(Chest. 2002;121:296-297.)
© 2002
American College of Chest Physicians
Mediastinal Abscess Due to Passage of a Broncholith*
Sean M. Studer, MD;
Richard F. Heitmiller, MD and
Peter B. Terry, MD, FCCP
*
From the Divisions of Pulmonary and Critical Care Medicine (Drs. Studer and Terry) and Thoracic Surgery (Dr. Heitmiller), Johns Hopkins University, Baltimore, MD.
Correspondence to: Sean M. Studer, MD, 1 Gustave L. Levy Pl, RMTI-Box 1104, Mount Sinai Medical Center, New York, NY 10029; e-mail: sean_studer{at}mssm.edu
 |
Abstract
|
|---|
We report a case of a 32-year-old woman who, after passage of
broncholiths, developed a mediastinal abscess that required surgical
drainage for treatment. Previously reported infectious complications
resulting from broncholiths include obstructive pneumonitis and
recurrent aspiration pneumonitis secondary to bronchoesophageal
fistulas. Because radiographic evidence of abnormal calcification in
the chest is common, but rarely is associated with broncholithiasis,
the patient’s history of lithoptysis was crucial to determining the
underlying etiology of her abscess.
Key Words: broncholithiasis • lithoptysis • mediastinal abscess
|
Introduction
|
|---|
Broncholiths
(bronchus + Gr. lithos [stone]) are generally defined as
calcified material within the lumen of the tracheobronchial tree,
although some authors1
2
3
expand the definition to include
extraluminal calcifications that cause symptoms due to airway
impingement. Broncholiths arise most commonly from the erosion and
extrusion of calcified necrotic material from bronchopulmonary lymph
nodes. Mycobacterial and fungal granulomatous lymphadenitis are the
most frequently cited infections that are responsible for tissue
calcification, although silicosis is a less commonly associated
noninfectious cause.4
5
6
Reported complications due to
broncholiths include chronic cough, hemoptysis, fever, purulent sputum,
wheezing, lithoptysis (ie, coughing productive of stones),
chest pain, and bronchoaortic fistulas.7
Bronchoesophageal
fistulas also occur leading to recurrent aspiration and
pneumonia.8
We describe an unusual case of infection that appears to be the
result of the erosion of broncholiths into the airways associated with
retrograde movement of organisms into the patient’s mediastinum with
subsequent abscess formation.
|
Case Report
|
|---|
A 32-year-old woman presented for pulmonary consultation in May
2000 because of cough, fever, and purulent secretions coupled with
"coughing up stones." Her medical history was significant only for
a history of "asthma," which was diagnosed at 23 years of age. She
was treated intensively for several years without significant
improvement, and then her symptoms spontaneously and gradually began to
disappear. Her asthma-like symptoms recurred again in December 1999 and
were intermittent until the sudden onset of lithoptysis and then cough
productive of purulent material 3 months later. After an initial
physical examination that was unremarkable, her evaluation included a
plain chest radiograph, bronchoscopy, and thoracic CT scan.
The plain chest radiograph was unremarkable, and bronchoscopy revealed
no apparent obstruction or mucosal abnormalities. The CT scan, however,
revealed a precarinal abscess with an air fluid level and punctate
calcifications intermittently outlining the rim of the abscess cavity
(Fig 1
). She was started on antibiotic therapy and was referred for a thoracic
surgery consultation.
The patient was scheduled for surgical drainage of the abscess and was
taken to the operating room 1 week later. Intraoperative bronchoscopy
revealed no fistula or eroding broncholiths; however, the bronchial
mucosa was erythematous, and extrinsic compression of the bronchus
intermedius was noted. A thoracotomy was performed, confirming a large
pretracheal abscess with extension into the subcarinal area. Fragments
of calcified and purulent material, as well as a sample of the abscess
wall, were removed and sent for mycobacterial, fungal, and bacterial
cultures. Cultures were positive only for Haemophilus
influenzae, supporting the respiratory origin of the infection. At
the time of hospital discharge, the patient’s fever had resolved and
her cough and chest pain were improved.
Antibiotic therapy was not continued after hospital discharge, and the
patient reported feeling well for the subsequent 8 weeks until her
symptoms of cough, purulent sputum, and lithoptysis returned. At that
time, oral antibiotic therapy appropriate for H
influenzae was restarted and a thoracic CT scan was repeated. No
recurrence of mediastinal abscess or new infiltrate was noted, and the
patient’s symptoms responded rapidly to antibiotic therapy. She
returned to work and was counseled that she would most likely continue
to expectorate broncholiths, but that, once she was treated adequately
with antibiotics, episodes of recurrent infection would be unlikely.
|
Discussion
|
|---|
Broncholithiasis, manifested as the "spitting of
stones," is a rare disorder that has been recognized for centuries
based on the writings of Aretaeus, Galen, and Aristotole.1
The natural history of this disease remains poorly defined, however,
and the clinical presentation is variable and often nonspecific. The
incidence of either fever or purulent sputum suggestive of respiratory
infection is estimated to be between 11% and 61%, based on previously
reported case series.1
2
7
9
10
The most common infectious
complication resulting from broncholithiasis appears to be bacterial
pneumonitis due to airway obstruction by a broncholith and the
associated airway inflammation and edema. Lung abscesses and
bronchoesophageal fistulas are potentially more serious complications
of symptomatic broncholithiasis and are responsible for cases of
prolonged or recurrent infection. In our case, the patient appears to
have developed an abscess due to retrograde movement of the
H influenzae organisms from the bronchi into the
mediastinum, presumably during the passage of a broncholith.
