(4_MeetingAbstracts):61A. doi:10.1378/chest.1704798
Abstract SESSION TITLE: Bronchology Student/Resident Case Report Posters SESSION TYPE: Medical Student/Resident Case Report PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM INTRODUCTION: Wheezing is a nonspecific symptom that usually heralds obstructive airway disease. We present a case of airway obstruction due to broncholithiasis mimicking asthma. CASE PRESENTATION: A 58-year-old woman was seen due to asthma exacerbations and recurrent left lower lobe pneumonia. She complained of wheezing and dry cough, without triggers. Her asthma was treated with inhaled corticosteroids and albuterol without control. History of hypertension, hyperlipidemia and seasonal allergies and she was nonsmoker. Exam: BP 118/65, HR 64, RR 17, Temp 97°F, Sat 97% on room air. Pulmonary auscultation with central wheezing. Spirometry FVC: 2.43(79%), FEV1: 1.52 (62%) and FEV1/FVC: 63%. Diagnosed with chronic persistant asthma and salmeterol/fluticasone was initiated without symptom control. The patient then was admitted to the hospital with left lower lobe pneumonia, the chest radiograph revealed a left lower lobe consolidation, multiple calcified granulomata and calcified mediastial and hilar adenopathy. CT scan of the chest revealed a calcified mass within the left main bronchus, a left lower lobe infiltrate, and multiple bilateral calcified granulomas. Flexible bronchoscopy confirmed a broncholith in the distal left mainstem bronchus obstructing the left lower lobe. A rigid bronchoscopy and broncholithectomy was performed without complications. Evaluation for granulomatous disease was unrevealing. Gross pathology showed a 2x1.2x1cm broncholith. The patient’s symptoms completely resolved 3 months after endoscopic broncholithectomy and bronchodilators were discontinued due to complete symptom resolution. DISCUSSION: Broncholithiasis in the US is most commonly due to Histoplasmosis. The patient presented with symptoms of recurrent pneumonia in the left lower lobe and wheezing. CT scan of the chest revealed pulmonary parenchymal and lymph node calcifications. Broncholiths are best removed surgically especially if causing hemoptysis or fistula with adjacent structures.
Endoscopic removal is reserved for lose endobronchial lesions that can be easlily retrieved by flexible or rigid bronchoscopy. CONCLUSIONS: Broncholithiasis is an uncommon condition mostly caused by granulomatous infection but can be due to other conditions previously described in the literature. In our case, the patient had been treated for asthma for several years without paying much attention to her chest imaging studies. Imaging studies can provide with clues regarding possible causes of airway obstruction. Reference #1: Anwer M, Venkatram S. J Bronchology Interv Pulmonol. 2011 Apr;18(2):181-3. Reference #2: Menivale F, Deslee GF, Vallerand H, Toubas O, Delepine G, Guillou PJ, Lebargy F. Ann Thorac Surg 2005;79:1774-6. Reference #3: Cerfolio RJ, Bryant AS, Maniscalco L. J Thorac Cardiovasc Surg. 2008 Jul;136(1):186-90. DISCLOSURE: The following authors have nothing to disclose: Paula Duran, Juan Sanchez No Product/Research Disclosure Information
Not Everything That Wheezes Is Asthma Paula Duran, MD; Juan Sanchez, MD Scott and White Healthcare. Texas A&M College of Medicine, Temple, TX Chest. 2013;144(4_MeetingAbstracts):61A. doi:10.1378/chest.1704798
Abstract SESSION TITLE: Bronchology Student/Resident Case Report Posters SESSION TYPE: Medical Student/Resident Case Report PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM INTRODUCTION: Wheezing is a nonspecific symptom that usually heralds obstructive airway disease. We present a case of airway obstruction due to broncholithiasis mimicking asthma. CASE PRESENTATION: A 58-year-old woman was seen due to asthma exacerbations and recurrent left lower lobe pneumonia. She complained of wheezing and dry cough, without triggers. Her asthma was treated with inhaled corticosteroids and albuterol without control. History of hypertension, hyperlipidemia and seasonal allergies and she was nonsmoker. Exam: BP 118/65, HR 64, RR 17, Temp 97°F, Sat 97% on room air. Pulmonary auscultation with central wheezing. Spirometry FVC: 2.43(79%), FEV1: 1.52 (62%) and FEV1/FVC: 63%. Diagnosed with chronic persistant asthma and salmeterol/fluticasone was initiated without symptom control. The patient then was admitted to the hospital with left lower lobe pneumonia, the chest radiograph revealed a left lower lobe consolidation, multiple calcified granulomata and calcified mediastial and hilar adenopathy. CT scan of the chest revealed a calcified mass within the left main bronchus, a left lower lobe infiltrate, and multiple bilateral calcified granulomas. Flexible bronchoscopy confirmed a broncholith in the distal left mainstem bronchus obstructing the left lower lobe. A rigid bronchoscopy and broncholithectomy was performed without complications. Evaluation for granulomatous disease was unrevealing. Gross pathology showed a 2x1.2x1cm broncholith. The patient’s symptoms completely resolved 3 months after endoscopic broncholithectomy and bronchodilators were discontinued due to complete symptom resolution. DISCUSSION: Broncholithiasis in the US is most commonly due to Histoplasmosis. The patient presented with symptoms of recurrent pneumonia in the left lower lobe and wheezing. CT scan of the chest revealed pulmonary parenchymal and lymph node calcifications. Broncholiths are best removed surgically especially if causing hemoptysis or fistula with adjacent structures.
Endoscopic removal is reserved for lose endobronchial lesions that can be easlily retrieved by flexible or rigid bronchoscopy. CONCLUSIONS: Broncholithiasis is an uncommon condition mostly caused by granulomatous infection but can be due to other conditions previously described in the literature. In our case, the patient had been treated for asthma for several years without paying much attention to her chest imaging studies. Imaging studies can provide with clues regarding possible causes of airway obstruction. Reference #1: Anwer M, Venkatram S. J Bronchology Interv Pulmonol. 2011 Apr;18(2):181-3. Reference #2: Menivale F, Deslee GF, Vallerand H, Toubas O, Delepine G, Guillou PJ, Lebargy F. Ann Thorac Surg 2005;79:1774-6. Reference #3: Cerfolio RJ, Bryant AS, Maniscalco L. J Thorac Cardiovasc Surg. 2008 Jul;136(1):186-90. DISCLOSURE: The following authors have nothing to disclose: Paula Duran, Juan Sanchez No Product/Research Disclosure Information