There was no evidence based on history, radiographic studies, or
bronchoscopy to suggest fistula formation. Our review of the medical
literature did not reveal any previously reported cases of mediastinal
abscess formation associated with the passage of a broncholith.
Bacterial mediastinal abscesses most frequently occur secondary to
surgical procedures, including median sternotomy for cardiac surgery,
mediastinotomy, and mediastinoscopy. Esophageal perforation and leakage
secondary to these procedures, surgery, and spontaneous causes, as well
as the extension of oral and cervical infections are other important
causes of bacterial medistinitis. A smaller proportion of mediastinal
infections is caused by the extension of subdiaphragmatic infections,
pneumonia, lung abscesses, and pleural empyema.11
Two possible reasons that mediastinal abscess has not been
previously reported as a complication of broncholithiasis may include a
low incidence and a lack of clinical recognition of this complication.
First, while the extrusion of broncholiths may not be uncommon in the
setting of mediastinal calcifications, the generally sterile
environment of the tracheobronchial tree is not predisposed to
bacterial seeding of the mediastinum before the airway mucosal injury
has healed. Second, broncholithiasis may go unrecognized in cases of
mediastinal abscess because the most common symptoms, which include
cough, hemoptysis, and chest pain, are nonspecific and a history of
lithoptysis is uncommon. A history of lithoptysis was noted in 3 to
16% of cases in which broncholithiasis was documented at bronchoscopy
or surgery in previous series.1
2
7
9
10
Our patient’s history of spontaneously resolving and then
recurring asthma provided another potential clue, in retrospect, to the
diagnosis of broncholithiasis. Her symptoms of cough, wheezing, and
purulent sputum, in the absence of lithoptysis, initially suggested the
more common clinical problem of asthma. Her lack of response to
standard asthma medications and the intermittent nature of her asthma
symptoms, however, as well the complete absence of symptoms for a
period of years, is not typical for asthma and is quite consistent with
symptomatic broncholithiasis. Groves and Effler1
specifically mentioned the occurrence of symptoms of an "asthmatic
nature" in their series of 27 patients with broncholithiasis as a
justification for the selected bronchoscopic evaluation of some
patients with chronic, nonsurgical pulmonary disease.
From a therapeutic standpoint for our patient, who continues to
intermittently experience lithoptysis, there are no data to support
further surgery. Should she develop complications such as recurrent
mediastinal abscess, localized bronchiectasis, or fistulas, this
recommendation may change,2
but there is no evidence to
suggest a benefit from the removal of calcified lymph nodes at the
present time.
Received for publication February 2, 2001.
Accepted for publication June 6, 2001.
|
References
|
|---|
-
Groves, LK, Effler, DB (1956) Broncholithiasis: a review of twenty-seven cases. Am Rev Respir Dis 73,19-30
-
Faber, LP, Jensik, RJ, Chawla, SK, et al (1975) The surgical implication of broncholithiasis. Thorac Cardiovasc Surg 70,779-789
-
Conces, DJ, Tarver, RD, Vix, VA (1991) Broncholithiasis: CT features in 15 patients. AJR Am J Roentgenol 157,249-253[Abstract/Free Full Text]
-
Baum, GL, Berstein, IL, Schwarz, J (1958) Broncholithiasis produced by histoplasmosis. Am Rev Tuberc 77,162-167
-
Carasso, B, Couropmitree, C, Heredia, R (1973) Egg-shell silicotic calcification causing broncho-esophageal fistula. Am Rev Respir Dis 108,1384-1387[ISI][Medline]
-
Scull, RE, Mark, EJ, McNeely, WF, et al (1991) Case records of the Massachusetts General Hospital: weekly clinicopathological exercises, Case 46–1991; a 64-year-old man with recurrent hemoptysis N Engl J Med 325,1429-1436[ISI][Medline]
-
Olson, EJ, Utz, JP, Prakash, UB (1999) Therapeutic bronchoscopy in broncholithiasis. Am J Respir Crit Care Med 160,766-770[Abstract/Free Full Text]
-
Davis, EW, Katz, S (1956) Broncholithiasis: a neglected cause of bronchoesophageal fistula. JAMA 160,555-557
-
Schmidt, HW, Clagett, OT, McDonald, JR (1950) Broncholithiasis. Thorac Cardiovasc Surg 19,226-245
-
Dixon, GF, Donnerberg, RL, Schonfeld, SA, et al (1984) Advances in the diagnosis and treatment of broncholithiasis. Am Rev Respir Dis 129,1028-1030[ISI][Medline]
-
Heitmiller RF, Yang SC. Thoracic Emergencies In: Eisele DW, McQuone SJ, ed. Emergencies of the head and neck. St. Louis, MO: Mosby, 2000; 301–316
This article has been cited by other articles:
|
|
|
|
 
J. W. Toth, M. Tucakovic, and L. Foulke
Therapeutic Bilateral Broncholithectomy using Flexible Bronchoscopy: A Case Report
Chest Meeting Abstracts,
October 1, 2004;
126(4):
964S - 964S.
[Abstract]
[Full Text]
[PDF]
|
|
|
TOP
Abstract
Introduction
